Endoscopic Sessions Research Articles

Leak After Sleeve Gastrectomy: Updated Algorithm of Treatment.

Laparoscopic sleeve gastrectomy (LSG) is currently the most common procedure performed worldwide, and still the leak is considered the main limitation. After an initial enthusiasm for stents, the endoscopic treatment evolved including in the current management the septotomy with balloon dilatation and pigtails insertions. The aim of this study was to evaluate the updated algorithm of endoscopic treatment of leak following LSG including septotomy and balloon dilatation. All consecutive patients treated by endoscopy between January 2018 and March 2020 for leak following LSG were included in the current study. After recording the demographic and the leak history, we have analyzed the number of endoscopic sessions, the duration of treatment, and the healing rate of endoscopic treatment for 3 groups: A, small orifice (< 10mm); B, large orifice (> 10mm) and acute leak; and group C with large orifice and late leak. A total of 53 patients received endoscopic treatment for leak following LSG. The leaks achieved complete healing after average duration of 3.2months (range 1-7months), 2.3months for group A, 4.2months for group B, and 3.7months for group C. The average number of endoscopic procedures was 2.8 (range 2-6) and was required for general population: for group A, 2.3 sessions; in group B, 3.4 sessions; and in group C, 2.7 sessions. Two out of 53 patients (3.8%) required additional treatment outside of the current algorithm, one in group A and another in group B. One patient was transferred for pulmonary abscess, and for another patient, the leak was considered chronic after a total of 14months, and a laparoscopic fistula-jejunostomy was performed with favorable outcomes. Although there is still no consensus for endoscopic management of leaks after LSG, the benefits of pigtails and the septotomy are undeniable, and it should be included in the armamentarium of any bariatric endoscopic service.

Endoscopic transpapillary gallbladder stenting to prevent acute cholecystitis in patients receiving FCEMS for benign biliary stricture.

Background and study aims Fully covered self-expanding metal stents (FCSEMS) are being increasingly used for benign biliary strictures (BBS); however, they are associated with risk of acute cholecystitis. Prophylactic endoscopic transpapillary gallbladder stenting (ETPGBS) can facilitate continuous gallbladder drainage and prevent acute cholecystitis from occlusion of cystic duct orifice by the FCSEMS. The aim of this study was to assess the technical feasibility, efficacy, and safety of ETPGBS to prevent acute cholecystitis in patients receiving FCSEMS for BBS. Patients and methods This was a retrospective analysis of a prospectively collected database at a single center of all patients who underwent prophylactic ETPGBS with FCSEMS for BBS between December 1, 2016 and November 30, 2020. Results A total of 71 ETPGBS were placed during the study period. Sixteen patients (mean age: 66.4 ± 19.8 years; 81 % male) underwent ETPGBS prior to biliary FCSEMS during the same endoscopic session. FCSEMS were left in place (stent dwell time) for a median of 173 days (range: 69–473; mean 196 ± 121) with resolution of BBS and successful removal of ETPGBS and FCSEMS in 12 patients. There was significant improvement in total bilirubin level (5.25 ± 5.53 vs 0.94 ± 0.85 gm/dL; P = 0.008). No episodes of acute cholecystitis or any other post-procedural complications were noted during the median follow-up of 337 days (range: 150–856; mean 394 ± 236). Conclusions ETPGBS prevented stent-related acute cholecystitis with continued efficacy of FCSEMS for BBS.

