Endoscopic repair of duodenal perforations, a scoping review.

BACKGROUND: There is a discrepancy in the surgical and endoscopic literature for managing duodenal perforations. Although often managed conservatively, surgical repair is the standard treatment for duodenal perforations. This contrasts with the gastroenterology literature, which now recommends endoscopic repair of duodenal perforations, which are more frequently iatrogenic from the growing field of advanced endoscopic procedures. This study aims to provide a scoping review to summarize the current literature content and quality on endoscopic repair of duodenal perforations. METHODS: The protocol for performing this scoping review was outlined by the Joanna Briggs Institute. All studies that reported primary outcomes of patients who had undergone endoscopic repair of duodenal perforations before February 2022, regardless of perforation etiology or repair type were reviewed, with studies after 1999 meeting inclusion criteria. The study excluded articles that did not report clinical outcomes of endoscopic repair, articles that did not describe where in the gastrointestinal tract the endoscopic repair occurred, pediatric patients, and animal studies. RESULTS: 7606 abstracts were screened, with 474 full articles reviewed and 152 studies met inclusion criteria. 560 patients had duodenal perforations repaired endoscopically, with a technical success rate of 90.4% and a survival rate of 86.7%. Most of these perforations (74.5%) were iatrogenic from endoscopic procedures or surgery. Only one randomized control trial (RCT) was found, and 53% of studies were case reports. CONCLUSION: These results suggest that endoscopic repair could emerge as a viable first-line treatment for duodenal perforation and highlight the need for more high-quality research in this topic.

The role of cannabinoids in regulation of nausea and vomiting, and visceral pain.

Marijuana derived from the plant Cannabis sativa has been used for the treatment of many gastrointestinal (GI) disorders, including anorexia, emesis, abdominal pain, diarrhea, and others. However, its psychotropic side effects have often limited its use. Several cannabinoid receptors, which include the cannabinoid receptor 1 (CB1), CB2, and possibly GPR55, have been identified throughout the GI tract. These receptors may play a role in the regulation of food intake, nausea and emesis, gastric secretion and gastroprotection, GI motility, ion transport, visceral sensation, intestinal inflammation, and cell proliferation in the gut. However, the regulation of nausea and vomiting by cannabinoids and the endocannabinoid system has shed new knowledge in this field. Thus far, despite evidence of visceral sensitivity inhibition in animal models, data in irritable bowel syndrome (IBS) patients is scarce and not supportive. Furthermore, many compounds that either act directly at the receptor or increase (or reduce) ligand availability have the potential to affect other brain functions and cause side effects. Novel drug targets such as FAAH and monoacylglycerol lipase (MAGL) inhibitors appear to be promising in animal models, but more studies are necessary to prove their efficiency. The promise of emerging drugs that are more selective and peripherally acting suggest that, in the near future, cannabinoids will play a major role in managing an array of GI diseases.

Long-term Outcomes of Bilateral Lateral Rectus Recession Using a Modified Normogram for Targeting Small Overcorrection in Intermittent Exotropia.

PURPOSE: To evaluate the surgical outcomes of a modified normogram for bilateral lateral rectus recession in the surgical management of intermittent exotropia, with a focus on achieving small overcorrection. METHODS: A retrospective medical chart review of 242 patients who underwent surgery for intermittent exotropia between October 2014 and June 2020 was performed. Our modified normogram reducing amount of recession targeted for small postoperative overcorrection within 5 prism diopters (PD). Patients were observed for at least 3 years. Esodeviation was denoted by negative numbers and positive values indicated exodeviation. A satisfactory outcome was defined as if distant angle of deviation ranged between ≤10 PD of exotropia and ≤5 PD of esotropia. Recurrence was defined as an exodeviation of >10 PD at distance. Overcorrection was defined as an esodeviation of >5 PD at distance. RESULTS: The mean preoperative deviation angles were 29.32 ± 3.92 PD at distance and 29.88 ± 4.41 PD at near. At postoperative day 1, the mean deviation angles at distance and near were -6.22 ± 1.44 and -6.22 ± 1.49 PD, respectively. Overcorrection within 6 PD of esodeviation was seen in 168 patients (69.42%), undercorrection with exophoria was noted in 11 patients (4.55%), and overcorrection by more than 6 PD of esodeviation was seen in 63 patients (26.03%) at postoperative day 1. The long-term success rate at postoperative 3 years was 77.27% (187 of 242), with a recurrence rate of 19.83% (48 of 242) and an overcorrection rate of 2.89% (7 of 242). A positive correlation between the angle of deviation at postoperative day 1 and 3 years was observed (r = 0.22, p = 0.001). The final success rate at the final examination after a mean follow-up of 38.60 ± 7.99 months was 83.06%. CONCLUSIONS: Our modified normogram for bilateral lateral rectus recession in intermittent exotropia surgery resulted in successful surgical outcomes with small overcorrection, reducing the risk of consecutive esotropia due to excessive overcorrection.

