Endoscopic Vacuum Therapy for Upper Gastrointestinal Leaks and Perforations: Analysis From a Multicenter Spanish Registry.

INTRODUCTION: Endoscopic vacuum therapy (EVT) is a novel technique for closing upper gastrointestinal (UGI) defects. Available literature includes single-center retrospective cohort studies with small sample sizes. Furthermore, evidence about factors associated with EVT failure is scarce. We aimed to assess the efficacy and safety of EVT for the resolution of UGI defects in a multicenter study and to investigate the factors associated with EVT failure and in-hospital mortality. METHODS: This is a prospective cohort study in which consecutive EVT procedures for the treatment of UGI defects from 19 Spanish hospitals were recorded in the national registry between November 2018 and March 2022. RESULTS: We included 102 patients: 89 with anastomotic leaks and 13 with perforations. Closure of the defect was achieved in 84 cases (82%). A total of 6 patients (5.9%) had adverse events related to the EVT. The in-hospital mortality rate was 12.7%. A total of 6 patients (5.9%) died because of EVT failure and 1 case (0.9%) due to a fatal adverse event. Time from diagnosis of the defect to initiation of EVT was the only independent predictor for EVT failure (odds ratio [OR] 1.03, 95% confidence interval [CI] 1.01-1.05, P = 0.005). EVT failure (OR 24.5, 95% CI 4.5-133, P = 0.001) and development of pneumonia after EVT (OR 246.97, 95% CI 11.15-5,472.58, P = 0.0001) were independent predictors of in-hospital mortality. DISCUSSION: EVT is safe and effective in cases of anastomotic leak and perforations of the upper digestive tract. The early use of EVT improves the efficacy of this technique.

EUS-guided gastroenterostomy versus duodenal self-expandable metal stent for malignant gastric outlet obstruction: results from a nationwide multicenter retrospective study (with video).

BACKGROUND AND AIMS: Traditionally, palliative treatment of malignant gastric outlet obstruction (GOO) has been surgical, but surgical treatment carries significant morbidity and mortality rates. Endoscopic placement of a duodenal self-expandable metal stent (D-SEMS) has been proven to be successful for this indication in the short term. However, D-SEMSs are likely to malfunction over time. EUS-guided gastroenterostomy (EUS-GE) may help overcome these limitations. We aimed to evaluate stent failure-free survival at 3 months. METHODS: A nationwide multicenter, observational study of D-SEMS and EUS-GE procedures for patients with malignant GOO was conducted at 7 academic centers from January 2015 to June 2020. Stent failure-free survival at 1, 3, and 6 months; technical and clinical success; adverse events (AEs); and patient survival were evaluated in both groups and compared. RESULTS: Ninety-seven patients were included in the D-SEMS group and 79 in the EUS-GE group. Pancreatic cancer was the main underlying malignancy in 53.4%. No statistically significant differences regarding technical (92.8% vs 93.7%) or clinical success (83.5% vs 92.4%) were found. AE rates did not differ between groups (10.3% vs 10.1%), although 2 events in the EUS-GE group required surgical management. Patients in the EUS-GE group had improved stent patency when compared with those patients in the D-SEMS group at 3 months (92.23% vs 80.6%; adjusted hazard ratio, .37; P = .033). CONCLUSIONS: EUS-GE seems to have improved patency outcomes when compared with D-SEMS placement for palliative treatment of malignant GOO. Prospective trials are needed to fully compare their efficacy and AE profile.

Endoscopic suturing for GI applications: initial results from a prospective multicenter European registry.

BACKGROUND AND AIMS: OverStitch devices (OverStitch and OverStitch Sx; Apollo Endosurgery, Inc, Austin, Tex, USA) are used for a wide range of applications. A European registry was created to prospectively collect technical and clinical data regarding both systems to provide procedural outcomes and to find correlation between procedural characteristics and outcomes. This study shows the initial results of the first 3 years of the registry. METHODS: Patients who underwent endoscopic suturing from January 2018 to January 2021 at 9 centers were enrolled. Data regarding the disease treated,suturing pattern and outcomes were registered. Technical feasibility (success reaching the target area), technical success (success placing sutures), and clinical success (complete resolution of the clinical issue) were recorded and analyzed. RESULTS: During the study period, 137 patients (57.7% men) were enrolled with 100% technical feasibility rate. Endoscopic suturing was successfully performed in 136 cases (16.7% with OverStitch Sx), obtaining a technical success rate of 99.3%. No adverse events were recorded. Overall clinical success was 89%. Mucosal defects were sutured in 32 patients (100% clinical success). Leaks/fistulas were treated in 23 patients (64.7% clinical success). The clinical success of stent fixations (n = 38) was 85%. Perforations (n = 22) were repaired with a clinical success of 94.7%. No significant correlation between location, suture pattern or number, and the success was found, except in case of fistulas where fistulas <1 cm treated by a continuous suture were more likely to achieve clinical success in the follow-up (P < .001). CONCLUSIONS: OverStitch-based suturing is technically feasible regardless of site and method of suturing, with no cases of failure. The overall technical success rate of 99.3% and the clinical outcome success rate of 89% demonstrate that OverStitch technology provides reliable suturing with clinical advantages, especially with fistulas <1 cm.

