Efficacy, Feasibility, and Safety of the X-Tack Endoscopic HeliX Tacking System: A Multicenter Experience.

BACKGROUND AND AIMS: The application of endoscopic suturing has revolutionized defect closures. Conventional over-the-scope suturing necessitates removal of the scope, placement of the device, and reinsertion. A single channel, single sequence, through-the-scope suturing device has been developed to improve this process. This study aims to describe the efficacy, feasibility, and safety of a through-the-scope suturing device for gastrointestinal defect closure. METHODS: This was a retrospective multicenter study involving 9 centers of consecutive adult patients who underwent suturing using the X-Tack Endoscopic HeliX Tacking System (Apollo Endosurgery). The primary outcomes were technical success and long-term clinical success. Secondary outcomes included adverse events, recurrence, and reintervention rates. RESULTS: In all, 56 patients (mean age 53.8, 33 women) were included. Suturing indications included fistula repair (n=22), leak repair (n=7), polypectomy defect closure (n=12), peroral endoscopic myotomy (POEM) site closure (n=7), perforation repair (n=6), and ulcers (n=2). Patients were followed at a mean duration of 74 days. Overall technical and long-term clinical success rates were 92.9% and 75%, respectively. Both technical and clinical success rates were 100% for polypectomies, POEM-site closures, and ulcers. Success rates were lower for the repair of fistulas (95.5% technical, 54.5% clinical), leaks (57.1%, 28.6%), and perforations (100%, 66.7%). No immediate adverse events were noted. CONCLUSION: This novel, through-the-scope endoscopic suturing system, is a safe and feasible method to repair defects that are ≤3 cm. The efficacy of this device may be better suited for superficial defects as opposed to full-thickness defects. Larger defects will need more sutures and probably a double closure technique to provide a reinforcement layer.

Outcomes of Radiofrequency Ablation Compared to Liquid Nitrogen Spray Cryotherapy for the Eradication of Dysplasia in Barrett's Esophagus.

INTRODUCTION: Current guidelines recommend endoscopic eradication therapy (EET) for Barrett's esophagus (BE) with dysplasia and intramucosal adenocarcinoma using either radiofrequency ablation (RFA) or liquid nitrogen spray cryotherapy (LNSC). The aims of this multicenter study are to compare the rate and number of treatment sessions of RFA vs. LNSC to achieve CE-D and CE-IM and assess outcomes for those who switched therapy. METHODS: This is a retrospective cohort study of patients with BE undergoing EET. Demographics, baseline variables, endoscopy details, and histology information were abstracted. RESULTS: One hundred and sixty-two patients were included in this study with 100 patients in the RFA group and 62 patients in the LNSC group. The rate of CE-D and CE-IM did not differ between the RFA group and LNSC group (81% vs. 71.0%, p = 0.14) and (64% vs. 66%, p = 0.78), respectively. The number of sessions to achieve CE-D and CE-IM was higher with LNSC compared to RFA (4.2 vs. 3.2, p = 0.05) and (4.8 vs. 3.5, p = 0.04), respectively. The likelihood of developing recurrent dysplasia was higher among patients who did not achieve CE-IM (12%) compared to those who did achieve CE-IM (4%), p = 0.04. Similar findings were found in those who switched treatment modalities. DISCUSSION: EET is highly effective in eradication of Barrett's associated dysplasia and neoplasia. Both RFA and LNSC achieved similar rates of CE-D and CE-IM although LNSC required more sessions. Also, achievement of CE-IM was associated with less recurrence rates of dysplasia.

Liquid Nitrogen Spray Cryotherapy is Associated With Less Postprocedural Pain Than Radiofrequency Ablation in Barrett's Esophagus: A Multicenter Prospective Study.

