Gastrointestinal Resection Research Articles

Feeding jejunostomy in upper gastrointestinal resections: a UK-wide survey.

The usage of a feeding jejunostomy has been a well-established practice in maintaining nutrition in patients undergoing resections for upper gastrointestinal cancer. As surgical technique has evolved, together with the adoption of enhanced recovery after surgery pathways, the routine insertion of feeding jejunostomy tubes appears to be changing. A survey was constructed using Google Forms. The link was distributed to consultant upper gastrointestinal surgeons via the Association of Upper Gastrointestinal Surgeons' membership database. Results were collated and analysed using Microsoft Excel. A total of 55 responses were received from 28 units across the UK; 27 respondents (49.1%) no longer routinely use feeding jejunostomy in upper gastrointestinal resections, oesophagectomy or gastrectomy. The most common primary feeding modality used by these respondents was oral diet 17 (65.4%), with total parenteral nutrition (19.2%) and nasojejunal (11.5%) routes also being used. Respondents who used feeding jejunostomies inserted them primarily for oesophagectomy (n = 27; 96.4%), with fewer surgeons using them in extended total gastrectomy (n = 12; 42.9%) and total gastrectomy (n = 11; 39.3%). Of the total, 20 surgeons (71.4%) would insert the jejunostomy using an open approach, with 19 (67.9%) employing a Witzel tunnel. Eleven respondents (39.3%) would continue feeding via the jejunostomy after discharge. Some 24 responders thought that feeding jejunostomies did not facilitate the enhanced recovery after surgery pathway (strongly and slightly disagree), whereas 17 considered that they did (strongly and slightly agree); 13 responders did not have strong views either way. There is a split in current practice regarding the usage of feeding jejunostomies. There is also a division of opinion on the role of feeding jejunostomy in enhanced recovery after surgery.

Loss of switch/sucrose non-fermenting complex protein expression in undifferentiated gastrointestinal and pancreatic carcinomas.

Undifferentiated carcinoma refers to an epithelial malignancy that lacks morphological evidence of differentiation. Recent studies have implicated the loss of constitutively expressed switch/sucrose non-fermenting (SWI/SNF) complex subunits in undifferentiated carcinomas of the gastrointestinal tract and other sites. In this study we examine the expression of SWI/SNF and mismatch repair (MMR) proteins in a series of undifferentiated carcinomas from the gastrointestinal tract and the pancreas. We searched pathology databases from four Canadian health centres for primary undifferentiated carcinoma from gastrointestinal and pancreatic resection specimens. Upon review of 31 cases, 19 were confirmed to be undifferentiated carcinomas (eight colonic, six gastric, three pancreatic, one appendiceal and one duodenal). Immunohistochemical analysis of SMARCA4, SMARCA2, SMARCB1, ARID1A, ARID1B, MSH2, MSH6, MLH1 and PMS2 was performed on whole sections. Five of 19 (26%) showed loss of core SWI/SNF proteins (two loss of SMARCA4, one loss of SMARCB1 and two concurrent loss of ARID1A and ARID1B). SMARCA4, SMARCB1, or ARID1A/ARID1B-deficient undifferentiated carcinoma consistently exhibited sheet-like growth pattern, with cellular discohesion and rhabdoid morphology. Nine of 17 undifferentiated carcinomas tested were MMR-deficient by immunohistochemistry. In comparison, none of the 12 poorly differentiated carcinomas that were originally diagnosed as undifferentiated carcinomas showed loss of SMARCA4, SMARCA2, SMARCB1 or ARID1B. Undifferentiated gastrointestinal/pancreatic carcinomas show frequent loss of expression of SWI/SNF complex proteins. The loss of these core components of SWI/SNF complex may contribute to the arrest of cellular differentiation, resulting in the undifferentiated histology and aggressive clinical behaviour.

Early prediction model of organ/space surgical site infection after elective gastrointestinal or hepatopancreatobiliary cancer surgery

