Telemetric capsule-based upper gastrointestinal tract - blood detection - first multicentric experience.

INTRODUCTION: Risk stratification in upper gastrointestinal bleeding (UGIB) currently relies on clinical parameters and risk scores. HemoPill® acute (Ovesco Endoscopy, Tuebingen, Germany) is a pill-shaped, orally administered sensor capsule for real-time blood detection. The aim of this study was to evaluate the system in clinical routine. MATERIAL AND METHODS: Sixty-one consecutive patients in whom the HemoPill® had been used at 12 international hospitals between July 2019 and March 2020 were retrospectively analysed. Indications for application were the clinical suspicion of UGIB, small bowel bleeding, of rebleeding after hemostasis. Primary endpoints were technical success and bleeding detection/exclusion. Secondary endpoints included adverse events and change of clinical course. RESULTS: The capsule was used in 45 (73%) patients with UGIB, in 12 (20%) patients with small bowel bleeding and in four (7%) patients for exclusion of rebleeding. Technical success was 98%. 35/60 (58%) cases were capsule-positive and among these, endoscopy showed bleeding in 20/35 (57%) cases. None of the 25 capsule-negative patients rebled. Emergency endoscopy could be avoided in 18/25 (72%) cases. Serious adverse events did not occur. CONCLUSION: HemoPill®-based blood detection is feasible and safe. Negative capsule results might 'downgrade' the need for urgent endoscopy.

Flexible percutaneous endoscopic retroperitoneal necrosectomy as rescue therapy for pancreatic necroses beyond the reach of endoscopic ultrasonography: A case series.

Minimally invasive or endoscopic transluminal drainage and necrosectomy are the standard of care for infected pancreatic fluid collections and necroses after pancreatitis. In an endoscopic treatment algorithm, necroses beyond the reach of safe endoscopic access are typically treated by percutaneous drainage. We aimed to evaluate percutaneous minimally invasive necrosectomy using a purely endoscopic technique in patients with extensive necrosis. In patients with necroses beyond safe transluminal reach, the percutaneous drainage canal was used for flexible endoscopic access and dilatation of the tract to 20 mm. Percutaneous endoscopic necrosectomy was carried out through this canal. We present a case series of 14 patients in whom between one and four necrosectomy (median two) sessions were done to remove solid necroses successfully in 13 out of 14 patients. There were no major complications apart from one patient with abdominal compartment syndrome secondary to delayed erosion of the splenic artery. Percutaneous flexible necrosectomy might evolve into an alternative to surgical minimally invasive necrosectomy in anatomical sites beyond transluminal endoscopic reach.

Prognostic relevance of gastric cancer staging by endoscopic ultrasound.

BACKGROUND: Recent trials and guidelines have established the use of neoadjuvant chemotherapy for resectable UICC stage II to IV gastric cancers. In this setting, preoperative staging is pivotal for correct patient selection. This cohort study was designed to assess the accuracy of endoscopic ultrasound (EUS) and the ability to select correctly patients for neoadjuvant chemotherapy on the basis of survival outcome. METHODS: Eighty-two consecutive Caucasian patients (46 male; median age 72 years) with gastric cancer underwent EUS staging and subsequent surgery without perioperative chemotherapy or radiotherapy. Patients were followed for a median of 800 days postoperatively. Pathology and EUS UICC and T stages were compared and evaluated as predictors of survival using Kaplan-Meier and Cox regression analysis. RESULTS: The overall accuracy of EUS for UICC classification compared with pathology was 62 %, and the accuracy for delineation of UICC I was 89 %. For the therapeutically relevant differentiation of early gastric cancer (UICC stage I), EUS (mean survival, 2,298 days, R2 = 0.23) and pathology (2,461 days, R2 = 0.24) predicted survival equally well. Similar results were obtained for T staging by EUS (mean survival, 2,065 days for uT1/2, R2 = 0.24) or pathology (2,185 days, R2 = 0.22). CONCLUSIONS: EUS identifies the low risk subgroup (uUICC stage I or uT1/2) with similar performance as pUICC stage I or stage pT1/2 in gastric cancer and very similar survival characteristics. EUS thus may be the noninvasive method of choice for preoperative selection of patients for immediate resection versus neoadjuvant chemotherapy.

Endoscopic ultrasound criteria to predict the need for intervention in pancreatic necrosis.

