Low delayed bleeding and high complete closure rate of mucosal defects with the novel through-the-scope dual-action tissue clip after endoscopic resection of large nonpedunculated colorectal lesions (with video).

BACKGROUND AND AIMS: Complete closure after endoscopic resection of large nonpedunculated colorectal lesions (LNPCLs) can reduce delayed bleeding but is challenging with conventional through-the-scope (TTS) clips alone. The novel dual-action tissue (DAT) clip has clip arms that open and close independently of each other, facilitating tissue approximation. We aimed to evaluate the rate of complete closure and delayed bleeding with the DAT clip after endoscopic resection of LNPCLs. METHODS: This was a multicenter prospective cohort study of all patients who underwent defect closure with the DAT clip after EMR or endoscopic submucosal dissection (ESD) of LNPCLs ≥20 mm from July 2022 to May 2023. Delayed bleeding was defined as a bleeding event requiring hospitalization, blood transfusion, or any intervention within 30 days after the procedure. Complete closure was defined as apposition of mucosal defect margins without visible submucosal areas <3 mm along the closure line. RESULTS: One hundred seven patients (median age, 64 years; 42.5% women) underwent EMR (n = 63) or ESD (n = 44) of LNPCLs (median size, 40 mm; 74.8% right-sided colon) followed by defect closure. Complete closure was achieved in 96.3% (n = 103) with a mean of 1.4 ± .6 DAT clips and 2.9 ± 1.8 TTS clips. Delayed bleeding occurred in 1 patient (.9%) without requiring additional interventions. CONCLUSIONS: The use of the DAT clip in conjunction with TTS clips achieved high complete defect closure after endoscopic resection of large LNPCLs and was associated with a .9% delayed bleeding rate. Future comparative trials and formal cost-analyses are needed to validate these findings. (Clinical trial registration number: NCT05852457.).

Predictors of 30-day re-admissions in patients with infective endocarditis: a national population based cohort study.

Infective endocarditis (IE) is a life threatening disease requiring lengthy hospitalizations, complex multidisciplinary management and high health care costs. In this study, we analyzed the National Readmissions' Database (NRD) to identify infective endocarditis cases and the causative organisms, clinical determinants, length of stay, in-hospital mortality, and 30-day hospital readmission rates. The study cohort was derived from Healthcare Cost and Utilization Project's National Readmission Database between 2010-15. We queried the National Readmissions' Database using the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) diagnostic code for infective endocarditis (421.0) and identified a total of 187,438 index admissions. SAS 9.4 (SAS Institute Inc., Cary, NC) was utilized for statistical analyses. A total of 187,438 patients with a primary diagnosis of IE were identified over 6 years (2010-2015). Twenty-four percent (44,151 patients) were readmitted within 30 days. Most common etiologies for readmission included sepsis (14%), acute heart failure (8%), acute kidney injury (6%), intracardiac device infection (5.6%) and recurrence of IE (2.7%). Predictors of increased readmissions included female sex, staphylococcus aureus infection, diabetes, chronic lung disease, chronic liver disease, acute kidney injury, acute heart failure and anemia. In-hospital mortality for the readmission of IE was 13%, and average length of stay during the re-admission was 12 days. IE is associated with high rates of index admission mortality and for 30-day readmissions of which are associated with a substantial risk of death.

Anticoagulation for intra-cardiac thrombi in peripartum cardiomyopathy: A review of the literature.

Peripartum cardiomyopathy is a type of non-ischemic cardiomyopathy with a high rate of thromboembolic events. Guiding strategies for anticoagulation in patients with peripartum cardiomyopathy and thromboembolic events are limited. Literature for all cases of peripartum cardiomyopathy with intracardiac thrombi were reviewed and summarized from twelve case reports. Based on the available literature, we conclude that patients with peripartum cardiomyopathy with ejection fraction of less than 30% should strongly consider anticoagulation therapy to avoid thromboembolic events. Future studies may be able to further elucidate the optimal indication and duration of anticoagulation.

Efficacy and Safety of Flexible Endoscopic Management of Zenker's Diverticulum.