BackgroundOrgan/space SSI is a significant clinical problem. However, early detection of organ/space SSI is difficult, and previous predictive models are limited in their prognostic ability. We aimed to develop and validate a prediction model of organ/space surgical site infection (SSI) using postoperative day 3 laboratory data in patients who underwent gastrointestinal or hepatopancreatobiliary cancer resection. MethodsThis retrospective cohort study using a single-center hospital data from April 2013 to September 2017 included all adult patients who underwent elective gastrointestinal or hepatopancreatobiliary cancer resection. The primary outcome was a presence of organ/space SSI including anastomotic leakage, pancreatic fistula, biliary fistula, or intra-abdominal abscess. We developed and validated a logistic regression model to predict organ/space SSI using laboratory data on postoperative day (POD) 3. Similar models using laboratory data on POD 1 or 5 were developed to compare the predictive ability of each model. ResultsA total of 1578 patients were included. Organ/space SSI was diagnosed in 107 patients, with median diagnosis days of 6 (interquartile range, 4–9 days) after surgery. A prediction model using five commonly measured variables on POD 3 was created with the area under the curve (AUC) of 0.883 (95%CI 0.819–0.946). The AUC of a model with POD 1 laboratory data was 0.751 (95%CI 0.655–0.848), while that of POD 5 laboratory data was 0.818 (95%CI 0.730–0.906). ConclusionsLaboratory data on POD 3 could forecast organ/space SSI precisely. Further prospective studies are warranted to investigate the clinical impact of this model.

Surgical Treatment of Port-Site Metastases After Laparoscopic Radical Resection of Gastrointestinal Tumors.

Aim: This study was performed to investigate the feasibility of surgical treatment of port-site metastasis after laparoscopic radical resection of gastrointestinal tumors. Patients and Methods: We retrospectively analyzed the clinical data and follow-up data of 8 patients with port-site metastases after gastrointestinal cancer resection in our hospital from January 2014 to January 2018. Results: Six of port-site metastases occurred within 6 months after gastrointestinal tumor resection, one of port-site metastases occurred in 10 months after the operation, and one of port-site metastases occurred in 30 months after the operation. Any metastasis to the abdominal cavity or distant metastasis was ruled out before the surgical treatment of the port-site metastases, and all patients recovered well after the extended operation. No incisional infection or incisional hernia occurred. By December 2019, 4 patients had died (they had survived for 12, 13, 18, and 24 months, respectively) and 5 patients had survived. The follow-up duration ranged from 19 to 28 months. Conclusions: Surgical resection of port-site metastases is not difficult because of their superficial location. Surgical treatment can improve the prognosis of patients without abdominal metastasis or distant metastasis/recurrence.

Perioperative intravenous contrast administration and the incidence of acute kidney injury after major gastrointestinal surgery: prospective, multicentre cohort study.

This study aimed to determine the impact of preoperative exposure to intravenous contrast for CT and the risk of developing postoperative acute kidney injury (AKI) in patients undergoing major gastrointestinal surgery. This prospective, multicentre cohort study included adults undergoing gastrointestinal resection, stoma reversal or liver resection. Both elective and emergency procedures were included. Preoperative exposure to intravenous contrast was defined as exposure to contrast administered for the purposes of CT up to 7 days before surgery. The primary endpoint was the rate of AKI within 7 days. Propensity score-matched models were adjusted for patient, disease and operative variables. In a sensitivity analysis, a propensity score-matched model explored the association between preoperative exposure to contrast and AKI in the first 48 h after surgery. A total of 5378 patients were included across 173 centres. Overall, 1249 patients (23·2 per cent) received intravenous contrast. The overall rate of AKI within 7 days of surgery was 13·4 per cent (718 of 5378). In the propensity score-matched model, preoperative exposure to contrast was not associated with AKI within 7 days (odds ratio (OR) 0·95, 95 per cent c.i. 0·73 to 1·21;P = 0·669). The sensitivity analysis showed no association between preoperative contrast administration and AKI within 48 h after operation (OR 1·09, 0·84 to 1·41; P = 0·498). There was no association between preoperative intravenous contrast administered for CT up to 7 days before surgery and postoperative AKI. Risk of contrast-induced nephropathy should not be used as a reason to avoid contrast-enhanced CT.

P392 Initial experience with fibrin glue combined with infliximab treatment of postoperative anastomotic fistula in patients with Crohn’s disease

Abstract Background Postoperative anastomotic fistula is one of the most frequent and potentially life-threatening complications following gastrointestinal resections in patients with Crohn’s disease. The purpose of this study was to report the results of using infliximab to treat postoperative anastomotic fistula in patients with Crohn’s disease. Methods A prospective parallel study of fibrin glue combined with infliximab vs. fibrin glue treatment was conducted. Demographic and clinical characteristics and outcomes were compared between the groups. Results Thirty-five patients with postoperative anastomotic fistula were evaluated; 14 received fibrin glue combined with infliximab treatment and 21 received fibrin glue treatment. No significant differences in demographic or clinical characteristics were found between the two groups (all p > 0.05). There were two recurrences in the fibrin glue group, and no recurrences in the fibrin glue combined with infliximab group(p = 0.506). No complications occurred in either group. Conclusion Infliximab strategy with combining fibrin glue is a simple and effective treatment alternative in the management of postoperative anastomotic fistula in Crohn’s disease.