An Unexpected Thoracic Finding in a Patient With COVID-19

Question: A 75-year old woman presented to the emergency department with a history of epigastric discomfort and rapidly worsening thoracic pain. She had no fever or cough. On physical examination, she appeared overweight (102 kg, height 162 cm). Laboratory examination revealed normal cardiac troponin levels and slight increase in inflammatory markers (C-reactive protein and neutrophil-lymphocyte ratio). As a nasal screening swab was positive for coronavirus 2019 (COVID-19) infection, she was transferred to the COVID isolation ward. A subsequent computed tomography scan of the chest showed no interstitial lung disease. However, the presence of a monstrous esophageal dilatation with sigmoid shape and dislodgment of the surrounding structures was seen. The esophagus appeared full of solid content compatible with accumulated undigested food residues (Figure A–C). The patient was then referred to our gastroenterology unit. Upper endoscopy was performed under general anesthesia with endotracheal intubation. Endoscopic esophageal findings are shown in Figure D. What is the most likely diagnosis and how should it be managed? Look on page 1112 for the answer and see the Gastroenterology web site (www.gastrojournal.org) for more information on submitting your favorite image to Clinical Challenges and Images in GI. The patient was suffering from type II achalasia, which was refractory to previous endoscopic and surgical treatment. In detail, she had undergone three endoscopic pneumatic dilation sessions in 2005 and ultimately laparoscopic Heller-Dor myotomy in 2015. In 2018, an esophageal high-resolution manometry was unsuccessful, probably because the catheter did not reach the stomach in the sigmoid dilated esophagus. We treated our patient with prolonged fasting and nasoesophageal tube placement at 35 cm from the incisors teeth. Multiple daily irrigations with saline solution were performed without apparent benefit. Three endoscopic sessions were then performed to clean the entire esophagus from the huge amount of feces-like food residues. We believe that 2 reasons were behind this ominous presentation. First, the patient suffered from poorly controlled hypothyroidism for which she was taking levothyroxine per os. Laboratory examination revealed high levels of thyrotropin (103 μU/mL) and low levels of free thyroxine (<2.5 pg/mL) and free tri-iodothyronine (1.5 pg/mL). Her severe hypothyroidism was probably due to the inability of oral levothyroxine to reach the stomach, thus decreasing the subjective awareness of her own clinical condition. Second, she was edentulous and this affected the chewing phase, favoring episodes of food impaction and accumulation of food in the esophagus. Surprisingly, she did not experience weight loss and her general nutritional status was good. Achalasia is an uncommon esophageal motility disorder, usually characterized by dysphagia to solids and liquids, chest pain, regurgitation, and weight loss. High-resolution esophageal manometry is the gold standard test for the diagnosis. Diagnostic findings include distal esophageal aperistalsis and integrated relaxation pressure of >15 mm Hg. Achalasia is classified as type 1 classic, type 2 compartmentalized high pressure in esophageal body, and type 3 spastic.1Weusten B.L.A.M. Barret M. Bredenoord A.J. et al.Endoscopic management of gastrointestinal motility disorders - part 1: European Society of Gastrointestinal Endoscopy (ESGE) Guideline.Endoscopy. 2020; 52: 498-515Crossref PubMed Scopus (41) Google Scholar In the last few years, peroral endoscopic myotomy is the most frequent endoscopic intervention for achalasia leading to outcomes that are comparable with those of laparoscopic Heller myotomy. Additional interventions are represented by pneumatic dilation and botulinum toxin injection. Esophagectomy is the last option to manage end-stage achalasia.2Familiari P. Greco S. Volkanovska A. et al.Achalasia: current treatment options.Expert Rev Gastroenterol Hepatol. 2015; 9: 1101-1114Crossref PubMed Scopus (11) Google Scholar,3Hammad A. Lu V.F. Dahiya D.S. et al.Treatment challenges of sigmoid-shaped esophagus and severe achalasia.Ann Med Surg (Lond). 2020; 61: 30-34Crossref PubMed Scopus (5) Google Scholar Peroral endoscopic myotomy was not considered for our patient because of the patent cardia (Figure E), the lack of manometric data, and the poor expected outcome in sigmoid esophagus. She was referred to the endocrinologist for further therapeutic workup. Moreover, dental prosthesis implantation was recommended.

Impact of COVID-19 on Gastroenterology Fellowship Training

The coronavirus disease 2019 (COVID-19) outbreak caused numerous social and cultural changes, but few studies focused on their effects on gastroenterology (GI) fellowship training. This study evaluated the impact of COVID-19 on GI fellowship training. A web-based questionnaire was sent out to GI fellows in Korea between 15 February and 15 March 2021. The questionnaire included questions regarding the characteristics of GI fellows, perception of COVID-19 outbreak, impact of COVID-19 outbreak, and telemedicine on the education of a GI fellowship. Among 111 answers, 94 respondents were analyzed. The GI fellows were provided with sufficient information about the COVID-19 outbreak (74.7%), well educated, and provided with personal protective equipment use (74.7% and 83.9%, respectively). On the other hand, outpatient schedule and volume decreased in 25.5% and 37.8% of respondents, respectively. Moreover, endoscopy sessions and volume decreased in 51.1% and 65.6% of respondents, respectively. As a result, 78.9% of respondents were concerned that the COVID-19 outbreak adversely affected their education. Telemedicine utilization was introduced during the COVID-19 outbreak, but only 20.0% and 10.6% of respondents agreed that telemedicine has benefits from the patient's and doctor's perspectives, respectively. In addition, only 25.9% of respondents were willing to continue telemedicine if adequately reimbursed, and 68.2% of respondents were concerned that it adversely affected their education. The COVID-19 outbreak has adversely affected GI fellowship training in Korea for outpatient clinics, gastrointestinal endoscopy, educational conferences, and telemedicine. This study highlights that GI fellowship training needs more attention in the COVID-19 outbreak.