Zenker's diverticulum (ZD), a pulsion diverticulum of hypopharynx is a rare but treatable cause of morbidity in geriatric population. Traditionally a surgical disease but due to its associated high morbidity, flexible endoscopy has become a lucrative option. We reviewed 997 patients from 23 original studies who underwent flexible endoscopic diverticulotomy (FED) of ZD. Composite technical and clinical success rate for the study cohort was 99.4% and 87.9%, respectively. Composite failure rate was 10.0% but close to half of them (45.3%) had success with repeat endoscopic intervention. Composite rate for symptom recurrence after long-term follow-up was 13.6% but more than half (61.8%) had success with repeat endoscopic intervention. Bleeding (6.6%) and perforation (5.3%) were 2 most common complications of FED. All bleeding events were successfully managed with observation or endoscopic therapy. Majority of perforation events (4.4%) were successfully managed with conservative care and only 0.9% required invasive management. No mortality was reported. Efficacy and safety of FED of ZD remained same irrespective of diverticulum size or prior surgical/endoscopic treatment. FED with diverticuloscope (FEDD) and FED with cap (FEDC) had comparable technical success rate (99.6% vs. 100.0%) but FEDD had higher clinical success rate compared with FEDC (86.8% vs. 75.4%). FEDD had twice the risk of symptom recurrence than FEDC (16.5% vs. 9.5%). FEDD had a comparable bleeding risk to FEDC (3.3% vs. 4.0%) but a much lower perforation rate (2.3% vs. 10.3%). Upper esophageal sphincterotomy and adequate length of septotomy are the cornerstones of FED. FED can be considered a safe and efficacious treatment modality for patients with ZD.

Endoscopic Ultrasound Guided Choledocho-Enterostomy by Using Lumen Apposing Metal Stent in Patients with Failed Endoscopic Retrograde Cholangiopancreatography: A Literature Review.

BACKGROUND: Endoscopic retrograde cholangiopancreatography (ERCP) has been the cornerstone in the management of malignant jaundice to provide symptomatic relief and/or to allow chemotherapy. Difficult biliary cannulation or the presence of concomitant duodenal obstruction may lead to its failure. METHOD: An extensive English literature search was done via PubMed and Google Scholar to identify 13 peer-reviewed original articles. RESULTS: Of 92 patients, 98.9% (91/92) successfully underwent EUS-guided biliary drainage by placement of a lumen-apposing metal stent (LAMS) across extrahepatic biliary tree and small bowel. Although technically challenging, a similar technical success was noted for patients with limited dilation of extrahepatic biliary tree (less than 1 cm) and altered gastrointestinal anatomy (Roux-en-Y, Whipple, or Billroth II). Of 91 patients, 98.9% (90/91) had clinical success. Procedure complications included perforation (2/92; 2.2%) and bleeding (1/92; 1.1%). Stent complications included obstruction (7/91; 7.7%), and migration (1/91; 1.1%) with all responding to endoscopic debridement of food or tumor, placement of plastic pigtail stent through the LAMS, or replacement with a new stent. No procedure-related mortality was noted. CONCLUSION: In the hands of an expert, EUS-guided biliary drainage with the use of LAMS is an efficacious and safe option for patients with distal malignant biliary stricture, not amenable to ERCP.

Utility of Dobutamine Stress Echocardiography in Cardiac Risk Stratification of Patients Undergoing Orthotopic Liver Transplantation.

Cardiovascular diseases are a major cause of morbidity and mortality in patients after orthotopic liver transplantation (OLT). This review includes major original articles published in the English-language literature of patients who underwent dobutamine stress echocardiography (DSE) before OLT for cardiac risk stratification. Of a total of 10 original articles (total 1699 patients undergoing DSE), 6 studies used DSE to predict major adverse cardiac events (MACE) in patients undergoing OLT and 4 reported the role of DSE in coronary artery disease (CAD) prediction in patients with end-stage liver disease. The composite incidence of MACE was 11.4%. In predicting postoperative MACE, DSE had a composite sensitivity of 0.12 (95% CI, 0.07-0.19), a specificity of 0.96 (95% CI, 0.94-0.97), a positive predictive value (PPV) of 0.26 (95% CI, 0.16-0.38), and a negative predictive value (NPV) of 0.89 (95% CI, 0.88-0.91). The presence of known CAD in a patient was shown to increase the risk of cardiac events after OLT significantly in three of six studies. The average prevalence of CAD was 14.4%. In predicting CAD, DSE had a composite sensitivity of 0.47 (95% CI, 0.32-0.62), specificity of 0.74 (95% CI, 0.68- 0.79), PPV of 0.23 (95% CI, 0.15-0.33), and NPV of 0.89 (95% CI, 0.84-0.93). This review emphasizes the need for standardizing cardiac risk stratification protocol to screen and prevent cardiac morbidity after OLT, standardizing MACE definition to allow more uniform reporting, and the need for safer and efficacious alternatives to DSE in the evaluation of OLT candidates.