Self-expandable metal stent fixation with a temporary Overstitch Apollo® suture as a rescue therapy for a reluctant tuberculous esophageal-mediastinal fistula.

We present the case of a 79 y.o. male diagnosed with tuberculosis and mediastinal lymphadenopathy fistulizing in the esophageal lumen. Despite a number of treatments, including over-the scope (OVESCO) clip, the patient had intolerance for oral intake and repeated infections.

The Use of the Overstitch Beyond Bariatric Endoscopy: A Pictorial Description.

The overstitch endoscopic suturing system has opened a novel arena in endoscopy. To properly apply endoscopic suturing techniques, it is important to understand suture patterns and the different traction methods available. Applications beyond tissue compression in bariatric endoscopy include: closure, traction and fixation. Closure could be applied to perforations, suture dehiscences, fistulas and stoma reduction. Traction could be applied either as a pulley method to improver resection or as an improved method to decrease a defect size and help pull it into an over the scope clip. Fixation has been mainly used to secure stents.

Evaluation of the short- and long-term effectiveness and safety of fully covered self-expandable metal stents for drainage of pancreatic fluid collections: results of a Spanish nationwide registry.

BACKGROUND AND AIMS: Initial reports suggest that fully covered self-expandable metal stents (FCSEMSs) may be better suited for drainage of dense pancreatic fluid collections (PFCs), such as walled-off pancreatic necrosis. The primary aim was to analyze the effectiveness and safety of FCSEMSs for drainage of different types of PFCs in a large cohort. The secondary aim was to investigate which type of FCSEMS is superior. METHODS: This was a retrospective, noncomparative review of a nationwide database involving all hospitals in Spain performing EUS-guided PFC drainage. From April 2008 to August 2013, all patients undergoing PFC drainage with an FCSEMS were included in a database. The main outcome measurements were technical success, short-term (2 weeks) and long-term (6 months) effectiveness, adverse events, and need for surgery. RESULTS: The study included 211 patients (pseudocyst/walled-off pancreatic necrosis, 53%/47%). The FCSEMSs used were straight biliary (66%) or lumen-apposing (34%). Technical success was achieved in 97% of patients (95% confidence interval [CI], 93%-99%). Short-term- and long-term clinical success was obtained in 94% (95% CI, 89%-97%) and 85% (95% CI, 79%-89%) of patients, respectively. Adverse events occurred in 21% of patients (95% CI, 16%-27%): infection (11%), bleeding (7%), and stent migration and/or perforation (3%). By multivariate analysis, patient age (>58 years) and previous failed drainage were the most important factors associated with negative outcome. CONCLUSIONS: An FCSEMS is effective and safe for PFC drainage. Older patients with a history of unsuccessful drainage are more likely to fail EUS-guided drainage. The type of FCSEMS does not seem to influence patient outcome.

Initial experience with EUS-guided cholangiopancreatography for biliary and pancreatic duct drainage: a Spanish national survey.

BACKGROUND: EUS-guided cholangiopancreatography (ESCP) allows transmural access to biliopancreatic ducts when ERCP fails. Data regarding technical details, safety, and outcomes of ESCP are still unknown. OBJECTIVE: To evaluate outcomes of ESCP in community and referral centers at the initial development phase of this procedure, to identify the ESCP stages with higher risk of failure, and to evaluate the influence on outcomes of factors related to the endoscopist. DESIGN: Multicenter retrospective study. SETTING: Public health system hospitals with experience in ESCP in Spain. PATIENTS: A total of 125 patients underwent ESCP in 19 hospitals, with an experience of <20 procedures. INTERVENTION: ESCP. MAIN OUTCOME MEASUREMENTS: Technical success and complication rates in the initial phase of implantation of ESCP are described. The influence of technical characteristics and endoscopist features on outcomes was analyzed. RESULTS: A total of 125 patients from 19 hospitals were included. Biliary ESCP was performed in 106 patients and pancreatic ESCP was performed in 19. Technical success was achieved in 84 patients (67.2%) followed by clinical success in 79 (63.2%). Complications occurred in 29 patients (23.2%). Unsuccessful manipulation of the guidewire was responsible for 68.2% of technical failures, and 58.6% of complications were related to problems with the transmural fistula. LIMITATIONS: Retrospective study. CONCLUSION: Outcomes of ESCP during its implantation stage reached a technical success rate of 67.2%, with a complication rate of 23.2%. Intraductal manipulation of the guidewire seems to be the most difficult stage of the procedure.

[Endoscopic mucosal resection of Abrikosoff's tumor of the esophagus]. / Mucosectomía endoscópica de un tumor de Abrikosoff esofágico.