A Simple Method for Endoscopic Treatment of Large Gastric Phytobezoars: "Hand-Made Bezoaratome".

Large gastric phytobezoars are generally resistant to standard chemical or endoscopic treatments. We presented our experience of an alternative endoscopic method using a hand-made tool called a "hand-made bezoaratome" for the treatment of large gastric phytobezoars. Patients who consulted or who were diagnosed with gastric bezoars at an education and research hospital between January 2015 and December 2018 were prospectively included in the study. Patients with phytobezoars of 50 mm and larger were included in the study. Patients with trichobezoars, lactobezoars, pharmacobezoars, under 18 years of age, and pregnant women were excluded. A 0.25 mm diameter guidewire and a mechanical lithotripter sheath were used to prepare the "hand-made bezoaratome." After the first procedure, patients were advised to consume 2500 mL of Coca Cola® or the same amount of pineapple juice per day, until the next procedure. Endoscopic procedures were performed at 5-day intervals until complete reabsorption of the bezoar was achieved. Patients were followed up for 6 weeks. The study group included 37 (21 males, mean age: 57.6 ± 12.5 years) patients. The median size of the phytobezoars was 71 mm (50-90). The median endoscopic procedure time was 853 s (380-1940 s). The success rate for endoscopic fragmentation was found to be 100%. No major complications occurred during the endoscopic procedures, but 1 patient (2.7%) required surgery for ileus due to an obstruction at the distal part of the jejunum, 61 h after the second endoscopic session. The overall success rate of the endoscopic treatment was 97.3%. Using a "hand-made bezoaratome" is effective and reliable for the endoscopic treatment of large gastric bezoars.

Abstract No. 91 Clinical outcomes of percutaneous biliary endoscopy: a 7-year single-institution experience

Percutaneous biliary endoscopy (PBE) is an emerging field of interventional radiology that includes choledochoscopy and cholecystoscopy, but data regarding clinical outcomes is limited. The purpose of this study was to evaluate outcomes of PBE performed at a single academic institution over a 7-year period. After IRB approval, retrospective medical record review was performed for all patients who underwent PBE at a single academic institution between June 2013 and February 2020. 38 patients (22 male; mean age 55.9 [range, 2-84] years) underwent 59 choledochoscopy sessions, while 22 patients (12 male; mean age 64.6 [range, 20-89] years) underwent 48 cholecystoscopy sessions. Indications for choledochoscopy included stone removal (18/38) or biliary stenosis visualization with or without biopsy (20/38) in patients who failed ERCP or could not undergo ERCP due to altered anatomy. Indications for cholecystoscopy included acute calculous cholecystitis (20/22) and symptomatic cholelithiasis (2/22) in patients with medical comorbidities precluding them surgical cholecystectomy. Technical success, complications, procedural and fluoroscopy time, and tube-free survival were assessed. Technical success was defined as visualization and initiation of stone removal, or in the case of biopsy, successful lesion visualization and tissue sampling. Overall mean follow-up time was 15.2 months from each patient’s last endoscopy session. The annual number of new PBE patients increased from 9 in 2014 to 32 in 2019. For choledochoscopy, the overall technical success was 89% (80% for biliary stenosis visualization/biopsy, 94% for stone removal), with one complication (1.7%) of intraprocedural bile duct perforation causing a small biloma that subsequently required aspiration. Mean procedure time was 191 minutes with mean fluoroscopy time of 15.2 minutes. In patients with obstructing biliary stones, biliary drains were able to be removed in 12 patients (67%), with mean tube-free survival of 14.2 months. For cholecystoscopy, overall technical success was 94% with no complication. Mean procedure time was 141 minutes with mean fluoroscopy time of 13.2 minutes. Cholecystostomy tubes were able to be removed in 13 patients (59.1%) with mean tube-free survival of 8.7 months. This study supports PBE as a safe and feasible intervention option for nonsurgical patients or those with altered anatomy precluding ERCP. In select patients with obstructing biliary stones or calculous cholecystitis who would otherwise require life-long biliary drainage, PBE may result in tube-free survival.