Biodegradable Stents: An Evolution in Management of Benign Intestinal Strictures.

Benign intestine strictures secondary to postoperative narrowing or inflammatory bowel disease can be managed surgically or conservatively. Some patients may not be suitable surgical candidates and some patients may choose not to have repeat surgery. Biodegradable (BD) stents offer a prolonged dilatory effect before gradual degradation and obviates the need of a second procedure for stent removal. BD stents have high technical success rates (mean, 94.4%; median, 100%; range, 86% to 100%) but widely variable clinical success rates (range, 45% to 100%). Stent migration is the most commonly reported complication (mean, 22.2%; range, 0% to 36%). In the future, with better understanding of the factors contributing to stent migration, improvement in present stent design and better anchoring techniques, the stent migration rate is expected to decrease and improve clinical outcome. The role of prophylactic BD stent placement to prevent stricture development postintestine surgery is an intriguing idea and needs to be explored. As of now, the use of BD stents is a reasonable option for patients with dilatation resistant intestinal strictures who are unfit for surgery or refuse to have surgical treatment.

New Developments in Mechanical Enhancement of Colonoscopy: Cuffs, Caps and Rings.

BACKGROUND: Colorectal cancer (CRC) is a common cause of cancer-related deaths. Early detection of precursor lesions in the adenoma-carcinoma sequence via colonoscopy can decrease mortality from CRC. SUMMARY: In this review article, we have summarized retrospective studies, prospective single center, multicenter studies and randomized controlled trials describing the efficacy of endocuff colonoscopy (EC), cap-assisted colonoscopy (CAC) and endorings colonoscopy (ERC). Indications, techniques, outcomes, limitations and complications reported are discussed. KEY MESSAGE: Use of colonoscope with cap, cuff or rings attached to its distal tip has been shown to increase the polyp detection rate and adenoma detection rate, predominantly for the small polyps (<1 cm) and proximal colon location. Evidence is uniform for EC and ERC but not for CAC. Benefits of shorter cecum intubation time, improved cecum intubation rates and decreased pain scores during colonoscopy done with assistance of cuff or cap has potential to decrease the number of incomplete colonoscopy and increase overall patient satisfaction, thus improving follow-up. In the absence of any additional adverse events, EC, CAC and ERC have potential to enhance the benefits of colonoscopy.

Endoscopic Bypass Using Endobarrier Devices: Efficacy in Treating Obesity and Metabolic Syndrome.

Obesity is a rapidly growing pandemic. Scope of pharmacotherapy and bariatric surgery in managing obesity is ever rising. The role of minimally invasive techniques to achieve preoperative weight loss and improve postbariatric surgery outcomes is an area of new interest. The initial experience with endobarrier devices in achieving weight loss among obese subjects has shown promising results. In addition, the impact of these interventions on comorbidities commonly associated with obesity like diabetes mellitus type 2 and hyperlipidemia has further expanded their potential for use in future. In this review article, we have summarized case report, prospective single and multicenter studies, and randomized-controlled trials describing the use of endobarrier devices. Indications, techniques, outcomes, limitations, and complications reported are discussed.

Quantification of interstitial cells of Cajal and fibrosis during gastric per-oral endoscopic myotomy and its association with clinical outcomes.

Background and study aims Alterations to interstitial cells of Cajal (ICC) and collagen fibrosis have been implicated in the pathogenesis of gastroparesis. We aimed to evaluate the feasibility and safety of pyloric muscle sampling during gastric peroral endoscopic myotomy (G-POEM) and the association between pyloric ICC density and degree of fibrosis with clinical outcomes. Patients and methods This was a single-center prospective study of gastroparetic patients who underwent G-POEM and intraprocedural pyloric muscle biopsies between January 2022 and April 2023. ICC count was estimated using CD117 stain and trichome for collagen fibrosis. Clinical response to G-POEM was defined as an improvement of ≥ 1 point on the Gastroparesis Cardinal Symptom Index. Results Fifty-six patients (median age 60 years, 71.4% women) underwent G-POEM (100% technical success; 71.4% clinical response). ICC depletion (< 10/high-power field) and fibrosis were encountered in 70.4% and 75% of the cases, respectively. There was no difference in mean ICC count between G-POEM responders vs. non-responders (7±3.6 vs. 7.7±3.3; P = 0.9). There was no association between ICC density or degree of fibrosis with the etiology of gastroparesis, duration of symptoms, gastric emptying rate, or pyloric impedance planimetry. Patients who did not respond to G-POEM had a significantly higher degree of moderate/severe fibrosis when compared with those who responded (81.3% vs. 25%; P = 0.0002). Conclusions Pyloric muscle biopsies during G-POEM was feasible and safe. ICC depletion and pyloric muscle fibrosis are common in gastroparetic patients. The degree of fibrosis may be related to pyloric dysfunction and clinical response to G-POEM. Additional studies are needed to confirm these results.

