Outcomes Of Endoscopic Intervention Research Articles

Outcomes of Endoscopic Intervention Using Over-the-Scope Clips for Anastomotic Leakage Involving Secondary Fistula after Gastrointestinal Surgery: A Japanese Multicenter Case Series.

The over-the-scope clip (OTSC) is a highly effective clipping device for refractory gastrointestinal disease. However, Japanese data from multicenter studies for anastomotic leakage (AL) involving a secondary fistula after gastrointestinal surgery are lacking. Therefore, this study evaluated the efficacy and safety of OTSC placement in Japanese patients with such conditions. We retrospectively collected data from 28 consecutive patients from five institutions who underwent OTSC-mediated closure for AL between July 2017 and July 2020. The AL and fistula were located in the esophagus (3.6%, n = 1), stomach (10.7%, n = 3), small intestine (7.1%, n = 2), colon (25.0%, n = 7), and rectum (53.6%, n = 15). The technical success, clinical success, and complication rates were 92.9% (26/28), 71.4% (20/28), and 0% (0/28), respectively. An age of <65 years (85.7%), small intestinal AL (100%) and colonic AL (100%), defect size of <10 mm (82.4%), time to OTSC placement > 7 days (84.2%), and the use of simple suction (78.9%) and anchor forceps (80.0%) were associated with higher clinical success rates. OTSC placement is a useful therapeutic option for AL after gastrointestinal surgery.

S1012 Outcomes of Endoscopic Therapy With Over-The-Scope Clip Placement for Fistula Closure in Patients With Inflammatory Bowel Disease

Introduction: Fistula management in patients with inflammatory bowel disease (IBD) is complex and requires a multidisciplinary team. Data regarding outcomes of endoscopic intervention with over-the-scope clip (OTSC) placement as a primary endoscopic therapy for fistula closure among IBD patients are limited. Aim: To assess the efficacy and safety of endoscopic therapy with emphasis on OTSC placement for fistula closure in patients with IBD. Methods: A retrospective review of the electronic medical records of patients with IBD who underwent fistula closure with OTSC from December 2011-January 2021 was performed. Data was abstracted for patient demographics, clinical characteristics, endoscopic techniques, and outcomes including need for surgery and fistula closure. Results: A total of 19 patients (13 females; mean age 40.3 (range 17-83) years; mean BMI 23.8 ±7.0 kg/m 2 ) were identified. Of these, 9 (47%) patients had a diagnosis of chronic ulcerative colitis, 9 (47%) Crohn’s disease and 1 (5%) indeterminate colitis. All patients had a history of IBD-related surgery and 10 (53%) patients developed fistulas within 6 months of surgery. Seventeen (89%) patients underwent OTSC placement at their index therapeutic endoscopy (ITE) for fistula closure. Adjunctive treatment modalities to OTSC, including argon plasma coagulation, fibrin glue and endoscopic suturing, were used in over 50% of patients at the ITE and the median number of endoscopic treatment sessions was 2 (range 1-9) (Table 1). Thirteen (68%) patients failed endoscopic therapy and 12 (63%) patients ultimately required surgical interventions, including fistula takedown and bowel resection in 3, bowel resection in 2, and diverting loop ileostomy in 4 and/or pouch excision in 5 patients. The mean time from ITE to surgery was 8.9 (range 0.3-35) months. Six (32%) patients were considered to have a successful endoscopic outcome, in whom 4 (21%) patients achieved complete resolution of symptoms and sustained fistula closure on imaging with a mean follow-up of 16.8 (range 0.5-41.5) months from the last endoscopic intervention. Two (10%) patients reported significant symptomatic improvement despite the absence of complete closure on follow-up imaging. No adverse events were reported as a direct result of OTSC placement. Conclusion: OTSC placement with or without adjunctive modalities is successful at closing fistulas in one-third of patients with IBD. Further studies are needed to identify patients who are more likely to benefit from endoscopic therapy.Table 1.: Endoscopic therapies for fistula closure in patients with IBD. Abbreviations: EC = enterocutaneous, IC = Ileocolonic anastomosis, OTSC = over-the-scope-clip, APC = argon plasma coagulation, FG = fibrin glue, ES = endoscopic suturing, SEMS = self-expandable metallic stent, AE = adverse events. *Stent migration requiring endoscopic removal. †Patients 17 and 19 were also treated with plug placement by interventional radiology, patient 17 at the time of the second endoscopy and patient 19 one month after his first endoscopic procedure.

Utility of Endoscopy in Hospitalized Patients with Gastrointestinal Hemorrhage and Pulmonary Hypertension.