Radiologic Predictors of Increased Number of Necrosectomies During Endoscopic Management of Walled-off Pancreatic Necrosis.

No established methods exist to predict who will require a higher number of endoscopic necrosectomy sessions for walled-off necrosis (WON). We aim to identify radiologic predictors for requiring a greater number of necrosectomy sessions. This may help to identify patients who benefit from aggressive endoscopic management. This is a multicenter retrospective study of patients with WON at 3 tertiary care centers. WON characteristics on preintervention computed tomography imaging were evaluated to determine if they were predictive of requiring more endoscopic necrosectomy. A total of 104 patients were included. Seventy patients (67.3%) underwent endoscopic necrosectomy, with median of 2 necrosectomies. WON largest transverse diameters (P=0.02), largest coronal diameters (P=0.01), necrosis pattern [likelihood ratio (LR)=17.85, P<0.001], spread (LR=11.02, P=0.01), hemorrhage (LR=8.64, P=0.003), and presence of disconnected pancreatic duct (LR=6.80, P=0.01) were associated with undergoing ≥2 necrosectomies. Patients with septations/loculations were significantly less likely to undergo ≥2 necrosectomies (LR=4.86, P=0.03). Several computed tomography radiologic features were significantly associated with undergoing ≥2 necrosectomies. These could help identify patients who will undergo a higher number of endoscopic necrosectomy sessions.

Impact of variceal eradication on rebleeding and prognosis in cirrhotic patients undergoing secondary prophylaxis.

Endoscopic therapy has been widely applied to prevent variceal rebleeding, but data addressing the effect of endoscopic variceal eradication (VE) are lacking. We aimed to clarify the clinical impact of VE and reveal the long-term incidence and mortality of gastrointestinal rebleeding. This prospective study included 228 cirrhotic patients who underwent secondary prophylaxis for variceal bleeding and achieved VE through a systematic procedure we proposed as endoscopic sequential therapy (EST). Rebleeding rates before and after VE were compared and cumulative incidence of rebleeding and mortality were calculated using the Kaplan-Meier method. A logistic regression model and P for trend were used to investigate the optimal time limit for VE. During a median (interquartile range) follow-up duration of 33.0 (23.0-48.75) months, rebleeding was identified in 28 patients (12.3%) after VE and in 27 patients (11.8%) during endoscopic sessions. The cumulative incidence of rebleeding before and after VE was 8.4% and 1.8% at 6 months, and 14.9% and 4.0% at 1 year respectively (P<0.001). The long-term incidence of all-cause/variceal rebleeding following VE was 10.4%/9.1%, and 31.5%/23.5% at 2 and 5 years respectively. Eleven patients (4.8%) died and the 5-year mortality was 9.3%. VE achieved within 6 months was associated with fewer rebleeding events compared to VE achieved after 6 months (5.5% vs. 20.0%, P=0.002), while logistic regression revealed an overall increasing trend in the odds ratio of rebleeding (vs. patients with VE time ≤6 months) for patients with 6< VE time ≤12 months and VE time >12 months (P for trend <0.001). VE further reduces rebleeding based on routine endoscopic prophylaxis and improves long-term prognosis. VE within 6 months seems to be the optimal timing and should therefore be advocated.

Esophageal Variceal Ligation Monotherapy versus Combined Ligation and Sclerotherapy for the Treatment of Esophageal Varices.