Impact of postoperative intensive care unit utilization on postoperative outcomes in adults undergoing major elective noncardiac surgery

ObjectiveThere is a wide variation between hospitals with respect to rates of use of postoperative intensive care unit (ICU) after major noncardiac surgery. Whether ICU care improves patient-centered outcomes remains unknown. Days alive and out of hospital (DAH) is a novel patient-centered outcome that has been validated for surgical patients. We conducted a population-based cohort study to evaluate the association of hospital-level postoperative ICU use with DAH after select major elective noncardiac surgery. DesignHistorical cohort study. SettingAcute hospitals in Ontario, Canada. PatientsAdults aged ≥40 years who underwent lower gastrointestinal, peripheral arterial disease and nephrectomy surgery between 2006 and 2016. InterventionThe main exposure was admission to ICU within 24 h after surgery. MeasurementThe primary outcome was DAH at 30 days (DAH30) and secondary outcomes were DAH at 90 and 180 days (DAH90 and DAH180). Hospitals were ranked into quartiles based on the hospital-specific proportion of patients admitted to ICU within 24 h post-surgery. Descriptive statistics and hierarchical multivariable quantile regression modeling were used to assess the unadjusted and adjusted association of hospital-level ICU use with the primary and secondary outcomes for each surgical procedure. Main resultsThe cohort included 91,950 patients. Median DAH30 was 23 days for lower gastrointestinal resection, 24 days for peripheral arterial disease and 26 days for nephrectomy. Higher hospital-specific use of ICU use after surgery was not associated with improved DAH30, DAH90 or DAH180 for any surgical group. ConclusionsHospital-specific ICU admission practice showed no association with the patient-centered outcome of DAH in select elective major noncardiac surgical procedures.

ICG vs. HSI in Gastrointestinal Resections

ICG vs. HSI in Gastrointestinal Resections

Optimal Dose of Dexmedetomidine for Perioperative Blood Glucose Regulation in Non-Diabetic Patients Undergoing Gastrointestinal Malignant Tumor Resection: A Randomized Double-Blinded Controlled Trial

Purpose To evaluate the optimal dose of dexmedetomidine for perioperative blood glucose regulation in non-diabetic patients with gastrointestinal malignant tumor. Methods One hundred patients were randomly divided into four groups: control group (group C), dexmedetomidine 1 μg/kg + 0.25 mcg/kg/h (group D1); + 0.5 mcg/kg/h (group D2); and + 1 mcg/kg/h (group D3). Blood glucose concentrations were measured before dexmedetomidine infusion (T1), 1 h after surgery beginning (T2), at the end of surgery (T3), and 1 h in PACU (T4). Duration of surgery, extubation time, anesthetics doses, adverse reactions, postoperative pulmonary infection, total peritoneal drainage 2 days after surgery and hospital stay were recorded. Results Compared with T1, blood glucose concentrations were higher at T4 in group C and at T2–4 in groups D1, D2, and D3 (p < 0.01). Compared with group C, blood glucose concentrations were higher at T2 and T3 in groups D2 and D3 (p < 0.05), but significantly lower at T4 in groups D1, D2, and D3 (p < 0.01). Propofol and remifentanil consumption in groups D1, D2, and D3 decreased significantly compared with group C (p < 0.01). In group D3, doses of ephedrine (p < 0.05) and atropine (p < 0.01) were higher, and extubation time was prolonged (p < 0.01) compared with the other groups. The incidence of bradycardia was higher in group D3 than that in group C (p < 0.05). Conclusions Dexmedetomidine loading dose of 1 mcg/kg followed by maintenance with 0.25 mcg/kg/h can regulate perioperative blood glucose well in non-diabetic patients undergoing gastrointestinal malignant tumor resection and reduce doses of anesthetics without extending extubation time.