Double-balloon enteroscopy with EUS-guided rendezvous for failed cannulation in patients with history of Roux-en-Y gastric bypass.

Video 1Double-balloon enteroscopy with EUS-guided rendezvous for biliary access in patients with a history of Roux-n-Y gastric bypass.

Ultrasound Assisted Endoscopic Gastric Bypass (USA-EGB): a potential endoscopic alternative to surgical bypass, a pre-clinical proof of concept study.

Background and study aims Endoscopic weight loss procedures have gained traction as minimally invasive options for the primary treatment of obesity. Thus far, we have developed endoscopic procedures that reliably address gastric restriction but result in significantly less weight loss than surgical gastrointestinal bypass. The goal of this nonsurvival study was to assess the technical feasibility of an endoscopic procedure, that incorporates both gastric restriction and potentially reversible gastrointestinal bypass. Methods Ultrasound-assisted endoscopic gastric bypass (USA-EGB) was performed in three consecutive live swine, followed by euthanasia and necropsy. Procedure steps were: 1) balloon-assisted enteroscopy that determines the length of the bypassed limb; 2) endoscopic ultrasound-guided gastroenterostomy that creates a gastrointestinal anastomosis using a lumen apposing metal stent; 3) endoscopic pyloric exclusion that disrupts transpyloric continuity resulting in complete gastrointestinal bypass; and 4) gastric restriction that reduces gastric volume. Results Complete gastrointestinal bypass and gastric restriction was achieved in all three swine. The mean total procedure time was 131 minutes (range 113-143), mean length of the bypassed limb was 92.5 cm and 180 cm, using short and long overtubes, respectively. There were no significant complications. Conclusions We successfully described USA-EGB in three consecutive live swine. Further studies are needed to access the procedures safety, efficacy, and clinical use.

Stepwise Algorithmic Approach to Endoscopic Removal of Biliary Partially Covered and Uncovered Self-Expanding Metal Stents.

Self-expanding metal stents play a crucial role in the management of patients with biliary obstruction. Endoscopic extraction of uncovered metal stents (UCMSs) and partially covered metal stents (PCMSs) could be challenging because of tissue ingrowth. No standardized technique can guarantee universal success. We present our technique and experience of endoscopic extraction of biliary stents in two patients with a UCMS and three patients with a PCMS. Three of the five patients had a previous failed attempt of stent extraction at an outside hospital. Overall, our composite success rate was 80% (4/5). The individual success rate was 100% (3/3) for PCMSs and 50% (1/2) for UCMSs. The stent-in-stent technique, in which a fully covered metal stent is placed through an existing UCMS/PCMS, was used in 60% (3/5) of the cases, with a success rate of 66.7% (2/3). We share our algorithmic approach to each case, with detailed emphasis on the technical aspects of the procedure.

Concomitant Sarcina-Associated Erosive Esophagitis and Refractory Helicobacter pylori Gastritis.

For unclear reasons, there has been an increasing number of reported cases of Sarcina infections in the gastrointestinal tract over the past several years. Associated clinical conditions with the infection most commonly include delayed gastric emptying from diabetes mellitus, a history of previous gastrointestinal surgery, and ulcer disease. The precise pathogenetic role of Sarcina infection in humans remains unclear. Because of the ubiquitous environmental presence of Sarcina and limited previously reported clinical cases, the link between symptoms along with endoscopic findings to Sarcina can be associative at best. When found in the upper GI tract, the decision to treat along with the chosen regimen remains debatable. Sarcina, however, has rarely been seen in the esophagus. We report the third case of Sarcina of the esophagus associated with Helicobacter pylori gastritis.

Atraumatic Splenic Hemorrhage as a Rare Complication of Pancreatitis: Case Report and Literature Review.

Splenic hemorrhage (hematoma and rupture) is a rare complication of pancreatitis. In this article, we present a rare case of spontaneous splenic rupture as a complication of acute pancreatitis. A literature review was also completed to describe the patient characteristics, associated pancreatitis etiology, clinical presentations, risk factors, diagnostic and treatment modalities, and outcomes.