Currently, endoscopic variceal ligation (EVL) monotherapy is the standard therapy for managing esophageal variceal hemorrhage. Patients generally need several sessions of endoscopy to achieve optimal variceal ablation, and the varices can recur afterward. Endoscopic injection sclerotherapy (EIS) is an older technique, associated with certain complications. This study aimed to evaluate the clinical efficacy of EVL alone versus combined EVL and EIS in the treatment of esophageal varices. This retrospective study included 84 patients, of which 40 patients were treated with EVL monotherapy and 44 patients were treated with combined EVL + EIS. The main outcomes were rebleeding rates, recurrence at six months, number of treatment sessions, length of hospital stay, cost of hospitalization, and procedural complications. At six months, the rebleeding rate and recurrence were significantly lower in the EVL + EIS group compared to the EVL group (2.3% versus 15.0%; and 9.1% versus 27.5%, respectively). The number of treatment sessions, length of hospital stay, and cost of hospitalization were significantly lower in the EVL + EIS group compared to those in the EVL group (2.3 ± 0.6 versus 3.2 ± 0.8 times; 14.5 ± 3.4 versus 23.5 ± 5.9 days; and 23918.6 ± 4220.4 versus 26165.2 ± 4765.1 renminbi, respectively). Chest pain was significantly lower in the EVL + EIS group compared to that in the EVL group (15.9% versus 45.0%). There were no statistically significant differences in the presence of fever or esophageal stricture in both groups. In conclusion, combined EVL + EIS showed less rebleeding rates and recurrence at six months and less chest pain and was more cost effective compared to EVL alone in the treatment of gastroesophageal varices.

Impact of the Coronavirus Disease 2019 Pandemic on Gastrointestinal Procedures and Cancers in the United States: A Multicenter Research Network Study

Impact of the Coronavirus Disease 2019 Pandemic on Gastrointestinal Procedures and Cancers in the United States: A Multicenter Research Network Study

Reflux Control After Barrett’s Esophagus Ablation

Esophageal adenocarcinoma (EAC) is difficult to treat and carries a poor prognosis. Barrett’s esophagus, which develops from long-standing gastroesophageal reflux disease, is the only known precursor to EAC. Endoscopic eradication therapy is a major advancement in the treatment of dysplastic Barrett’s esophagus and early EAC; however, failure to eradicate disease and a high rate of recurrence with risk of progression currently remain unacceptably high with the use of acid suppressive medication for reflux. Herein, we describe the physiology of gastroesophageal reflux and review the current literature on endoscopic eradication therapy for Barrett’s esophagus. We summarize that antireflux surgery for reflux control as an adjunct to endoscopic eradication therapy may decrease the need for multiple endoscopic sessions (to achieve eradication), decrease the risk for recurrence/progression, and potentially decrease the need for surveillance.

Endoscopic Vacuum Therapy to Seal Recalcitrant Esophageal Leak After Esophageal Surgery in Children

Postoperative esophageal leak is a serious adverse event that occurs in up to 20% following esophageal surgery. Increasingly, endoscopy is utilized to manage leaks refractory to surgical washout and drainage including endoscopic vacuum-assisted closure (EVAC) using negative pressure therapy to achieve source control and granulation. In this report, successful use of this endoscopic strategy to seal a persistent leak after esophageal diverticulectomy is described. A two-year-old male born with esophageal atresia and tracheoesophageal fistula underwent primary anastomosis on the first day of life. Two years later, he presented symptomatic from a diverticulum at the anastomosis and underwent diverticulectomy complicated by esophageal leak at the diverticulectomy site. Despite multiple surgical interventions to seal the leak and obtain source control, the esophageal leak persisted. A multidisciplinary team of surgeons, gastroenterologists, and radiologists determined in consensus with the family of the patient to proceed with EVAC beginning with intracavitary placement of a dressing sponge secured on a nasoesophageal tube. After six endoscopic sessions, the esophageal leak was determined to be closed on endoscopic and fluoroscopic imaging. The patient was ultimately discharged home nine days after removal of the endoscopic vacuum. The leak site remained closed on fluoroscopic esophagram studies performed 6 months later. Negative pressure therapy successfully closed a refractory esophageal leak in a child resulting from diverticulectomy. Future investigations should employ larger series to compare the efficacy, tolerance, and duration of therapy needed to close leaks from EVAC versus stenting.

Feasibility of EUS-guided hepaticogastrostomy for inoperable malignant hilar biliary strictures.

