EUS-guided entero-colostomy with Lumen Apposing Metal Stent as a rescue treatment for malignant intestinal occlusion: a multicentre study.

BACKGROUND AND STUDY AIMS: Surgery is the first-choice treatment for malignant intestinal obstruction (MIO), however many patients are deemed unfit for surgery. Endoscopic ultrasound guided enterocolostomy (EUS-EC) with lumen apposing metal stents (LAMS) could represent a new treatment option. Primary aim was technical success of EUS-EC. Secondary aims: clinical outcome, safety, hospital stay. PATIENTS AND METHODS: Consecutive patients undergoing EUS-EC for MIO from November 2021 to September 2023 were retrospectively enrolled at four tertiary referral European centres. All cases were discussed in multidisciplinary meetings, patients declared unfit for surgery, colonic stent placement or refused surgery. RESULTS: Twelve patients were enrolled (58.3% female, median age 72.5 [42-85]). Colonic adenocarcinoma was the primary tumor in 75% of cases and 91.7% of patients had a Stage IV disease. Technical success was achieved in all procedures (100%). No LAMS misdeployment or other procedural adverse events and 3 (25%) severe post-procedural complications were observed. Clinical success was achieved in 10 (83.3%) patients, 5 (50%) resuming chemotherapy after procedure. Median post-procedural hospital stay was 9[1-20] days and overall median survival was 47.5[2-270] days. CONCLUSIONS: EUS-EC is a feasible technique and could be considered as a possible alternative to standard approaches for MIO in highly selected patients.

Accuracy of visual on-site evaluation (Vose) In predicting the adequacy of Eus-guided fine needle biopsy: A single center prospective study.

OBJECTIVE: Endoscopic ultrasound is the standard procedure for the diagnosis of pancreatic lesions and new needles have been developed to improve tissue acquisition (FNB). Rapid onset evaluation (ROSE) decreases the number of needle passes but is not always available. We introduced an easy and rapid method of direct classification of EUS-FNB sample namely Visual on-site evaluation (VOSE). AIMS: To assess the accuracy of VOSE in predicting the histological adequacy of specimens. To evaluate the diagnostic power of FNB and the rate of core tissue obtained. METHODS: Prospective single center study on patients with pancreatic lesions that underwent EUS-FNB. VOSE parameters were presence of blood, macroscopic visible core (MVC), number, color and length of specimen. The association between VOSE tool and histological adequacy was assessed. Fisher's exact test and Student's t-test used to compare categorical and continuous variables. Logistic regression analysis was used to assess association between variables. RESULTS: 99 patients (58.6% male; mean age 68.4 ± 10) enrolled, including 102 lesions. Total number of passes was 358 with median number of 4 (range, 2-4). The 92.7% of samples were adequate and it was higher with the 22-G needle than with 25G (96.5% vs 89.2% p 0.01). VOSE "red-mixed specimen" was associated with a higher probability of histological adequacy (OR 2.39 95% CI 1.03-5.42 p = 0.04). CONCLUSIONS: The VOSE tool "red-mixed specimen" can be used to predict the histological adequacy and guide the number of needle passes. Overall, FNB provides a high rate of adequate and diagnostic specimen and high rate of core tissue especially with the 22G needle.

Role of fluorescence confocal microscopy for rapid evaluation of EUS fine-needle biopsy sampling in pancreatic solid lesions.

BACKGROUND AND AIMS: EUS fine-needle biopsy (EUS-FNB) sampling is the standard procedure for diagnosis of pancreatic lesions. Fluorescence confocal microscopy (FCM) allows imaging of tissues in the fresh state, requiring minimal preparation without damage or loss of tissue. Until now, no data exist on FCM in the field of microhistologic specimens. We aimed to assess the diagnostic performance of FCM in predicting histologic adequacy of EUS-FNB samples in pancreatic solid lesions and to assess the agreement between FCM evaluation and final histology. METHODS: In this single-center prospective study on consecutive patients with pancreatic lesions receiving EUS-FNB, the obtained samples have been evaluated at FCM and classified as "inadequate" or "adequate" (benign, suspicious, or malignant). The kappa test was used to quantify agreement. The diagnostic accuracy of FCM was assessed. A P < .05 was considered to be statistically significant. RESULTS: From April 2020 to September 2020, 81 patients were enrolled. In all cases FCM showed the macro image of the sample and created a digital image. Of the samples, 92.6% was defined as adequate at the FCM evaluation and confirmed at histopathology. Histologic diagnoses were 8% benign, 17.3% atypical/suspicious, and 74.7% malignant with satisfactory agreement with the FCM evaluation (Cohen's κ coefficient, .95; 95% confidence interval [CI], .89-1.01; P = .001). The sensitivity of the FCM evaluation was 100% (95% CI, 95%-100%), specificity 66.7% (95% CI, 22.3%-95.7%), accuracy 97% (95% CI, 90.7%-99.7%), positive predictive value 97% (95% CI, 91.8%-99%), and negative predictive value 100%. CONCLUSIONS: FCM represents a new technique successfully applicable to microhistologic specimens. It provides fast information about sample adequacy in small specimens with good agreement in the final histology.