Postoperative developed intra-abdominal desmoid tumor after surgical resection of gastrointestinal malignancy: A review of 10 cases

Purpose Desmoid tumors are locally aggressive tumors with no known potential for metastasis. They tend to recur even after complete excision. Sometimes it is not easy to differentiate between intra-abdominal desmoid and tumor recurrence, especially after gastrointestinal (GI) tumor resection. The current study aims to review the characteristics, management, and outcomes of patients with intra-abdominal desmoid tumor post GI resection. Methods During the period between 2007 and 2018, after a retrospective review of patients’ clinical data, 10 patients were finally included. Medical records were screened for demographic, clinical, pathological data, management strategy, postoperative morbidity, mortality, recurrence rate and follow-up. Results The study comprised 10 patients (8 males). The median age was 53.5 years (range, 35–68 years). Two patients diagnosed as familial adenomatous polyposis (FAP). All the patients underwent previous GI resection: three (30%) for colon cancer, three (30%) gastrectomy, two (20%) total proctocolectomy with ileal pouch-anal anastomosis (TPC+IPAA) for FAP, one (10%) low anterior resection (three rectal cancers) and one (10%) distal pancreatectomy. The tumor was found to be in bowel mesentery in eight cases (80%). The median tumor size was 5.3 cm (range, 2.6–19.0 cm). Six patients (60%) underwent open resection, while four patients (40%) underwent laparoscopic surgery. Complications occurred in five cases (50%) and ranged from Clavien-Dindo (II–III). The median follow-up period was 16.5 months (1.5–136.0 months) with recurrence in one case (10%). Pathology came out to be desmoid tumor fibromatosis in all cases. Conclusion When a mass develops after surgical resection for abdominal GI malignancy and tends to be large in size, located in the bowel mesentery and away from previous primary tumor site, most probably it is desmoid rather than tumor recurrence. Keywords: Fibromatosis, Abdominal, Adenomatous polyposis coli, Mesentery, Neoplasm recurrence

The relationship between aortic calcification and anastomotic leak following gastrointestinal resection: A systematic review.

Anastomotic leak (AL) is a significant complication of gastrointestinal (GI) surgery. Impaired perfusion of the anastomosis is thought to play an important role. The degree of aortic calcification (AC) visible on preoperative CT imaging may be associated with an increased risk of AL following GI resection. This review assessed the relationship between AC and AL in patients undergoing GI resection. MEDLINE, EMBASE and the Cochrane library were systematically searched between 1946 and 2019. Relevant keywords were grouped to form a sensitive search strategy: surgical procedure (e.g. digestive system surgical procedure), calcification (e.g. vascular calcification, calcium score) and outcome (e.g. anastomotic leak). Studies assessing the degree of AC on preoperative imaging in relation to AL in adult patients requiring resection and anastomosis were included. The quality of each study was assessed using the Newcastle-Ottawa scale. Bias was assessed using the RevMan risk of bias tool. Nine observational studies were included: four in patients undergoing oesophageal resection (n=1446) and five in patients undergoing colorectal resection (n=556). AL occurred in 20% of patients following oesophagectomy and 14% of patients following colorectal resection. Adjustment for relevant confounders was limited in most studies. Two studies reported a relationship between the degree of AC and AL in patients undergoing oesophagectomy, independent of age and comorbidity. One study reported an association between AC and AL following colorectal resection, while three studies reported higher calcium scores in the iliac arteries of patients who developed colorectal AL. Overall study quality was moderate to good using the Newcastle-Ottawa scale. Detection and reporting bias was evident in the studies examining AL following colorectal resection. The current evidence suggests that the degree of AC may be associated with the development of AL, in particular in patients undergoing oesophagectomy. Further prospective data with adequate adjustment for confounders are required. CRD42018081128.

Subclassification of Multivisceral Resections for T4b Colon Cancer with Relevance for Postoperative Complications and Oncological Risks

BackgroundMultivisceral resection for T4b colon cancer constitutes a heterogeneous group of surgical procedures. The purpose of this study was to explore clinically distinct categories of multivisceral resection, with subsequent correlation to postoperative complications and oncological outcomes. MethodsIn this multicenter cohort study, all consecutive patients without metastases who underwent multivisceral resection for pT4bN0-2M0 colon cancer between 2000 and 2014 were included. Multivisceral resection was divided into four categories: (i) gastrointestinal (including the stomach), (ii) urologic ((partial) bladder and ureter), (iii) solid organ (spleen, kidney, liver, pancreas, and uterus), and (iv) abdominal wall/omentum/ovaries. The primary outcome was surgical complications and secondary outcomes were 5-year intra-abdominal recurrence, disease-free survival, and overall survival. ResultsIn total, 130 patients who underwent curative intent resection of pT4 colon cancer were included. Patients who underwent multivisceral resection within multiple categories were assigned to one of the categories based on hierarchy of clinical impact after exploratory analysis. For the primary endpoint, 55 patients were assigned to gastrointestinal, 14 to urologic, 14 to solid organ, and 47 to abdominal wall/omentum/ovaries multivisceral resection. Gastrointestinal multivisceral resection was independently associated with surgical complications (HR 3.9, 95% CI 1.4–10.6). Abdominal wall/omentum/ovaries multivisceral resection was significantly related with intra-abdominal recurrence (HR 7.8, 95% CI 1.0–57.8). The 5-year disease-free survival and overall survival showed no significant differences per multivisceral resection category. ConclusionsMultivisceral resections for T4b colon cancer are heterogeneous procedures considering risk profiles. The proposed multivisceral resection subclassification needs validation, but might improve comparability between studies and hospitals (auditing).