Rare Metastasis of Esophageal Adenocarcinoma to the Female Reproductive Tract.

Esophageal cancer is common and typically metastasizes to the liver, lung, and lymph nodes. Reproductive tract metastases are extremely rare. In fact, to the best of our knowledge, only 2 cases of esophageal carcinoma metastasizing to the ovaries have been reported. Thus, increased recognition of unusual metastatic sites is necessary to decrease the morbidity and mortality from distant esophageal metastases. We present a case of ovarian and fallopian tube metastases from esophageal adenocarcinoma in a 59-year-old woman.

COVID-19 related biliary injury: A review of recent literature.

Since its emergence in 2019, it has become apparent that coronavirus 2019 (COVID-19) infection can result in multi systemic involvement. In addition to pulmonary symptoms, hepatobiliary involvement has been widely reported. Extent of hepatic involvement ranges from minor elevation in liver function tests (LFTs) to significant hepatocellular or cholestatic injury. In majority of cases, resolution of hepatic injury or improvement in LFTs is noted as patients recover from COVID-19 infection. However, severe biliary tract injury progressing to liver failure has been reported in patients requiring prolonged intensive care unit stay or mechanical ventilation. Due to the timing of its presentation, this form of progressive cholestatic injury has been referred to as COVID-19 cholangiopathy or post-COVID-19 cholangiopathy, and can result in devastating consequences for patients. COVID-19 cholangiopathy is recognized by dramatic elevation in serum alkaline phosphatase and bilirubin and radiologic evidence of bile duct injury. Cholangiopathy in COVID-19 occurs weeks to months after the initial infection and during the recovery phase. Imaging findings and pathology often resemble bile duct injury associated with primary or secondary sclerosing cholangitis. Etiology of COVID-19 cholangiopathy is unclear. Several mechanisms have been proposed, including direct cholangiocyte injury, vascular compromise, and cytokine release syndromes. This review summarizes existing data on COVID-19 cholangiopathy, including reported cases in the literature, proposed pathophysiology, diagnostic testing, and long-term implications.

Evaluation of timed barium esophagram after per-oral endoscopic myotomy to predict clinical response.

Background and study aims The aim of this study was to evaluate whether timed barium esophagram within 24 hours post-per-oral endoscopic myotomy (POEM) (TBE-PP) could predict clinical outcomes. Patients and methods This was a single-center retrospective study of prospectively collected data on consecutive patients with ≥ 6-month follow-up who underwent POEM followed by TBE-PP. Esophageal contrast retention 2 minutes after TBE-PP was assessed as Grade 1 (< 10 %), 2 (10 %-49 %), 3 (50 %-89 %) or 4 (> 90 %). Eckardt score, esophagogastroduodenoscopy (EGD), high-resolution manometry (HRM) and function lumen imaging probe (FLIP) of the esophagogastric junction (EGJ) were obtained at baseline. These tests along with pH testing of antisecretory therapy were repeated 6 and 24 months after POEM. Clinical response by Eckardt score ≤ 3, EGJ-distensibility index (EGJ-DI) > 2.8 mm 2 /mm Hg, and integrated relaxation pressure (IRP) < 15 mm Hg and incidence of gastroesophageal reflux disease (GERD) were compared by transit time. Results Of 181 patients (58 % male, mean 53 ±â€Š17 yr), TBE-PP was classified as Grade 1 in 122 (67.4 %), Grade 2 in 41 (22.7 %), Grade 3 in 14 (7.7 %) and Grade 4 in 4 (2.2 %). At 6 months, overall clinical response by ES (91.7 %), IRP (86.6 %), EGJ-DI (95.7 %) and the diagnosis of GERD (68.6 %) was similar between Grade 1 and Grade 2-4 TBE-PP. At 24 months, Grade 1 had a higher frequency of a normal IRP compared to Grades 2-4 (95.7 % vs. 60 %, P  = 0.021) but overall response by ES (91.2 %), EGJ-DI (92.3 %) and the diagnosis of GERD (74.3 %) were similar. Conclusions Contrast emptying rate by esophagram after POEM has limited utility to predict clinical response or risk of post-procedure GERD.

