Safety and efficacy of EUS-guided coil and glue injection for the primary prophylaxis of gastric variceal hemorrhage.

BACKGROUND AND AIMS: Gastric variceal bleeding (GVB) is associated with high morbidity and mortality. EUS-guided coil and cyanoacrylate (CYA) injection (EUS-CCI) has been shown to be an effective therapy in acute bleeding and secondary prophylaxis; however, there is a paucity of data on primary prophylaxis. METHODS: In this single-center observational study, adult patients with high-risk gastric varices (GV; size >10 mm or cherry red spot) without prior bleeding underwent EUS-CCI for the primary prophylaxis of GVB between June 2009 and December 2019. The primary outcome was post-treatment GVB. RESULTS: Eighty patients with a mean variceal size of 22.5 ± 9.4 mm and a mean length of follow-up of 3.0 ± 2.4 years were included. The etiology of portal hypertension was cirrhosis in 71 patients (88.7%) and noncirrhotic in 9 (11.3). The mean model for end-stage liver disease score was 12.3 ± 3.7 in patients with cirrhosis. The mean coil number was 1.5 (range, 1-3) and mean glue volume injected 2 mL (range, .5-5). Technical success was achieved in 100%, 96.7% had EUS confirmation of GV obliteration, and 67.7% were obliterated with 1 treatment session. Post-treatment GVB occurred in 2 patients (2.5%) and adverse events in 4 (4.9%). No deaths related to GVB occurred, and emergent transjugular intrahepatic shunts were not needed during the follow-up period. CONCLUSIONS: In patients with high-risk GV, EUS-CCI for primary prophylaxis is highly effective at preventing GVB with a low rate of adverse events. Primary prophylaxis of high-risk GV with coil and CYA glue injection should be considered in centers with the appropriate expertise.

Underwater versus conventional EMR for colorectal polyps: systematic review and meta-analysis.

BACKGROUND AND AIMS: Underwater EMR (UEMR) has emerged as an attractive alternative to conventional EMR (CEMR) for the resection of colorectal polyps. The purpose of this systematic review and meta-analysis was to compare UEMR and CEMR for the resection of colorectal polyps with respect to efficacy and safety. METHODS: A literature search was performed across multiple databases, including MEDLINE/PubMed, The Cochrane Library, CINAHL, Google Scholar, and Scopus, for studies that were published until May 2020. Only studies that compared the resection of colorectal polyps using UEMR with CEMR were included. Outcomes examined included rates of en bloc resection, recurrence, postprocedure bleeding, perforation, and resection time. RESULTS: Seven studies totaling 1237 polyps were included: 614 polyps were resected with UEMR and 623 polyps with CEMR. UEMR was associated with a significant increase in the rate of overall en bloc resection (odds ratio [OR], 1.84; 95% confidence interval [CI], 1.42-2.39; P < .001; I2 = 38%), with subgroup analysis showing a significant increase in the rates of en bloc resection in polyps ≥20 mm (OR, 1.51; 95% CI, 1.06-2.14; P = .02; I2 = 44%) but not in polyps <20 mm (OR, 1.07; 95% CI, .65-1.76; P = .80; I2 = 27%), and with a significant reduction in the rate of recurrence (OR, .30; 95% CI, .16-.57; P = .0002; I2 = 0%), again driven by improvements in polyps ≥20 mm. There was no significant difference in postprocedure bleeding (OR, 1.11; 95% CI, .57-2.17; P = .76; I2 = 0%) or perforation (OR, .72; 95% CI, .19-2.83; P = .64; I2 = 0%). CONCLUSIONS: The results of this systematic review and meta-analysis demonstrate that UEMR is a safe and efficacious alternative to CEMR. With appropriate training, UEMR may be strongly considered as a first-line option for resection of colorectal polyps.

Endoscopic ultrasound-guided gastroenterostomy using an oroenteric catheter-assisted technique: a retrospective analysis.