Iron Deficiency Anemia Caused By Malabsorption from Proton Pump Inhibition

Introduction: Iron deficiency anemia (IDA) not responding to oral iron replacement usually requires a hematologic evaluation. 48 patients taking a proton pump inhibitor (PPI) and not responding to oral iron replacement were found to have an elevated serum gastrin (SG). No patient had gastrointestinal bleeding, gastric resection, bariatric surgery, or menorrhagia. Other causes for iron malabsorption such as celiac disease or helicobacter infection were not present. 94 percent responded to intravenous iron (IV iron). Methods: All patients previously had undergone diagnostic gastrointestinal evaluations. Testing for celiac disease and helicobacter infection was negative. Gastric biopsies did not demonstrate atrophy. Most referrals were from gastroenterologists. Results: 94% responded to IV iron with a rise in their hemoglobin of &amp;gt;/= 2 grams per cent. 83 percent (40/48) were women. Iron dextran (ID) at a fixed dose of 825 mgm was given to 85% of the patients. Twelve of these 41 patients were given a second infusion of ID as the first dose did not produce a satisfactory response. Ferric carboxymaltose and ferumoxytol were each given once at the fixed recommended dose, and second infusions was not necessary. Four patients received iron sucrose at a weight based dose, and a second series of infusions were not necessary. One patient responded to ferumoxytol after a suboptimal response to iron dextran. An elevated SG was defined as &amp;gt;100 pg/mL. The average SG was 370.25 pg/mL (114 to 2101 pg/mL). Hemoglobin rose an average of 3.35 gram% (9.56 to 12.91 gm%). The change in hemoglobin was minus 0.4 to plus 7.0 gm% with a baseline hemoglobin ranging between 6.6 to 14.3 gm% and rising between 9.3 to 16.2 gram%. Ferritin rose an average of 14.8 to 158 ng/mL with baseline ferritin ranging between 3 to 73 ng/mL and rising between 22 to 659 ng/mL The average MCV rose from 75.89 to 84.93 fL with baseline MCV ranging between 61 to 93 fL rising between 69 to 96 fL The average iron saturation rose from 7.49 to 22.89% with baseline saturation ranging between 2 to 34% and rising between 10 to 39%. Discussion: Dietary iron consists of both heme and non heme iron. Heme iron is derived from the hemoglobin and myoglobin in animal food sources such as meat, seafood, and poultry. Heme iron is in the ferrous (II) oxidation state, is easily absorbable, and contributes 10% or somewhat more of total absorbed iron. Non heme iron is in the ferric (III) form and is derived from plants and iron fortified food. Normally 1-2 mgm of iron is absorbed daily. Heme iron is well absorbed after its release by pancreatic enzymes. Non heme iron is less well absorbed and requires acid secretion from gastric parietal cells for the denaturing of ingested proteins and subsequent proteolysis. PPI causes decreased hydrogen ion (H+) production by inhibiting the hydrogen/potassium pump within gastric parietal cells. The elevated SG derives from G cell hyperplasia as a response to the lowered H+ activity caused by PPI. The decreased H+ activity inhibits the release of ferric iron from non animal sources. Iron absorption occurs in the proximal duodenum through the action of a brush border ferrireductase such as duodenal cytochrome B which reduces ferric iron to ferrous iron. With less ferric iron available for reduction less ferrous iron is absorbed, and iron deficiency results. Intravenous iron fully corrected the IDA in 94% of treated patients. Two of the 3 non responders were obese and only received one infusion of ID. Perhaps a second infusion might have been beneficial. However no relation between weight, response, and ID dosing could be detected. Both patients had normal hemoglobins before the iron infusion but were very symptomatic from their iron deficiency. Both patients experienced a rise in their hemoglobin (1.9 gram% and 1.4 gm%). The third non responder actually had a fall in the hemoglobin from 10.5 to 10.1 gm%. No clear explanation was apparent. No clear explanation for the female predominance was apparent. Conclusion: In 2009 119 million prescriptions for PPI were written in the USA. The gastrointestinal literature suggests that anemia from PPI is uncommon. Very likely IDA due to IM from PPI is much more common than recognized and should be considered for any iron deficient patients without evidence for other causes for IDA. Intravenous iron is highly effective. Disclosures No relevant conflicts of interest to declare.