Esophageal Hypervigilance and Visceral Anxiety Are Contributors to Symptom Severity Among Patients Evaluated With High-Resolution Esophageal Manometry.

OBJECTIVES: Symptoms are inconsistently associated with esophageal motor findings on high-resolution manometry (HRM). We aimed to evaluate predictors of dysphagia severity, including esophageal hypervigilance and visceral anxiety, among patients evaluated with HRM. METHODS: Adult patients undergoing HRM at 4 academic medical centers (United States and France) were prospectively evaluated. HRM was completed and analyzed per the Chicago Classification v3.0. Validated symptom scores, including the Brief Esophageal Dysphagia Questionnaire and Esophageal Hypervigilance and Anxiety Scale, were completed at the time of HRM. RESULTS: Two hundred thirty-six patients, aged 18-85 (mean 53) years, 65% female, were included. Approximately 59 (25%) patients had a major motor disorder on HRM: 19 achalasia, 24 esophagogastric junction outflow obstruction, 12 absent contractility, and 4 jackhammer. Approximately 177 (75%) patients did not have a major motor disorder: 71 ineffective esophageal motility and 106 normal motility. Having a major motor disorder was a significant predictor of dysphagia severity (Radj = 0.049, P < 0.001), but the Esophageal Hypervigilance and Anxiety Scale score carried a predictive relationship of Brief Esophageal Dysphagia Questionnaire that was 2-fold higher than having a major motor disorder: Radj = 0.118 (P < 0.001). This finding remained when evaluated by the major motor disorder group. HRM metrics were nonsignificant. DISCUSSION: In a prospective, international multicenter study, we found that esophageal hypervigilance and visceral anxiety were the strongest predictors of dysphagia severity among patients evaluated with HRM. Thus, an assessment of esophageal hypervigilance and visceral anxiety is important to incorporate when evaluating symptom severity in clinical practice and research studies.

Role of Esophageal Motility, Acid Reflux, and of Acid Suppression in Nonobstructive Dysphagia.

GOALS: The present study was aimed at evaluating, in dysphagic patients, the role of high-resolution manometry (HRM) findings, presence of gastroesophageal reflux disease (GERD), and proton-pump inhibitor (PPI) therapy on dysphagia perception. BACKGROUND: A relevant proportion of patients with nonobstructive dysphagia present normal esophageal HRM findings. Patients with GERD often complain of dysphagia and factors, such as hypersensitivity, might be involved in its occurrence. STUDY: In total, 37 nonerosive reflux disease (NERD) patients with only dysphagia (group 1) and 52 patients with both dysphagia and typical GERD symptoms (group 2) were evaluated with symptom scores, HRM combined with impedance and 24 hours impedance-pH monitoring. In total, 44 NERD patients, not presenting dysphagia, underwent the same protocol. A total of 22/37 group 1 patients [11 with pathologic acid exposure time (AET)] were treated with esomeprazole 40 mg oid for 4 weeks and were reassessed during the last week of therapy. RESULTS: A total of 15/37 group 1 patients (40%), 27/52 group 2 patients (52%), and 19/44 (43%) NERD patients presented pathologic AET [P=not significant (NS)]. Group 1 patients with a pathologic AET showed a significantly lower mean distal contractile integral (DCI) and a significant correlation (ρ=-0.71) between individual DCI and total bolus transit time values. During PPI therapy, in group 1 patients with pathologic AET, the mean dysphagia score value decreased significantly [7.5 (range, 3 to 9) before, 4 (range, 2 to 6) during PPI; P<0.01)] and mean DCI value increased significantly. CONCLUSIONS: In total, 40% of dysphagic patients show a pathologic AET and reduced peristaltic vigor. In these patients, an adequate PPI therapy significantly decreases dysphagia frequency and severity and improves the esophageal peristaltic force.

A Rare Sigmoid-Colon Schwannoma in a Premenopausal Woman: A Case Report.

Background: Schwannomas of the gastrointestinal tract are a rare type of spindle cell tumor of peripheral nerve. Commonly, schwannomas are discovered incidentally, as they are usually asymptomatic. Case: 46-year-old female patient, suffering from secondary amenorrhea and nonspecific intermittent pelvic pain associated with constipation. During gynecological visit an ultrasonographic systematic transvaginal examination was performed. At the sigmoid-rectal level an intraluminal solid mass was described and an urgent colonoscopy was prescribed. Endoscopic submucosal dissection was performed with en-bloc resection. On immunohistochemical analysis, S100 was strongly positive in tumor cells. Finally, a benign schwannoma of the sigmoid colon was diagnosed. Conclusion: Our case highlights the importance of an adequate transvaginal pelvic examination with the evaluation of all pelvic organs. It could be challenging to make diagnosis in an early stage on asymptomatic patients.