Inter-relationship between retinal and choroidal vasculatures using optical coherence tomography angiography in normal eyes.

PURPOSE: To quantify vascular and structural macular variables in healthy eyes and to investigate correlations between these variables and age using optical coherence tomography angiography. MATERIALS AND METHODS: A total of 261 eyes of 261 subjects with normal fundus were included. Central macular thickness, ganglion cell layer to inner plexiform layer thickness, outer retina layer thickness, subfoveal choroidal thickness, and choroidal vascularity index were measured using optical coherence tomography. Foveal avascular zone area, vascular density, and flow void area were measured using optical coherence tomography angiography. RESULTS: Vascular density in the superficial capillary plexus was correlated with central macular thickness, ganglion cell layer to inner plexiform layer thickness, and outer retina layer thickness (P < 0.001, P = 0.004, and P < 0.001, respectively). Vascular density in the deep capillary plexus was correlated with central macular thickness and outer retina layer thickness (P = 0.003 and P = 0.001, respectively). Vascular density of choriocapillaris was correlated with vascular density of superficial capillary plexus and deep capillary plexus (P < 0.001 and P = 0.001, respectively). CONCLUSION: Vascular density of choriocapillaris varies with retinal vascular density rather than the structure of choroid using optical coherence tomography angiography. In contrast, retinal vascular density changes as the retinal structure. Our results provide more information about the relationship between retina and choroid.

Clinical Manifestations of Delayed-onset Consecutive Esotropia after Surgical Correction of Intermittent Exotropia.

PURPOSE: To evaluate the clinical features and prognosis of a delayed-onset consecutive esotropia (ET) after surgical correction of intermittent exotropia. METHODS: Thirty-four patients who developed consecutive ET after primary bilateral lateral rectus recession for the surgical correction of intermittent exotropia were evaluated retrospectively and were divided into two groups: delayed-onset consecutive ET group and the continuous consecutive ET group. Patients who developed esodeviation after once recovering to orthotropia within 1 month after the operation were included in the delayed-onset consecutive ET group, and patients with continuous esodeviation after the operation were included in the continuous consecutive ET group. We evaluated preoperative and postoperative angle of deviation, suppression, stereopsis, and follow up periods between the two groups and compared re-operation and success following non-surgical treatment between the continuous consecutive ET group and the delayed-onset consecutive ET group. RESULTS: Among 34 patients with consecutive ET, 27 patients (79.4%) were included in the delayed-onset consecutive ET group, and seven patients (23.3%) were included in the continuous group. Success rate of non-surgical treatment was not statistically significant between two groups (p = 0.55), but it was higher in the delayed-onset group with 37.5%, and 25% of patients in continuous group were successfully recovered to straight alignment. Duration of orthotropia in delayed-onset group was 7.4 ± 6.0 months (range, 2-29 months). Age, sex, preoperative refractive error, preoperative exodeviation, suppression, and near steroacuity were not statistically significant between two groups (p > 0.05, all). In the delayed-onset group, three patients (11.1%) underwent re-operation, while three patients (42.9%) in continuous consecutive ET group underwent re-operation (p = 0.048). CONCLUSIONS: Re-operation rate of delayed-onset consecutive ET after surgical correction of intermittent exotropia was lower than that of continuous consecutive ET.