Background and Objectives: EUS-guided biliary drainage (EUS-BD) has emerged as a complementary technique for primary drainage or as a rescue technique after failed endoscopic retrograde cholangiography. The objective of this study was to demonstrate the feasibility of EUS-BD for malignant hilar stenosis (MHS), both as an initial and rescue procedure.Patients and Methods: This study was a retrospective work based on a prospective registry of patients with malignant drainage stenosis of the hilum. For this analysis, only patients who underwent EUS-BD drainage were included. The drainage procedure could be performed by EUS-BD alone or in combination with another technique, for initial drainage or reintervention.Results: Between January 2015 and September 2018, 20 patients were included. The mean patient age was 68 years. Seven patients had primary liver tumors and 13 had obstructions caused by metastasis. Four patients had Type II stenosis, 7 had Type IIIA, 2 had Type IIIb, and 7 had Type IV stenosis. Sixteen patients underwent EUS-guided hepaticogastrostomy (EUS-HGS) for initial drainage and four as reintervention. For initial drainage, 2 patients underwent EUS-HGS alone and 14 underwent EUS-HGS in combination with another technique: 11 combined with endoscopic retrograde cholangiopancreatography (ERCP), 2 with percutaneous transhepatic drainage, and 1 with ERCP and percutaneous transhepatic drainage. The technical success rate for EUS-HGS in the drainage of MHS was 100%, and the clinical success rate was 95%. The mean percentage of liver drained was 84%, with an average 1.7 endoscopic sessions and an average 2.7 protheses. The early complication rate was 35% and the mortality rate was 5%. Five EUS-HGS/ERCP combination drainage procedures were performed in one session and six were performed in two sessions with similar complication rates and percentages of liver segments drained.Conclusion: EUS-BD is a feasible and safe technique for initial drainage and for reintervention procedures. The EUS-HGS/ERCP combination seemed to be useful in cases of complex stenosis and could be performed during the same session or in two sessions.

Management of esophageal strictures after endoscopic resection for early neoplasia.

Background:Endoscopic resection of extensive esophageal neoplastic lesions is associated with a high rate of esophageal stricture. Most studies have focused on the risk factors for post-endoscopic esophageal stricture, but data on the therapeutic management of these strictures are scarce. Our aim is to describe the management of esophageal strictures following endoscopic resection for early esophageal neoplasia.Methods:We included all patients with an endoscopic resection for early esophageal neoplasia followed by endoscopic dilatation at a tertiary referral center. We recorded the demographic, endoscopic, and histological characteristics, and the outcomes of the treatment of the strictures.Results:Between January 2010 and December 2019, we performed 166 endoscopic mucosal resections and 261 endoscopic submucosal dissections for early esophageal neoplasia, and 34 (8.0%) patients developed an esophageal stricture requiring endoscopic treatment. The indication for endoscopic resection was Barrett’s neoplasia in 15/34 (44.1%) cases and squamous cell neoplasia (SCN) in 19/34 (55.9%) cases. The median [(interquartile range) (IQR)] number of endoscopic dilatations was 2.5 (2.0–4.0). Nine of 34 (26.5%) patients required only one dilatation, and 22/34 (65%) had complete dysphagia relief following three endoscopic treatment sessions. The median number of dilatations was significantly higher for SCN [3.0 (2–7); range 1–17; p = 0.02], and in the case of circumferential resection [4.0 (3.0–7.0); p = 0.03]. Endoscopic dilatation allowed a sustained dysphagia relief in 33/34 (97.0%) patients after a mean follow-up of 25.3 ± 22 months.Conclusion:Refractory post-endoscopic esophageal stricture is a rare event. After a median of 2.5 endoscopic dilatations, 97.0% of patients were permanently relieved of dysphagia. Circumferential endoscopic esophageal resections should be considered when indicated.

Advanced endoscopic imaging for detecting and guiding therapy of early neoplasias of the esophagus.

Esophageal cancers, largely adenocarcinoma in Western countries and squamous cell cancer in Asia, present a significant burden of disease and remain one of the most lethal of cancers. Key to improving survival is the development and adoption of new imaging modalities to identify early neoplastic lesions, which may be small, multifocal, subsurface, and difficult to detect by standard endoscopy. Such advanced imaging is particularly relevant with the emergence of ablative techniques that often require multiple endoscopic sessions and may be complicated by bleeding, pain, strictures, and recurrences. Assessing the specific location, depth of involvement, and features correlated with neoplastic progression or incomplete treatment may optimize treatments. While not comprehensive of all endoscopic imaging modalities, we review here some of the recent advances in endoscopic luminal imaging, particularly with surface contrast enhancement using virtual chromoendoscopy, highly magnified subsurface imaging with confocal endomicroscopy, optical coherence tomography, elastic scattering spectroscopy, angle-resolved low-coherence interferometry, and light scattering spectroscopy. While there is no single ideal imaging modality, various multimodal instruments are also being investigated. The future of combining computer-aided assessments, molecular markers, and improved imaging technologies to help localize and ablate early neoplastic lesions shed hope for improved disease outcome.