Abrikosoff's tumor (AT), or granular cell tumor (GCT), is relatively rare in the gastrointestinal tract, where the most common site is the esophagus. This tumor is usually found incidentally when an upper gastrointestinal endoscopy is carried out for another reason. Endoscopically, GCT appears as a small, yellow and submucosal lesion covered by normal mucosa. Endoscopic ultrasonography shows a homogeneous hypoechoic lesion with well defined margins. The definitive diagnosis is histological. The origin of GCT is neurogenic and the tumor is composed of eosinophilic granular cytoplasm and PAS-positive cells, which show the S-100 protein on immunohistochemistry. Although GCT is usually clinically and histologically benign, some malignant cases have been reported. Consensus is lacking on the treatment and follow-up of this tumor. Currently, endoscopic mucosal resection is a safe and effective technique to treat submucosal esophageal lesions, allowing subsequent histologic analysis. We present three patients with esophageal CGT, who were definitively treated with endoscopic mucosal resection.

Mucosectomía endoscópica de un tumor de Abrikosoff esofágico / Endoscopic mucosal resection of Abrikosoff´s tumor of the esophagus

El tumor de Abrikosoff (TA), o tumor de células granulares(TCG), se localiza raramente en el tracto gastrointestinal.Cuando asienta en el tubo digestivo, habitualmente apareceen el esófago. El diagnóstico suele establecerse de forma accidentalal realizar una endoscopia digestiva alta por otrosmotivos. Endoscópicamente, es una lesión submucosa de pequeñotamaño, de coloración amarillenta y generalmenterecubierta por mucosa normal. El TA es homogéneo, hipoecogénicoy con bordes bien definidos en el examen ecoendoscópico.El diagnóstico definitivo es histológico. El TCG es deorigen neurogénico y está formado por células eosinófilasgranulares PAS-positivas, que en la inmunohistoquímicamanifiestan la proteína S-100. El TA es normalmente un tumorbenigno, aunque se han descrito casos de malignidad.No hay acuerdo sobre cómo debe ser el tratamiento y el seguimientode este tumor. En la actualidad la mucosectomíaendoscópica es una técnica eficaz y segura que se puede aplicara lesiones submucosas esofágicas, lo que permite el análisishistológico posterior de toda la lesión. Presentamos 3casos de pacientes diagnosticados de TCG esofágico que fuerontratados mediante mucosectomía endoscópica como tratamientodefinitivo

Abrikosoff’s tumor (AT), or granular cell tumor (GCT), isrelatively rare in the gastrointestinal tract, where the mostcommon site is the esophagus. This tumor is usually foundincidentally when an upper gastrointestinal endoscopy is carriedout for another reason. Endoscopically, GCT appearsas a small, yellow and submucosal lesion covered by normalmucosa. Endoscopic ultrasonography shows a homogeneoushypoechoic lesion with well defined margins.The definitive diagnosis is histological. The origin of GCT isneurogenic and the tumor is composed of eosinophilic granularcytoplasm and PAS-positive cells, which show the S-100 protein on immunohistochemistry. Although GCT isusually clinically and histologically benign, some malignantcases have been reported. Consensus is lacking on the treatmentand follow-up of this tumor. Currently, endoscopicmucosal resection is a safe and effective technique to treatsubmucosal esophageal lesions, allowing subsequent histologicanalysis. We present three patients with esophagealCGT, who were definitively treated with endoscopic mucosal resection (AU)

Use of self-expanding metal stents to treat malignant colorectal obstruction in general endoscopic practice (with videos).

BACKGROUND: Self-expanding metal stents (SEMS) are being increasingly used to solve malignant colorectal obstruction (MCRO). Patients can then either undergo scheduled surgery or have the stent left in place as a definitive palliative treatment. The majority of reports on the use of SEMS in MCRO come from single centers; therefore, its use in general endoscopic practice is not clearly known. OBJECTIVE: To study the use of SEMS for MCRO in a wide endoscopic practice. DESIGN: Retrospective study. SETTING: A survey was carried out among endoscopists in 13 hospitals in Spain (6 tertiary referral centers and 7 community hospitals). PATIENTS: Those who presented with MCRO. INTERVENTIONS: A total of 175 attempts to insert colorectal SEMS were made during a 12-month period (October 2003 to September 2004). MAIN OUTCOME MEASURES: Technical and clinical success and possible differences according to the type of hospital. RESULTS: There was a mean of 1.2 attempts/mo per center (range, 2-0.5 attempts/mo per center). Insertion success was achieved in 162 (92.6%) and acceptable colonic decompression in 138 of 175 (78.8%) attempts and in 138 of 162 (85.1%) of successfully inserted stents. SEMS served as a bridge to scheduled surgery in 72 of 175 (41%) and as a palliative definitive treatment in 66 of 175 (37.7%). The major complication was perforation, which occurred in 7 of 175 occasions (4%) and led to death in 2 patients (1%). There were other less severe complications (25 [14%]). No significant differences in outcome of stent placement procedures were found between both categories of centers. LIMITATIONS: Retrospective study involving many centers and the possibility of bias for different assessments of outcomes. CONCLUSIONS: In this study, success rates for SEMS placement and colonic decompression in MCRO were acceptable, without substantial differences according to the type of hospital. This procedure appeared to be feasible in general endoscopic practice.