BACKGROUND : This study evaluated an oroenteric catheter (OEC)-assisted technique to distend the enteric loop for endoscopic ultrasound-guided gastroenterostomy (EUS-GE) in patients with gastric outlet obstruction (GOO). METHODS : Patient outcomes were reviewed. Proximal enteric loops were filled with water via an OEC (7 Fr or 8 Fr), providing a target for EUS-GE using a lumen-apposing metal stent (15-mm caliber). Clinical success was defined as toleration of a non-liquid diet by Day 3. RESULTS : 42 patients (mean age 73.1 [SEM 2.8] years; 23 male) underwent EUS-GE for malignant (n = 37) and benign (n = 5) duodenal strictures. EUS-GE creation was successful in 41/42 (98 %), with mean procedure time of 36 (SEM 3) minutes and no serious complications. Clinical success was achieved in 39/42 (93 %) at 5.7 (SEM 2.6) months' follow-up. Of 14 patients who died, 13 (93 %) maintained oral intake until death. EUS-GE provided good symptom relief in all 28 surviving patients until follow-up. CONCLUSIONS : OEC-assisted EUS-GE provided satisfactory relief of GOO symptoms, with high technical success (98 %) and no serious complications.

Endoscopic ultrasound-guided gastroenterostomy versus open surgical gastrojejunostomy: clinical outcomes and cost effectiveness analysis.

BACKGROUND: Early data suggests that endoscopic ultrasound-guided gastroenterostomy (EUS-GE) is a safe and efficacious option for gastric outlet obstruction (GOO). However, there is a scarcity of data comparing outcomes with open gastrojejunostomy (OGJ). METHODS: Single-center retrospective cohort study of adult patients hospitalized with GOO who underwent EUS-GE or OGJ between January 1, 2014 and February 28, 2020. Primary outcomes were technical and clinical success. RESULTS: Sixty-six patients were included of which 40 (60.0%) underwent EUS-GE and 26 (40.0%) underwent OGJ. Baseline characteristics were similar with respect to age (70.5 vs 69.7, p = 0.81), sex (42.5% vs 42.3% female, p = 0.99), median length of follow-up (98.0 vs 166.5 days, p = 0.8), prior failed intervention for GOO (22.5% vs 26.9%, p = 0.68), and the presence of altered anatomy (12.5% vs 30.8%, p = 0.07) between EUS-GE and OGJ, respectively. Technical success was achieved in 37 (92.5%) of EUS-GE and 26 (100%) of OGJ patients (p = 0.15). EUS-GE was associated with faster resumption of oral intake (1.3 vs 4.7 days, p < 0.001) and shorter length of stay (5 vs 14.5 days, p < 0.001). There were no significant differences in symptom recurrence (17.5% vs 19.2%, HR 1.85, CI 0.52-6.65, p = 0.34), reintervention (20% vs 11.5%, HR 0.82, CI 0.22-3.15, p = 0.78), death within 30 days (12.5% vs 3.8%, HR 0.80, CI 0.09-6.85, p = 0.84), or 30-day readmission (17.5% vs 24.1%, HR 1.69, CI 0.53-5.41, p = 0.37) between EUS-GE and OGJ, respectively. EUS-GE patients initiated chemotherapy sooner (17.7 vs 31.3 days, p = 0.033) and had lower overall costs as compared to OGJ ($49,387 vs $124,192, p < 0.001). CONCLUSION: There were no significant differences in technical or clinical success, symptom recurrence, reintervention, 30-day readmission, or 30-day mortality between EUS-GE and OGJ. EUS-GE patients experienced shorter delays to resumption of oral intake and chemotherapy, had shorter lengths of stay, and reduced hospital costs. Further prospective comparative studies are warranted to verify our results.

Effectiveness of combination endoscopic therapy for colonic anastomotic leaks.

BACKGROUND: Colonic anastomotic leaks are associated with significant morbidity and mortality. Whereas small case series suggest that fully covered self-expandable metal stents (FCSEMS) are effective, no larger studies have examined the impact of combination endoscopic therapy on colonic anastomotic leaks. METHODS: Our retrospective cohort study reviewed 51 patients undergoing endoscopic therapy for colonic anastomotic leaks between 2011 and 2018. Patients receiving combination therapy involving FCSEMS plus local closure (n = 24) were compared with patients receiving FCSEMS alone (n = 18) or endoscopic suturing alone (n = 9). The primary outcomes were technical and clinical success (resolution of leak, removal of percutaneous drains, avoidance of surgical reoperation, and reversal of temporary diversion). RESULTS: Clinical success was achieved in 55 % of patients. Clinical success was achieved in 18/24 patients (75 %) with combination therapy compared with 6/18 patients receiving FCSEMS alone (33 %, adjusted risk ratio [RR] 2.16, 95 % confidence interval [CI] 1.10 - 4.24; P = 0.02) and 4 /9 patients undergoing endoscopic suturing alone (44 %, RR 1.91, 95 %CI 0.84 - 4.31; P = 0.10). Stent migration occurred in 40 % of patients. CONCLUSIONS: This large series demonstrates that combination therapy was associated with a higher rate of clinical success, and future prospective studies are warranted.