GOALS AND BACKGROUND: Two common endoscopic therapies for eradication of dysplastic Barrett's esophagus are radiofrequency ablation (RFA) and liquid nitrogen spray cryotherapy (LNC). There is no data comparing postprocedural pain. This study aimed to compare the incidence of postprocedural pain between the 2 ablation modalities. METHODS: This is a multicenter prospective study in which pain intensity scores and the presence of dysphagia were assessed immediately before and after treatment, 48 hours posttreatment and at 3 weeks posttreatment using validated instruments. RESULTS: Of 94 patients, 35 underwent LNC and 59 underwent RFA [36 with focal radiofrequency ablation (RFA-F) and 23 with circumferential radiofrequency ablation (RFA-C)]. Immediately posttreatment, patients in the LNC group reported an average Numeric Pain Scale score that was lower than in the RFA groups [LNC 0.41 vs. RFA-F 1.18 (P=0.026), LNC 0.41 vs. RFA-C 1.38 (P=0.010)]. These differences persisted at 48 hours posttreatment [LNC 0.76 vs. RFA-F 1.77 (P=0.013), LNC 0.76 vs. RFA-C 1.73 (P=0.018)]. The odds of pain after RFA were at least 5 times greater than after LNC [immediately posttreatment odds ratio, 5.26 (95% confidence interval, 1.85-14.29) and 48 h posttreatment odds ratio, 5.56 (95% confidence interval, 2.27-14.29)]. There was no difference in dysphagia after treatment in either group, at any time point (P=0.429). CONCLUSION: LNC was associated with less postprocedural pain when compared with RFA. These results help inform patients and physicians about the expected symptoms after ablative endotherapy.

Endoscopic Cyanoacrylate Injection with Post-injection Audible Doppler Assessment of Gastric Varices: A Single-Institution Experience.

BACKGROUND AND AIMS: Gastric varices (GV) have higher rates of morbidity and mortality from hemorrhage than esophageal varices. Several studies have shown the safety and efficacy of cyanoacrylate (CA) injection for acute gastric variceal hemorrhage. We report data from our experience with CA injection for GV before and after routine use of post-injection audible Doppler assessment (ADA) for GV obturation and describe long-term outcomes after this therapy. METHODS: We retrospectively identified patients who had documented GV, underwent CA injection, and had at least 2 weeks of follow-up. We recorded and analyzed the survival and rebleeding rates with patient demographics, clinical data, and endoscopy findings between two groups of patients who were categorized by CA injection prior to and after inception of the ADA technique. RESULTS: Seventy-one patients were identified with 16 patients analyzed in a group where ADA was not used (Pre-ADA) and 55 analyzed where ADA was used (Post-ADA). No rebleeding events were observed within 1 week of initial CA injection. No embolic events were reported after any initial CA injection within 4 weeks. The rate of bleed-free survival at 1 year was 69.6% in the Pre-ADA group and 85.8% in the Post-ADA without statistical significance. The all-cause 1-year mortality was 13.8% in the Pre-ADA group and 10.7% in the Post-ADA group without statistical significance. CONCLUSIONS: ADA of CA-injected GV does not appear to significantly affect adverse events or clinical outcomes; however, our findings are limited by small sample size and cohort proportions allowing for significant type II statistical error. Further prospective investigation is required to determine the impact of ADA on clinical outcomes after GV obturation.

Azithromycin versus erythromycin infusions prior to endoscopy in upper gastrointestinal bleeding.

Background: Intravenous erythromycin prior to endoscopy for upper gastrointestinal bleeding (GIB) improves outcomes but requires immediate preparation delaying administration in emergency cases. Azithromycin is readily available and does not require prolonged preparation. The aim of the study was to assess the effect of azithromycin in improving the quality of endoscopic visualization in upper GIB compared to erythromycin. Methods: Patients admitted with upper GIB who received erythromycin or azithromycin before urgent endoscopy were included. Primary outcome of the quality of visualization was assessed by two gastroenterologists, blinded to the choice of infusion, using a scoring system ranging from 0 to 8, with a maximum of 2 points assigned to the fundus, body, antrum and bulb. Results: Sixty-six patients were included; 25 received azithromycin and 41 received erythromycin. Mean total visualization score was significantly higher with azithromycin compared to that with erythromycin (6.8±1.4 vs. 5.5±2.2, respectively; P=0.01) and remained significant after adjusting for confounders (Diff: 0.01, 1.88; P=0.05). Secondary outcomes analyses showed a shorter LOS when given azithromycin compared to erythromycin [6 (3 to 9) vs. 8 (7 to 16) days, respectively, 95% CI: 1.03, 3.89; P=0.04]. Time between initiating the infusion and endoscopy was longer with azithromycin (Diff: 40.64 min; 95% CI: 7.23, 74.05; P=0.02). Need for second look endoscopy, procedure time, blood transfusion requirements and procedure-related complications did not differ between the groups. Conclusions: Azithromycin infusion before endoscopy for upper GIB was associated with better visualization than that of erythromycin. Randomized trials are needed to validate these findings.

Liquid nitrogen spray cryotherapy for intramucosal carcinoma and extensive gastric intestinal metaplasia with dysplasia.