Customized bariatric stents for sleeve gastrectomy leak: are they superior to conventional esophageal stents? A systematic review and proportion meta-analysis.

Recently, there has been a burgeoning interest in the utilization of customized bariatric stents (CBS) for management of sleeve gastrectomy leak (SGL). We aimed to conduct a proportion meta-analysis to evaluate the cumulative efficacy and safety of these new stents and to compare them with the conventional esophageal stents (CES). A systematic literature search of the PubMed, Cochrane Library, Scopus, Web of Science and Google Scholar databases was conducted through May 1, 2020. Primary outcomes were technical and clinical success and post-procedure adverse events of CBS and CES. Secondary outcomes were number of stents and endoscopic sessions per patient, and time to leak closure. A proportion meta-analysis was performed on outcomes using a random-effects model, and the weighted pooled rates (WPRs) or mean difference with 95% confidence interval (CI) were calculated. The WPR with 95% CI of technical success, clinical success, and stent migration for CBS were 99% (93-100%) I2 = 34%, 82% (69-93%) I2 = 58%, and 32% (17-49%), I2 = 69%, respectively. For CES, the WPR (95% CI) for technical success, clinical success, and stent migration were 100% (97-100%) I2 = 19%, 93% (85-98%) I2 = 30%, and 15% (7-25%), I2 = 41%, respectively. Adverse events other than migration were very low with both types of stents. On proportionate difference, CBS had lower clinical success (11%) and higher migration rate (17%) in comparison to CES. In successfully treated patients, CBS was associated with lower mean number of stents and endoscopic sessions, and shorter time to leak closure compared to CES. The overall quality of evidence was very low. In treatment of SGL, there is very low level evidence that CES are superior to CBS in terms of clinical success and migration rate, though may require more stent insertions and endoscopic procedures. The evidence however remains very uncertain. Perhaps relevant to some types of stents, CBS are promising; however design modification is strongly recommended to improve outcomes.

Double-Balloon Endoscopy in Crohn Disease: A Tertiary Referral Center Experience.

Crohn disease (CD) affects the small bowel in 80% of patients. Double balloon endoscopy (DBE) provides the potential for direct and extensive mucosal visualization with the potential for diagnostic monitoring and therapeutic intervention. This study aimed to investigate the safety and effectiveness of DBE in small-bowel CD. From our DBE database, patients with CD at the time of index DBE (January 2004-January 2013) were identified. Data collection included demographics, CD phenotype (age at diagnosis, disease location, disease activity), procedural information, adverse events (perforation, pancreatitis, death), therapeutic intervention (stricture dilation), and outcome (escalation or maintenance of existing therapy, referral to surgery). A total of 184 DBEs were performed in patients with inflammatory bowel disease over 162 endoscopic sessions. In this cohort, 115 patients had previously diagnosed CD. A diagnosis of CD was made in 22 patients. Of those with known CD, 140 DBEs were performed in 82 patients; DBE findings led to escalation of medical therapy in 26% of patients, maintenance of therapy in 26% of patients, and surgery in 18% of patients. We considered DBE to have failed in 11% (n = 18) of patients. During 46 endoscopic sessions, in 29 patients, 103 strictures were dilated via balloon dilation. Of patients undergoing dilation with clinical follow-up, 19 of 24 (79%) patients were surgery-free during the study period. Overall, there were 2 perforations. We found that DBE is a safe and effective procedure in patients with suspected or established CD. Furthermore, patients undergoing dilation of strictures via DBE had an 80% surgery-free rate within the follow-up period.

Staple Line Leaks Following Laparoscopic Sleeve Gastrectomy: Low Efficacy of the Over-the-Scope Clip.