Colon mucosal neoplasia referred for endoscopic mucosal resection: Recurrence of adenomas and prediction of submucosal invasion.

BACKGROUND: Endoscopic mucosal resection (EMR) is an effective and minimally invasive alternative to surgery for large polyps and laterally spreading lesions. Gross morphology and surface characteristics may help predict submucosal invasion of the lesion (SMIL) during endoscopic evaluation. This is one of the largest single-center studies reporting endoscopic mucosal resection for larger (≥ 20 mm) colorectal lesions in the United States. AIM: To determine the recurrence rate of adenomas and endoscopic features that may predict submucosal invasion of colonic mucosal neoplasia. METHODS: This is a retrospective cohort study of all the patients referred for endoscopic mucosal resection for lesions ≥ 20 mm, spanning a period from January 2013 to February 2017. The main outcome measure was identifying features that may predict submucosal invasion of mucosal lesions and predict recurrence of adenomas on follow-up surveillance colonoscopy performed at 4-6 mo. RESULTS: A total of 480 patients with 500 lesions were included in the study. The median age was 68 (Inter quantile range: 14) with 52% males. The most common lesion location was ascending colon (161; 32%). Paris classification 0-IIa (Flat elevation of mucosa - 316; 63.2%); Kudo Pit Pattern IIIs (192; 38%) and Granular surface morphology (260; 52%) were most prevalent. Submucosal invasion was present in 23 (4.6%) out of 500 lesions. The independent risk factors for SMIL were Kudo Pit Pattern IIIL + IV and V (Odds ratio: 4.5; P value < 0.004) and Paris classification 0-IIc (Odds ratio: 18.2; P value < 0.01). Out of 500, 354 post-endoscopic mucosal resection scars were examined at surveillance colonoscopy. Recurrence was noted in 21.8% (77 cases). CONCLUSION: There was overall low prevalence of SMIL in our study. Kudo pit pattern (IIIL + IV and V) and Paris classification 0-IIc were the only factors identified as an independent risk factor for submucosal invasion. The independent risk factor for recurrence was adenoma size (> 40 mm). Almost all recurrences (98.8%) were treated endoscopically.

The Right to Write: Who 'Owns' the Case Report?

In this Letter to the Editor, Agrawal et al. debate the conflicts that can arise regarding the authorship of case reports. Like all other medical journals, EJCRIM has zero tolerance for the willful undisclosed re-submission of papers that have already been published elsewhere. However, this may occasionally happen by accident, especially in large healthcare institutions in which multiple teams of physicians may care for a patient throughout their illness. EJCRIM endorses and recommends to all potential authors the very sensible suggestions made by Agrawal et al. to avoid such an error occurring. EJCRIM would also encourage authors to consider the following: The first author should ensure that no one else involved in the case has reported it or plans to report it. This is especially important for physicians working in large healthcare centres, and/or for case reports of patients who have been under investigation or treatment for prolonged periods.On rare occasions EJCRIM will consider a case that has already been published, provided that this is fully and explicitly disclosed, and there is a clear reason why re-publication is justified. An example might be where new information has come to light that significantly changes the conclusions of the original report. As in all reports published by EJCRIM the decision to publish will depend on the educational value, or learning points, of the case.

Impact of Video Aid on Quality of Bowel Preparation Among Patients Undergoing Outpatient Screening Colonoscopy.

AIM: To investigate the effect of video aid on quality of bowel preparation. STUDY: A retrospective study was done on patients undergoing outpatient screening colonoscopy. All subjects received educational video prior to colonoscopy in addition to the standard counseling. Patient charts were reviewed to collect data regarding quality of bowel preparation (adequate or inadequate). The study population was stratified into four groups according to viewing status: Group I 0% (control group), Group II <50%, Group III >50% to <75%, and Group IV watched ⩾75% of the video. RESULTS: A total of 338 patients with an average age of 59.1 years and 60.3% females were included in the final study cohort. Of the patients in Groups I, II, III, and IV, 94.3%, 90.9%, 100%, and 91.7%, respectively, had adequate preparation (P value = .827). Adenoma detection rate (ADR) for Groups I, II, III, and IV was 28.8%, 50%, 50%, and 22.6%, respectively (P value = .305). The mean cecal intubation time was 20.7, 16.4, 16.57, and 17 minutes for Groups I, II, III, and IV, respectively (P value = .041). CONCLUSIONS: Video aid use for patients undergoing screening colonoscopy lacked a statistically significant impact on the quality of bowel preparation, ADR, and advanced adenoma detection rate when compared with standard practice.