BACKGROUND AND AIMS: Gastric intestinal metaplasia with dysplasia (GIM-D) that is visible as a discrete limited lesion on endoscopy is readily treated using endoscopic mucosal resection or endoscopic submucosal dissection. However, there are few options for more extensive and invisible dysplasia. Ablating a wide swath of tissue with argon plasma coagulation or radiofrequency ablation can be challenging and carries risks, including postprocedure ulceration. Liquid nitrogen spray cryotherapy is an established treatment for dysplasia in Barrett's esophagus, but its use for GIM-D has not been previously reported. METHODS: Three patients with intramucosal adenocarcinoma and GIM-D underwent a total of 10 sessions of spray cryotherapy. In all cases, spray cryotherapy was performed after passing an orogastric decompression tube into the stomach for active suctioning. Ablations were performed in cycles of 20 to 40 seconds, with at least 45 seconds between cycles to allow for tissue thawing. Between 2 and 7 ablations were performed during each procedure. Before each procedure, Sydney protocol biopsy specimens were obtained. No patient reported any postprocedure adverse events. RESULTS: The first patient underwent 3 sessions of spray cryotherapy; there was no evidence of GIM-D after 1 session, no evidence of gastric intestinal metaplasia after 3 sessions, and no recurrence after 29 months. The second patient underwent 5 sessions of spray cryotherapy; after 1 session there was no adenocarcinoma, and at 14 months there was only GIM-D. The third patient underwent 2 spray cryotherapy sessions, and after 1 session there was gastric intestinal metaplasia but no GIM-D. CONCLUSIONS: Very few treatment modalities exist for extensive GIM-D. We present 3 cases in which off-label spray cryotherapy was used to treat extensive high-grade dysplasia with good treatment effect and patient tolerance. This adds to the body of literature supporting spray cryotherapy as a safe, well-tolerated, and effective treatment for extensive GIM-D.

Co-existing inflammatory bowel disease and Barrett's esophagus is associated with esophageal dysplasia: a propensity score-matched cohort.

Background and study aims Barrett's esophagus (BE) and inflammatory bowel disease (IBD) predispose to the development of dysplasia and cancer. It is unclear if the inflammatory cascade seen in IBD affects disease progression in BE. We aimed to determine if patients with BE who have co-existing IBD had a higher risk of dysplasia, nodular disease, or longer segments than BE patients without IBD. Patients and methods This was a multicenter, retrospective propensity score-matched cohort study. We compared rates of dysplasia, nodular disease, and segment length in patients with BE and IBD (cases) to patients with BE who did not have IBD (controls). Controls were 1:1 propensity score matched with controls for age, sex, body mass index (BMI), smoking, and hiatal hernia. Results A total of 132 patients were included in the IBD + BE group and 132 patients in the BE group. Patients with IBD + BE had higher rates of esophageal dysplasia compared to controls (15.9 % vs. 6.1 % [adjusted odds ratio [OR]: 2.9, 95 % CI: 1.2-6.9]) and more nodules (9.8 % vs. 3.0 % [adjusted OR: 3.5, 95 % CI: 1.1-11.0]). IBD + BE group was also associated with longer BE segments (43.9 % vs. 12.1 % [OR: 5.7, 95 % CI: 3.0-10.6]). Conclusions Co-existing IBD may increase the risk of dysplasia and esophageal nodules in patients with BE. Our findings may have implications for BE surveillance intervals in IBD patients. Prospective studies are needed to confirm our findings.

Prospective evaluation of quality of life in patients with Zollinger-Ellison syndrome.

BACKGROUND: Zollinger-Ellison syndrome (ZES) is associated with complicated ulcer disease of the upper gastrointestinal tract. While management of ZES has dramatically improved with proton pump inhibitor therapy, quality of life in medically treated patients has not been evaluated. METHODS: Over a 3-year period, 52 patients with ZES were prospectively evaluated at 6-month intervals with upper endoscopy and gastric acid analysis to evaluate the efficacy of current drug therapy and completion of SF36v2 forms. At each 6-month visit, patients' medication and problem lists were reviewed, comorbidities assessed, and any gastrointestinal symptoms recorded. Co-morbidity was represented as a simple illness count for the main analysis. The chronic disease score and the Charlson index were used for sensitivity analyses. RESULTS: The unadjusted norm-based estimate of mental component score (MCS) for 52 patients with ZES (mean age 58, 65% male) was 49.8 (95% CI 46.4, 53.1). The unadjusted estimate of the physical component score (PCS) was 42.3 (95% CI 38.9, 45.7). As the number of illnesses or number of medications increased, there was a monotonic decrease in PCS scores. With multivariable adjustment, the coefficient for number of medications became non-significant. An increase in each of the co-morbidity indexes was associated with a decrease in PCS. Results did not vary by representation of co-morbidity. MCS was not significantly different from the general population. CONCLUSIONS: Patients with medically managed ZES have norm-based estimates of the mental component scores as measured by the SF-36v2 that approximate normal values, while the physical component scores were decreased with this reduction largely explained by co-morbid illness.