Attempted underwater en bloc resection for large (2-4 cm) colorectal laterally spreading tumors (with video).

OBJECTIVE: To evaluate the feasibility and outcomes of attempted underwater en bloc resection (UEBR) of large colorectal laterally spreading tumors (LSTs). DESIGN: Prospective, observational study. SETTING: Tertiary academic referral center. PATIENTS: Fifty patients meeting the inclusion and exclusion criteria. INTERVENTIONS: Standardized UEBR technique involving attempted en bloc resection without submucosal injection by using a large 33-mm snare. MAIN OUTCOME MEASUREMENTS: Complete endoscopic en bloc resection, histologic complete resection, procedure time, adverse events, and follow-up data. RESULTS: Over 13 months, UEBR was attempted in 50 patients (median age, 68 years) with 53 LSTs 2 to 4 cm in size. The median LST size was 30 mm (range 20-40 mm). The median procedure and resection times were 38 minutes (range 17-87 minutes) and 3 minutes (range 1-32 minutes), respectively. Complete endoscopic en bloc resection with the 33-mm snare was successful in 29 of 53 lesions (55%). Of these, histology showed neoplasia-free margins in 79%. Final histology was tubular adenoma (n = 26), sessile serrated adenoma (n = 10), tubulovillous adenoma (n = 14), villous adenoma (n = 2), and intramucosal carcinoma (n = 1). Adverse events (4%) were delayed bleeding in 1 and abdominal pain in 1 patient each. There were no perforations. Forty patients with a total of 43 adenomas had follow-up colonoscopy with biopsies of the resection site after a median of 31 weeks (range 7-71 weeks) after resection. Residual adenoma was found in 2 of 43 (5%). LIMITATIONS: Single-center, limited follow-up. CONCLUSION: On an intention-to-treat basis, complete endoscopic en bloc resection was achieved in 55% of lesions with complete histologic resection verified in 79% of the en bloc specimens. UEBR without submucosal injection appears safe. Refinements are needed to improve UEBR success rates.

Plastic biliary stent patency in patients with locally advanced pancreatic adenocarcinoma receiving downstaging chemotherapy.

BACKGROUND: Plastic stents in patients with biliary obstruction caused by pancreatic adenocarcinoma are typically exchanged at 3-month intervals. Plastic stents may have reduced durability in patients receiving chemotherapy. OBJECTIVE: To determine the duration of plastic biliary stent patency in patients undergoing chemotherapy for pancreatic adenocarcinoma. DESIGN: Retrospective, multicenter cohort study. SETTING: Three tertiary academic referral centers. PATIENTS: A total of 173 patients receiving downstaging chemotherapy for locally advanced or borderline resectable pancreatic adenocarcinoma from 1996 to 2013. INTERVENTIONS: Placement of 10F or larger plastic biliary stents. MAIN OUTCOME MEASUREMENTS: Primary outcome was overall duration of stent patency. Secondary outcomes included the incidence of premature stent exchange (because of cholangitis or jaundice) and hospitalization rates. RESULTS: A total of 233 plastic stents were placed, and the overall median duration of stent patency was 53 days (interquartile range [IQR] 25-99 days). Eighty-seven stents were removed at the time of surgical resection, and 63 stents were exchanged routinely per protocol. The remaining 83 stent exchanges were performed for worsening liver function test results, jaundice, or cholangitis, representing a 35.6% rate of premature stent exchange. The median stent patency duration in the premature stent exchange group was 49 days (IQR 25-91 days) with a 44.6% hospitalization rate. The overall rate of cholangitis was 15.0% of stent exchanges, occurring a median of 56 days after stent placement (IQR 26-89 days). LIMITATIONS: Retrospective study. CONCLUSIONS: Plastic biliary stents placed during chemotherapy/chemoradiation for pancreatic adenocarcinoma have a shorter-than-expected patency duration, and a substantial number of patients will require premature stent exchange. Consideration should be given to shortening the interval for plastic biliary stent exchange.

EUS-Guided Cholecystoduodenostomy for a Poor Surgical Candidate With Chronic Octreotide-Associated Gallstones From Metastatic Neuroendocrine Tumor.