BACKGROUND: The natural course and treatment strategies for asymptomatic or oligosymptomatic pancreatic necrosis are still poorly defined. The aim of this retrospective study was to establish criteria for the need of intervention in patients with pancreatic necrosis. METHODS: A total of 31 consecutive patients (18 male, median age 58 yrs.) diagnosed with pancreatic necrosis by endoscopic ultrasound, in whom a decision for initial conservative treatment was made, were followed for the need of interventions such as endoscopic or surgical intervention, or death. RESULTS: After a median follow-up of 243 days, 21 patients remained well without intervention and in 10 patients an endpoint event occurred. In a multivariate logistic regression analysis of the clinical and endosonographic parameters, liquid content was the single independent predictor for intervention (p = 0.0006). The presence of high liquid content in the pancreatic necrosis resulted in a 64% predicted endpoint risk as compared to 2% for solid necrosis. CONCLUSIONS: Pancreatic necrotic cavities with high liquid content are associated with a high risk of complications. Therefore, close clinical monitoring is needed and early elective intervention might be considered in these patients.

Endoscopic ultrasound-guided endoscopic necrosectomy of the pancreas: is irrigation necessary?

BACKGROUND: Findings have shown endoscopic necrosectomy to be beneficial for patients with symptomatic pancreatic necrosis accessible for an endoscopic approach. The available studies show that endoscopic necrosectomy requires a multitude of subsequent procedures including repeat irrigation for removal of the necrotic material. This study aimed to investigate the need for additional irrigation in patients with necrotizing pancreatitis treated by endoscopic necrosectomy. METHODS: The study enrolled 35 consecutive patients (27 men) with a median age of 59 years who had pancreatic necrosis treated with endoscopic necrosectomy. Endoscopic ultrasound-guided internal drainage and consecutive endoscopic necrosectomy was combined with interval multistenting of the cavity. Neither endoscopic nor external irrigation was part of the procedure. RESULTS: An average of 6.2 endoscopy sessions per patient were needed for access, necrosectomy, and stent management. The in-hospital mortality rate was 6% (2/35), including one procedure-related death resulting from postinterventional aspiration. The immediate morbidity rate was 9% (3/35). It was possible to achieve clinical remission for all the surviving patients with no additional surgery needed for management of the necroses. The median follow-up period was 23 months. CONCLUSION: Neither endoscopic nor external flushing is needed for successful endoscopic treatment of symptomatic necroses. Even without irrigation, the outcome for patients treated with endoscopic necrosectomy is comparable to that described in the published data.

New flexible endoscopic controlled stapler technique for the treatment of Zenker's diverticulum: A case series.

AIM: To report about the combination and advantages of a stapler-assisted diverticulotomy performed by flexible endoscopy. METHODS: From November 2014 till December 2015 17 patients (8 female, 9 male, average age 69.8 years) with a symptomatic Zenker diverticulum (mean size 3.5 cm) were treated by inserting a new 5 mm fully rotatable surgical stapler (MicroCutter30 Xchange, Cardica Inc.) next to an ultrathin flexible endoscope through an overtube. The Patients were under conscious sedation with the head reclined in left position, the stapler placed centrally and pushed forward to the bottom of the diverticulum. The septum was divided by the staple rows under flexible endoscopic control. RESULTS: In eleven patients (64.7%) the stapler successfully divided the septum completely. Mean procedure time was 21 min, medium size of the septum was 2.8 cm (range 1.5 cm to 4 cm). In four patients the septum was shorter than 3 cm, in seven longer than 3 cm. To divide the septum, averagely 1.3 stapler cartridges were used. Two minor bleedings occurred. Major adverse events like perforation or secondary haemorrhage did not occur. After an average time of two days patients were discharged from the hospital. In 6 patients (35.3%) the stapler failed due to a thick septum or insufficient reclination of the head. Follow up endoscopy was performed after an average of two months in 9 patients; 4 patients (44.4%) were free of symptoms, 5 patients (55.6%) stated an improvement. A relapse of symptoms did not occur. CONCLUSION: Flexible endoscopic Zenker diverticulotomy by using a surgical stapler is a new, safe and efficient treatment modality. A simultaneously tissue opening and occlusion prevents major complications.

EUS-guided alcohol ablation of an insulinoma.

BACKGROUND: Surgical resection is currently considered to be the criterion standard for treatment of insulinomas. Alternative treatments, despite medication with diazoxide, are lacking. EUS-guided ethanol ablation of endocrine tumors has not been reported before. INTERVENTION: A 78-year-old woman was referred with typical symptoms of an insulinoma. Diagnosis was confirmed by laboratory findings, EUS, and EUS-guided FNA. Because of severe complications during several hypoglycemic episodes, a poor general condition, and strict refusal of surgical resection, the decision was made to ablate the insulinoma by EUS-guided alcohol injection. A total of 8 mL 95% ethanol was injected into the tumor. RESULTS: The patient was discharged and exhibited no further hypoglycemic episodes, and her general condition improved rapidly. Based on clinical, morphologic, and biochemical criteria, we achieved a durable complete remission of the tumor. CONCLUSIONS: EUS-guided ablation may become a minimally invasive alternative for patients with insulinomas in whom surgery is not feasible.