The over-the-scope clip (OTSC) enables non-surgical management of gastrointestinal defects. The aim of this study was to report our experience with OTSC for patients with staple line leaks following laparoscopic sleeve gastrectomy (LSG). A prospectively maintained IRB-approved institutional database was queried for all patients treated with OTSC for staple line leaks following LSG from 2010 to 2018. Primary outcome was complete resolution of leak following OTSC. Secondary outcome was the number of additional procedures needed following OTSC. Twenty-six patients (13 males, 13 females) were treated with OTSC for staple line leaks following LSG. The median age was 35years (range 18-62), and mean body mass index was 44kg/m2. The median time from index operation to leak diagnosis and from leak diagnosis to OTSC was 18days (range 2-118), and 6days (range 1-120), respectively. The initial endoscopic treatment was OTSC (n = 19), stent (n = 5), clip (n = 1), and clip and biologic glue (n = 1). OTSC alone led to final resolution of leak in 8 patients (31%) within 43days of clip deployment (range 5-87). Five leaks resolved after a combination of OTSC and stent (19%) and one leak (4%) resolved after endoscopic suturing following a failed OTSC. Eleven patients (42%) failed endoscopic management and underwent total gastrectomy and esophagojejunostomy. One mortality (4%) was noted. The number of additional endoscopic sessions ranged from 1 to 10 (median 2). OTSC carries a low success rate for controlling staple line leaks following LSG.

S2937 Hyperplastic Gastric Polyps, “Size Matters”

INTRODUCTION: Hyperplastic gastric polyps are common incidental finding during EGD. They are usually asymptomatic but can present with iron deficiency anemia, gastric outlet obstruction and dysplasia especially when larger than one centimeter. CASE DESCRIPTION/METHODS: A 57-year old man without significant medical history was referred for iron deficiency anemia and occasional rectal bleeding for 1 year. His physical examination was unremarkable and family history was negative for malignancy or polyposis. Colonoscopy was normal. EGD revealed numerous large pedunculated polyps, as in Figures 1 and 2. They measured approximately 2 to 4 cm and stretched across the gastric lumen with a stalactite-like appearance. Some of the polyps were erythematous with small erosions and stigmata of recent bleeding. The polyps were removed with a hot snare over several endoscopy sessions. Pathology revealed hyperplastic polyps without dysplasia and negative stain for H. pylori. DISCUSSION: Hyperplastic polyps are equally common in men and women and typically occur in the sixth and seventh decades. They are usually found in the antrum and often are multiple. Large hyperplastic polyps often become lobulated and pedunculated, and the surface epithelium typically is eroded, which may result in chronic blood loss and iron deficiency anemia. The classic association of gastric hyperplastic polyps has been with mucosal atrophy, whether caused by H pylori infection or autoimmune gastritis. However, in recent years these polyps have increasingly been found in the background of a normal or reactive gastric mucosa without evidence of current or prior H pylori infection. Between 1% and 20% of hyperplastic polyps have been reported to harbor foci of dysplasia. Mutations of the p53 gene, chromosomal aberrations, and microsatellite instability all have been detected in these polyps. The overall prevalence of carcinoma in hyperplastic polyps is less than 2%, and it is more frequent in polyps larger than 2 cm. In view of the potential cancer risk, all hyperplastic polyps larger than 1 cm should be excised completely. Additionally, random biopsies from the intervening non-polypoid mucosa should be obtained. If present, H pylori should be eradicated and an endoscopic follow-up evaluation should be scheduled between 3 and 6 months after therapy to confirm successful eradication. The best intervals for such surveillance are unclear (e.g. annual, bi-annual, or some other interval) as is the number of years for which it should be continued.Figure 1Figure 2

Effect of successive endoscopic procedures in polyp and adenoma detection rates: Too early is not always too good.

A retrospective cross-sectional study was undertaken among consecutive patients on whom colonoscopy and/or esophagogastroduodenoscopy were performed between January 2012 and August 2014. Data regarding polyp and adenoma detection, cecal intubation, and bowel cleansing quality as well as demographical data of subjects were extracted. Endoscopic procedures were classified according to the time slotsof the proceduresthroughout the endoscopy session in three groups: from the 1st to 4th endoscopystudy (round 1), from the 5th to the 8th study (round 2), above the 9th study (round 3). We compared PDR and ADR among rounds. Overall, 3388 patients were enrolled. Median age was 50years (range 18-95) and 52.39% were female. There was a significant difference in terms of PDR among rounds (36.83%, 41.24%, and 43.38%, respectively, p= 0.007) and a non-significant numerical difference when ADR was compared (23.2%, 25.71%, and 26.78%, p= 0.07). On multivariate analysis, ADR was significantly associated with age (odds ratio [OR] 1.02 [1.01-1.03]), and male sex (OR 1.64 [1.38-1.94]). Theoretical endoscopist's fatigue due to cumulative performance of endoscopies does not diminish colonoscopy quality. Both PDR and ADR seem to improve after endoscopist's cumulative rounds of performed endoscopies. This could be due to a "warm-up" effect.