Varying practices in tumor regression grading of gastrointestinal carcinomas after neoadjuvant therapy: results of an international survey.

Tumor regression grading is routinely performed on neoadjuvantly treated gastrointestinal cancer resections. Challenges in tumor regression grading include grossing standards, multiple grading systems, and difficulty interpreting therapy-induced changes. We surveyed gastrointestinal pathologists around the world for their practices in handling neoadjuvantly treated gastrointestinal cancer specimens and reporting tumor regression using a 23-question online survey. Topics addressed grossing, histologic work-up, tumor regression grading systems, and degree of difficulty identifying and estimating residual cancer within treatment effect. Two-hundred three responses were received, including 173 participants who completed the entire questionnaire. Fifty percent of the participants were from Europe, 29% from North America, 10% from Australia, and 11% from other continents. Ninety-five percent routinely report a tumor regression grade and 92% have standardized grossing and histologic work-up: 27% always completely embed the entire tumor bed, 54% embed the complete tumor site if not a grossly apparent, large mass. Fifty-nine percent use hematoxylin & eosin alone for assessment; the remaining use additional stains. In North America and Australia, the American Joint Committee on Cancer (AJCC)/College of American Pathologists (CAP)/Ryan system is routinely used for gastroesophageal (71%) and rectal carcinomas (77%). In Europe, the Mandard system is common (36%) for gastroesophageal tumors, followed by AJCC/CAP/Ryan (22%), and Becker (10%); for rectal CA, the Dworak system (30%) is followed by AJCC/CAP/Ryan (24%) and Mandard (14%). This regional differences were significant (p < 0.001 each). Fifty-one percent prefer a four-tiered system. Sixty-six percent think that regressive changes in lymph nodes should be part of a regression grade. Sixty-nine percent consider identifying residual tumor straight-forward, but estimating therapy-induced fibrosis difficult (57%). Free comments raised issues of costs for work-up and clinical relevance. In conclusion, this multinational survey provides a comprehensive overview of grossing and histologic work-up with regards to tumor regression grading in gastrointestinal cancers with partly significant regional differences particularly between North America and Europe.

Drainage fluid C-reactive protein and total Leucocytic count levels as early detectors of anastomotic leakage postgastrointestinal resection

Aim Anastomotic leakage (AL) following gastrointestinal resection is a complication associated with significant morbidity and mortality. C-reactive protein (CRP) is produced by the liver in response to inflammatory cytokines and is used as an indicator for postoperative complications. This study investigated the role of CRP and total leukocyte count (TLC) in blood and drainage fluid in the prediction of AL following gastrointestinal resection. Patients and methods Serum and drainage fluid CRP and TLC in blood and drainage fluid were measured on the first, third, and fifth postoperative days (PODs) in 96 patients who underwent gastrointestinal resection. Results CRP in the drainage fluid was significantly elevated in patients who developed AL compared with those who did not have leak on all PODs (P=0.003, Conclusion CRP in the drainage fluid was found to be a predictor of AL following gastrointestinal resection especially on the third and fifth PODs with cutoff values of 137.5 and 171.5 mg/l, respectively.

160 Endoscopic Full-Thickness Resection of Gastrointestinal Lesions With the Over-The-Scope Device: A Single Center Experience