Deglutition Syncope Treated With Peroral Endoscopic Myotomy.

Deglutition syncope is a rare, neurally mediated reflex syncope associated with swallowing. It is typically associated with pharyngoesophageal disorders with secondary abnormal vagal reflex causing atrioventricular cardiac block and cerebral hypoperfusion. Diagnosis can be delayed and challenging. Various treatment options have been reported, including withholding cardiac blocker agents, diet modifications, and pacemaker placement. We present a case of persistent deglutition syncope secondary to esophagogastric junction outflow obstruction that failed medical therapy and was managed successfully with peroral endoscopic myotomy with excellent long-term outcome.

Full-thickness resection device (FTRD) for treatment of upper gastrointestinal tract lesions: the first international experience.

Background and study aims The Full-Thickness Resection Device (FTRD) provides a novel treatment option for lesions not amenable to conventional endoscopic resection techniques. There are limited data on the efficacy and safety of FTRD for resection of upper gastrointestinal tract (GIT) lesions. Patients and methods This was an international multicenter retrospective study, including patients who had an endoscopic resection of an upper GIT lesion using the FTRD between January 2017 and February 2019. Results Fifty-six patients from 13 centers were included. The most common lesions were mesenchymal neoplasms (n = 23, 41 %), adenomas (n = 7, 13 %), and hamartomas (n = 6, 11 %). Eighty-four percent of lesions were located in the stomach, and 14 % in the duodenum. The average size of lesions was 14 mm (range 3 to 33 mm). Deployment of the FTRD was technically successful in 93 % of patients (n = 52) leading to complete and partial resection in 43 (77 %) and 9 (16 %) patients, respectively. Overall, the FTRD led to negative histological margins (R0 resection) in 38 (68 %) of patients. A total of 12 (21 %) mild or moderate adverse events (AEs) were reported. Follow-up endoscopy was performed in 31 patients (55 %), on average 88 days after the procedure (IQR 68-138 days). Of these, 30 patients (97 %) did not have any residual or recurrent lesion on endoscopic examination and biopsy, with residual adenoma in one patient (3 %). Conclusions Our results suggest a high technical success rate and an acceptable histologically complete resection rate, with a low risk of AEs and early recurrence for FTRD resection of upper GIT lesions.

Acute pancreatitis secondary to the use of the anabolic steroid trenbolone acetate.

BACKGROUND: The use of performance-enhancing drugs has increased dramatically in the last decade with high prevalence reported among the young athlete population. Many of these drugs contain anabolic steroids and may carry potential significant side effects and health risks. We report a case of anabolic steroid-induced acute pancreatitis (AP) that recurred after the reuse of the same drug by the patient, confirming the causative relationship. CASE REPORT: A 24 year-old male presented with severe epigastric pain. His past medical history was significant for two hospitalizations during the last year with AP. During his hospital admissions, extensive workup was performed ruling out the common and uncommon causes of AP. Upon further pressing, the patient admitted to a history of past and current anabolic steroid use for athletic performance enhancement. He began this use four years ago and most recently started using trenbolone acetate (TA). The correlation between the timing of the anabolic steroids administration and the attacks of AP, along with ruling out other causes, confirmed TA as the cause of pancreatitis. DISCUSSION: The side effects associated with the use of these increasingly prevalent drugs are difficult to study in clinical trials due to the unethical nature of their consumption. In addition, these medications are difficult to study due to the varied usage cycles and patterns, unknown origin and source, as well as often high dose ingestion. Physicians and body builders need to be aware of the possible serious consequences of their use.

Spontaneous transmural perforation in eosinophilic esophagitis: RARE case presentation and role of esophageal stenting.

Eosinophilic esophagitis (EoE) is a rare disease of the esophagus that is characterized by eosinophilic infiltrate within the esophageal mucosa resulting in chronic inflammation and stenosis. It typically presents with symptoms of esophageal dysfunction with dysphagia and food impaction being the most common presenting complaints. Herein we describe a rare case presentation of a young patient with spontaneous esophageal perforation in the setting of undiagnosed EoE. We suggest that the placement of a covered esophageal stent can provide full closure of the perforation and restoration of the integrity of the GI tract without the need for more invasive open repair. The patient had a short recovery time with no reported postoperative complications upon 30 months follow up. We believe that it's important to consider and rule out EoE in patients with a history of dysphagia and esophageal perforation.