Chronic octreotide use has been associated with gallstone formation. Historically, cholecystectomy has been the defining treatment for those who have gallstone-related disease. For those who are poor surgical candidates, percutaneous and endoscopic approaches have been used. We describe the endoscopic management of a 74-year-old man with significant gallstone burden and associated sequelae because of chronic octreotide for metastatic neuroendocrine tumor through endoscopic ultrasound-guided cholecystoduodenostomy with gallstone extraction using lumen-apposing metal stents.

Utilization of an overtube for placement of a lumen-apposing metal stent for removal of a capsule endoscope retained proximal to an ileal stricture.

Video 1Narration of case and demonstration of overture-mediated lumen-apposing metal stent placement for removal of retained capsule endoscopy.

Declining Colectomy Rates for Nonmalignant Colorectal Polyps in a Large, Ethnically Diverse, Community-Based Population.

INTRODUCTION: Despite studies showing improved safety, efficacy, and cost-effectiveness of endoscopic resection for nonmalignant colorectal polyps, colectomy rates for nonmalignant colorectal polyps have been increasing in the United States and Europe. Given this alarming trend, we aimed to investigate whether colectomy rates for nonmalignant colorectal polyps are increasing or declining in a large, integrated, community-based healthcare system with access to advanced endoscopic resection procedures. METHODS: We identified all individuals aged 50-85 years who underwent a colonoscopy between 2008 and 2018 and were diagnosed with a nonmalignant colorectal polyp(s) at the Kaiser Permanente Northern California integrated healthcare system. Among these individuals, we identified those who underwent a colectomy for nonmalignant colorectal polyps within 12 months after the colonoscopy. We calculated annual colectomy rates for nonmalignant colorectal polyps and stratified rates by age, sex, and race and ethnicity. Changes in rates over time were tested by the Cochran-Armitage test for a linear trend. RESULTS: Among 229,730 patients who were diagnosed with nonmalignant colorectal polyps between 2008 and 2018, 1,611 patients underwent a colectomy. Colectomy rates for nonmalignant colorectal polyps decreased significantly from 125 per 10,000 patients with nonmalignant polyps in 2008 to 12 per 10,000 patients with nonmalignant polyps in 2018 (P < 0.001 for trend). When stratified by age, sex, and race and ethnicity, colectomy rates for nonmalignant colorectal polyps also significantly declined from 2008 to 2018. DISCUSSION: In a large, ethnically diverse, community-based population in the United States, we found that colectomy rates for nonmalignant colorectal polyps declined significantly over the past decade likely because of the establishment of advanced endoscopy centers, improved care coordination, and an organized colorectal cancer screening program.

A randomized controlled cross-over trial and cost analysis comparing endoscopic ultrasound fine needle aspiration and fine needle biopsy.

BACKGROUND AND STUDY AIMS: Techniques to optimize endoscopic ultrasound-guided tissue acquisition (EUS-TA) in a variety of lesion types have not yet been established. The primary aim of this study was to compare the diagnostic yield (DY) of endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) to endoscopic ultrasound-guided fine needle biopsy (EUS-FNB) for pancreatic and non-pancreatic masses. PATIENTS AND METHODS: Consecutive patients referred for EUS-TA underwent randomization to EUS-FNA or EUS-FNB at four tertiary-care medical centers. A maximum of three passes were allowed for the initial method of EUS-TA and patients were crossed over to the other arm based on on-site specimen adequacy. RESULTS: A total of 140 patients were enrolled. The overall DY was significantly higher with specimens obtained by EUS-FNB compared to EUS-FNA (90.0 % vs. 67.1 %, P = 0.002). While there was no difference in the DY between the two groups for pancreatic masses (FNB: 91.7 % vs. FNA: 78.4 %, P = 0.19), the DY of EUS-FNB was higher than the EUS-FNA for non-pancreatic lesions (88.2 % vs. 54.5 %, P = 0.006). Specimen adequacy was higher for EUS-FNB compared to EUS-FNA for all lesions (P = 0.006). There was a significant rescue effect of crossover from failed FNA to FNB in 27 out of 28 cases (96.5 %, P = 0.0003). Decision analysis showed that the strategy of EUS-FNB was cost saving compared to EUS-FNA over a wide range of cost and outcome probabilities. CONCLUSIONS: RESULTS of this RCT and decision analysis demonstrate superior DY and specimen adequacy for solid mass lesions sampled by EUS-FNB.