INTRODUCTION: While endoscopic transmural resection (EMR) and endoscopic submucosal dissection (ESD) are the conventional endoscopic resection methods for gastrointestinal (GI) lesions, endoscopic full-thickness resection (eFTR) is a promising minimally invasive modality for gastrointestinal lesions resection with good outcomes and less complications compared to EMR and ESD. Full thickness resection device (FTRD) is an over-the-scope device that has been developed for one-step eFTR. In this study, we report our experience with FTRD for GI lesions. METHODS: We retrospectively analyzed data from 17 patients who underwent eFTR with FTRD at our institution. Complete resection (R0), technical success, and clinical outcomes were studied. RESULTS: The indications for eFTR were recurrent/residual adenoma (12 cases), primary non-lifting adenoma (2 cases), submucosal lesions resection (2 cases), and early carcinoma (1 case). Eleven patients were males and six were females. The median age was 60 years (range 32–84). Locations of the lesions were: (3) in the cecum, (8) in the ascending colon, (2) in the transverse colon, (2) in the hepatic flexure, (1) in the rectum, and (1) in the stomach. Technical success rate was 13/17 (76%). Three of the unsuccessful attempts were due to inability to advance the endoscope to the cecum in one case and inability to pull up fibrotic lesions in the other two cases. The fourth unsuccessful case was due to device malfunction as the lesion was snared but the clip was not deployed. The mean maximum diameter of lesions after resection was 18.3 mm (range 13–22). R0 resection rate was 14/14 (100%). Microscopic full-thickness resection was achieved in 43% (6/14). The median procedure time was 67 minutes (range 31–140). The case with the device malfunction was complicated by perforation and delayed minor bleeding. The perforation was managed during the procedure with hemostatic clips. Another case had delayed minor bleeding without requiring blood transfusion. All patients were discharged on the same day except patients with complication as they required 1–2 days of inpatient observation. CONCLUSION: Discussion eFTR using FTRD is a safe minimally invasive procedure with good clinical outcomes. eFTR is currently indicated for treatment of non-lifting lesions, incomplete polypectomy, submucosal.

900 Efficacy and Safety of Endoscopic Full-Thickness Resection Device (FTRD) for Gastrointestinal Lesions Full-Thickness Resection: A Meta-Analysis Study

INTRODUCTION: Endoscopic full-thickness resection (EFTR) is an emerging minimally invasive resection procedure for GI lesions not amenable to conventional resection methods. Endoscopic full-thickness resection device (FTRD) is an over-the-scope single-step device that has been developed recently for EFTR. In this meta-analysis, we aim to assess efficacy and safety of FTRD for EFTR of GI lesions. METHODS: Methods: A comprehensive literature review was performed. Studies with &lt; 5 cases were excluded. Rates of histologic complete resection (R0), technical success, and complications were extracted. Pooled estimates and the 95% CI were calculated depending on heterogenicity. Heterogenicity was assessed using I2 statistics. RESULTS: Nine studies (5 retrospective and 4 prospective) including 480 patients with 489 lesions were included. Indications were difficult adenomas (355), early carcinoma (82), and subepithelial lesions (SEL) (47). Locations of the lesions: stomach (5), duodenum (20), proximal colon (220), distal colon (98), and rectum (141). 57% of patients were male with median of age 66.5 years (range 20-92). Mean size of the lesions was 15.36 mm (range 1-40). Median procedure time was 46.56 minutes (range 3-190). Mean hospital stay was 3.23 days (range 0-11). Pooled overall R0 resection rate and technical success rate were 81.12% (95% CI: 77.63-84.6; I2 56.7%) and 90.39% (95% CI: 87.76-93.00; I2 10.2%), respectively. The pooled R0 resection rate was 81.59% (95% CI: 76.96-85.63) for difficult adenomas, 83.47% (95% CI: 73.19-91.00) for early carcinomas, and 81.59% (95% CI:68.25-91.05) for SELs. For locations; R0 resection rate were 78.42% (95% CI: 72.17-85.50), 76.97% (95% CI: 62.56-87.88), and 80.59% (95% CI: 67.56-90.09) for proximal, distal colon, and rectum, respectively. The complications were as follows: minor bleeding 2.89 (95% CI: 1.60-4.76), major bleeding 0.88 (95% CI: 0.26-2.15), perforation 2.23% (95% CI: 1.12-3.95), postpolypectomy syndrome 1.26% (95% CI: 0.48-2.68), local trauma 0.9% (95% CI: 0.27-2.19), and other complications 1.91% (95% CI: 0.90-3.54). Of 50 patients with peri-appendicular lesion, the rate of appendicitis was 14.29% (95% CI: 6.38-26.23). The rate of complications that required surgery was 1.55 (95% CI: 0.66-3.06). No procedural death related was found. There was no correlation between mean lesion’s size and complications rates CONCLUSION/DISCUSSION: FTRD is a safe and effective procedure for lesions not suitable for conventional resection.