High-resolution Manometry Findings During Solid Swallows Correlate With Delayed Reflux Clearance and Acid Exposure Time in Non-erosive Reflux Disease Patients.

BACKGROUND/AIMS: The role of esophageal motility in determining gastroesophageal reflux disease (GERD) severity has not been completely evaluated. A few studies have investigated high-resolution manometry (HRM) patterns during solid swallows. The present study evaluates the HRM patterns of non-erosive reflux disease (NERD) patients during both liquid and solid swallows and their correlation with the severity of GERD. METHODS: In 23 NERD patients and 15 healthy volunteers (HVs) HRM was performed during a standard solid meal in a seated position, followed by 24-hour impedance-pH monitoring. RESULTS: Of the 31 patients, 10 showed a pathological acid exposure time (AET; NERD patients), 13 a normal pH profile with positive symptom association probability (SAP; reflux hypersensitivity patients), and 8 normal AET and SAP (functional heartburn patients). Mean distal contractile integral and distal latency values, in all patient groups and HVs, were significantly higher during solid swallows. In the group of 10 NERD patients, the number of large breaks of the esophageal peristalsis was 16 out of 100 liquid swallows (16%) and 31 out of 171 solid swallows (18%). Fourteen out of 100 liquid swallows (14%) and 25 out of 171 solid swallows (15%) resulted ineffective. Mean reflux clearing time at multichannel intraluminal impedance-pH was 17.6 ± 3.7 seconds. NERD patients presented, during solid swallows, a significantly higher proportion of large peristaltic breaks and of ineffective swallows than reflux hypersensitivity and functional heartburn patients. CONCLUSION: HRM during solid swallows reveals motor abnormalities, undetected during liquid swallows, which might be involved in delaying reflux and acid clearance in patients with GERD.

Esophageal shortening after rapid drink test during esophageal high-resolution manometry: A relevant finding?

BACKGROUND: Esophageal shortening (ES) might be observed during high-resolution manometry (HRM), in particular after the rapid drink test (RDT). We aimed to assess its diagnostic value in patients referred for HRM. METHODS: HRM of patients without previous esophagogastric surgery or endoscopic treatment was retrospectively reviewed using the Chicago Classification v3.0. ES and pan-esophageal pressurization were analyzed during the RDT (200-ml free drinking in a sitting position). RESULTS: A total of 2141 cases (1291 females, mean age 54 years) were reviewed. During the RDT, ES occurred in 4% and pan-esophageal pressurization in 14% of patients. ES was almost exclusively encountered in patients with impaired esophagogastric junction relaxation or major disorders of peristalsis. Among 31 patients with ES and no definite diagnosis of achalasia, 19 had follow-up and 13 (68%) changed diagnostic category: two adenocarcinoma of the cardia, and 11 cases of atypical achalasia. The positive predictive value of ES for a significant esophageal disorder was 95%. CONCLUSION: ES is rarely observed during the RDT. When present, it is associated with major motility disorders, especially achalasia. When the diagnostic criteria for achalasia are not fulfilled, further complementary examinations should be performed to rule out incomplete forms of achalasia or an infiltrative process of the cardia.

Role of Mixed Reflux and Hypomotility with Delayed Reflux Clearance in Patients with Non-cardiac Chest Pain.

BACKGROUND/AIMS: Gastroesophageal reflux disease (GERD) is the most common cause of non-cardiac chest pain (NCCP). Currently available data reveal a weak relationship between NCCP and dysmotility. Moreover, it is unclear why some refluxes are perceived as heartburn and others as NCCP. We aimed to evaluate the role of the reflux pattern and the esophageal motility in patients with NCCP. METHODS: Forty-eight patients with NCCP (Group 1) and 50 only typical GERD symptoms (Group 2) were included and underwent high-resolution manometry (HRM) and multichannel intraluminal impedance-pH monitoring. RESULTS: Impaired peristalsis was found in 60% of patients with NCCP and in 24% of patients with typical symptoms (P < 0.05). In patients belonging to Group 1, the majority of reflux episodes associated with chest pain were acid and mixed. The proportion of mixed refluxes was higher than that in Group 2. In Group 1, the reflux clearing time at 5, 9, and 15 cm, measured in reflux episodes associated to NCCP was longer than in reflux episodes associated to typical symptoms (mean ± 95% CI: 27.2 ± 5.6, 23.3 ± 4.4, and 14.6 ± 2.3 seconds vs 18.3 ± 3.5, 13.3 ± 2.2, and 11.1 ± 1.8 seconds; P < 0.01). CONCLUSIONS: The presence of gas in the refluxate seems to be associated with NCCP. The impaired motility observed in NCCP patients may play a relevant role in delaying reflux clearing, hence increasing the time of contact between refluxate and esophageal mucosa.