Neoadjuvant cryotherapy improves dysphagia and may impact remission rates in advanced esophageal cancer.

Background and study aims Liquid nitrogen spray cryotherapy (LNSC) can provide rapid dysphagia relief, and is postulated to stimulate a local antitumor immune response. The aim of this prospective pilot clinical trial was to evaluate the safety and efficacy of LNSC when administered prior to chemoradiotherapy. Patients and methods Treatment-naïve adult patients with dysphagia at the time of biopsy-proven squamous carcinoma or adenocarcinoma of the esophagus were prospectively enrolled at two tertiary medical centers. Patients underwent a single session of LNSC. The primary outcome measure was change in dysphagia at 1 and 2 weeks post-cryotherapy. A secondary outcome measure was clinical complete response rate (CR) following chemoradiotherapy. Results Twenty-five patients were screened, of whom 21 patients were eligible and enrolled. There were seven with metastatic and 14 with locally advanced cancer. The primary outcome of dysphagia improvement of ≥ 1 point occurred in 15/21 patients (71 %) at 1 week, and 10/20 patients (50 %) at 2 weeks. The median dysphagia score improved by 1 at 1 week ( P  = 0.0003), and 0.5 at 2 weeks ( P  = 0.02). Six of nine patients (67 %) with locally advanced cancer who completed chemoradiation did not have residual tumor cells on mucosal biopsy, and five of nine patients (56 %) had a clinical CR. There were no serious cryotherapy-related complications. Conclusions LNSC provided safe and effective palliation for esophageal cancer patients who presented with dysphagia at index diagnosis. Its combination with chemoradiotherapy did not lead to any serious toxicity. Our study provides a scientific rationale for pursuing larger clinical trials addressing synergistic effects of combining LNSC with chemoradiation.

Laparotomy-Assisted Endoscopic Injection of Jejunal Varices for Overt Small Bowel Bleeding.

A 54-year old male liver transplant recipient with Roux-en-Y choledochojejunostomy was admitted for symptomatic anemia. Despite endoscopies and a bleeding scan, active bleeding was not visualized. Angiography and abdominal computed tomography demonstrated possible jejunal varices at the choledochojejunal anastomosis. Double-balloon enteroscopy demonstrated varices with overlying clots in the Roux limb at the anastomosis. Due to the extensive loop formation and unstable position of the endoscope, therapeutic intervention could not be performed. Operative enterotomy and intraoperative endoscopy were subsequently required. A varix in the jejunum with venous flow on Doppler was injected twice with cyanoacrylate and successfully obturated.

Multicenter Evaluation of Octreotide as Secondary Prophylaxis in Patients With Left Ventricular Assist Devices and Gastrointestinal Bleeding.

BACKGROUND: Gastrointestinal (GI) bleeding is one of the most common complications after continuous-flow left ventricular assist device implantation. More than one third of patients with incident bleed go on to develop recurrent GI bleeding. Octreotide, a somatostatin analog, is proposed to reduce the risk of recurrent GI bleeding in this population. METHODS AND RESULTS: This multicenter, retrospective analysis evaluated 51 continuous-flow left ventricular assist device patients who received secondary prophylaxis with octreotide after their index GI bleed from 2009 to 2015. All patients had a hospitalization for GI bleed and received octreotide after discharge. Patient demographics, medical and medication history, and clinical characteristics of patients who rebled after receiving octreotide were compared with non-rebleeders. These data were also compared with matched historical control patients previously enrolled in the HMII (HeartMate II) clinical trials, none of whom received octreotide, to provide a context for the bleeding rates. Twelve patients (24%) who received secondary octreotide prophylaxis developed another GI bleed, whereas 39 (76%) did not. There were similar intergroup demographics; however, significantly more bleeders had a previous GI bleeding history before left ventricular assist device placement (33% versus 5%; P=0.02) and greater frequency of angiodysplasia confirmed during endoscopy (58% versus 23%; P=0.03). Fewer patients in this study experienced a recurrent GI bleed compared with a matched historical control group that did not receive octreotide (24% versus 43%; P=0.04). CONCLUSIONS: Patients with continuous-flow left ventricular assist device receiving secondary prophylaxis with octreotide had a significantly lower GI bleed recurrence compared with historical controls not treated with octreotide. Additional prospective studies are needed to confirm these data.