2125 Overcoming the Challenge of Full Thickness Resection of Gastric Lesions Using Colonic Full Thickness Resection Device (FTRD): Novel Technique

INTRODUCTION: Colonic FTRD (over the scope full thickness resection device) is safe, feasible and approved for colorectal lesions. However, it’s role for upper gastrointestinal (UGI) lesions resection need to be further studied. Colonic FTRD system’s cap diameter is 21 mm which makes it very challenging to insert through the mouth for UGI lesions. We present a case of endoscopic full thickness resection (eFTR) of stomach lesion using colonic FTRD using a novel technique for upper esophagus dilation to assist in the insertion of colonic FTRD through the mouth. CASE DESCRIPTION/METHODS: Case Presentation A 49-year-old female was referred to us for endoscopic resection of submucosal lesion suspected for gastric stromal tumor (GIST) prior to bariatric gastric bypass surgery. EGD revealed the lesion in the gastric body. Endoscopic ultrasound (EUS) confirmed it as well demarcated hypoechoic lesion measuring 0.8 cm × 0.8 cm arising from the intersection of submucosal layer and muscularis layer without adjacent lymphadenopathy. FTRD under general anesthesia was planned. eFTR technique: To assist the insertion of colonic FTRD, upper esophagus was dilated with savory dilator size 51 French for 1 minute, then with 55 French for 1 minute and then with 60 French for 5 minutes. Pediatric colonoscope installed with FTRD was gently advanced into the stomach lumen. Circumferential marking of the lesion was done using FTRD marking probe. Favorable positioning was achieved. FTRD grasper was used to grasp and mobilize the tissue into the cap. Clip was applied and snare was hooked to high frequency generator performing high frequency snare resection. Endoscope was removed along with resection specimen. Histopathology revealed fibrotic nodule with complete resection (R0). Endoscopy at 3-month revealed no recurrence. DISCUSSION: UGI FTRD is not yet approved in the US. Our case illustrates that colonic FTRD can be used for UGI lesion. Our novel technique of serial esophageal dilation before insertion of larger size FTRD is unique. Similar technique can be used for insertion of future UGI FTRD system as well as its cap diameter is still larger at 19.5 mm which can still be challenging in patients with small upper GI caliber. Since muscularis propria was missing in resected tissue, it opens up a question if device is only capable of eFTR in lower GI tract (thin GI wall as compared to upper GI wall) or if it can achieve similar results with respect to true “full thickness resection” as eFTR in lower GI tract.

Risk Factors for Delayed Bleeding after Therapeutic Gastrointestinal Endoscopy in Patients Receiving Oral Anticoagulants: A Multicenter Retrospective Study

Background/Aims: Delayed bleeding is among the adverse events associated with therapeutic gastrointestinal endoscopy. The aim of this study was to evaluate risk factors for delayed bleeding after gastrointestinal endoscopic resection in patients receiving oral anticoagulants as well as to compare the rates of occurrence of delayed bleeding between the oral anticoagulants used. Methods: We retrospectively analyzed a total of 772 patients receiving anticoagulants. Of these, 389 and 383 patients were receiving direct oral anticoagulants (DOACs) and warfarin, respectively. Therapeutic endoscopic procedures performed included endoscopic submucosal dissection (ESD), endoscopic mucosal resection, polypectomy, and cold polypectomy. Results: Delayed bleeding occurred in 90 patients (11.7%) with no significant difference between the DOAC and warfarin groups (9.5 and 13.8%, respectively). Delayed bleeding occurred significantly more frequently with apixaban than with rivaroxaban (13.5 vs. 6.4%; p < 0.05). A multivariate analysis identified continued anticoagulant therapy (OR 2.29), anticoagulant withdrawal with heparin bridging therapy (HBT; OR 2.18), anticoagulant therapy combined with 1 antiplatelet drug (OR 1.72), and ESD (OR 3.87) as risk factors for delayed bleeding. Conclusion: This study identified continued anticoagulant therapy, anticoagulant withdrawal with HBT, anticoagulant therapy combined with 1 antiplatelet drug, and ESD as risk factors for delayed bleeding after therapeutic endoscopy in patients receiving oral anticoagulants. Delayed bleeding rates were not significantly different between those receiving DOACs and warfarin. It was also suggested that the occurrence of delayed bleeding may vary between different DOACs and that oral anticoagulant withdrawal should be minimized during therapeutic gastrointestinal endoscopy, given the thromboembolic risk involved.

Effects and mechanism of Laifuchengqi decoction of the recovery of gastrointestinal function after gastrointestinal resection

Effects and mechanism of Laifuchengqi decoction of the recovery of gastrointestinal function after gastrointestinal resection