Gastrointestinal hemorrhage (GIH) has been reported as one of the most common GI complications in patients with pulmonary hypertension (PH). There is paucity of data on the national burden of GIH in patients with PH. We aimed to assess the prevalence, trends and outcomes of endoscopic interventions in patients with PH who were admitted with GIH. We queried National Inpatient Sample (NIS) database from 2005 to 2014 and identified the patients hospitalized with primary or secondary discharge diagnosis of PH (ICD 9 CM Code: 416.0, 416.8, and 416.9). Using Clinical Classification Software Coding system (153) patients with concurrent diagnosis of GIH were then identified. We studied the prevalence and trends of GIH in PH, factors associated with GIH, use of endoscopy, factors associated with utilization of endoscopic interventions, endoscopy outcomes including mortality, and overall healthcare burden. Out of 7,586,973 PH hospitalizations 3.2% (N = 246,358) had concurrent GIH, with a rising prevalence of GIH in PH patients during the last decade. Clinical predictors for GIH in PH included older age, congestive heart failure, anticoagulation therapy and concurrent alcohol abuse. Mean length of stay (LOS) in PH patients hospitalized with GIH was significantly higher than without GIH (8.6 vs. 6.4days, p < 0.01) along with a significant increase in hospitalization cost ($20,189 vs. $14,807, p < 0.01). Similarly, odds of in-hospital mortality increase by ~ 1.5 times in PH patients with GIH than those without it (adjusted odds ratio [aOR: 1.45, 95%CI: 1.43-1.47]). Endoscopic interventions were performed in 48.6% of patients with PH and GIH during their hospitalization. Older patients were more likely to undergo endoscopy, as well as the patients who received blood transfusion, and those with hypovolemic shock. Patients with acute respiratory failure and acute renal failure were less likely to get endoscopy. Mean LOS in patients undergoing endoscopic intervention was significantly higher than those who did not receive any intervention (8.7 vs. 8.4days, p < 0.01), without a substantial increase in hospitalization cost ($20,344 vs. $20,041, p < 0.01). Also, there was a significant decrease in in-hospital mortality in patients undergoing endoscopic interventions. Concurrent GIH in patients with PH increases length of stay; healthcare costs and increases in-hospital mortality. Use of endoscopic interventions in these patients is associated with reduced length of stay, in-hospital mortality without significantly increasing the overall health care burden and should be considered in hospitalized patients with PH who are admitted with GIH. Future studies comparing GIH patients with and without PH should be done to assess if PH is a risk factor for worse outcomes. No IRB required due to use of national de-identified data.

Endoscopic intervention in pancreatitis: perspectives from a gastroenterologist.

The last decade has seen a dramatic paradigm shift for the treatment of pancreatitis and its related complications away from surgery to minimally invasive endoscopic approaches. In this review, we provide an overview of the indications, techniques and outcomes of endoscopic interventions in the management of acute and chronic pancreatitis. Emphasis is placed on drainage of pancreatic pseudocysts and treatment of pain in chronic pancreatitis.

Outcomes of Endoscopic Intervention for Gastrointestinal Bleeding in the Setting of Severe Thrombocytopenia

Outcomes of Endoscopic Intervention for Gastrointestinal Bleeding in the Setting of Severe Thrombocytopenia

Gastrojejunal Stricture After Gastric Bypass and Efficacy of Endoscopic Intervention

The Roux-en-Y gastric bypass procedure (RYGBP) is an effective treatment for morbid obesity. Anastomotic strictures are a common complication after RYGBP. This study examines the frequency of post-RYGBP gastrojejunal strictures (GJS), methods of evaluation, and the outcome of endoscopic intervention. Medical records of patients who had RYGBP for morbid obesity at our institution during four consecutive years were reviewed for patient demographics, medical comorbidities, surgical technique, and outcomes. Radiographic and endoscopic findings of those patients suspected to have GJS were noted. The impact of patient-related variables and surgical technique on risk of GJS, time to diagnosis of GJS, and treatment outcomes for GJS was determined. Of 888 patients, 503 had open RYGBP (57%) and 385 laparoscopic RYGBP (43%). Ninety-four patients (10.6%) underwent esophagogastroduodenoscopy (EGD) for possible GJS and 58 (6.5%) were found to have anastomotic stricture. Laparoscopic RYGBP was associated with increased incidence of GJS (43/385, 11.1%) compared with open RYGBP (15/503 or 2.9%, P = 0.0003). A total of 125 dilations were performed with an average of 2.2 dilations per patient. None of the strictures needed surgical revision. There were four perforations (3.2%) related to EGD. Mean time to diagnosis of GJS was 66.2 days. Eighty-seven of 94 patients underwent radiologic upper gastrointestinal (UGI) evaluation prior to EGD. UGI evaluation demonstrated a positive predictive value (PPV) of only 66% [95% confidence interval (CI) 52-77], and negative predictive value (NPV) of 83% (95% CI 65-93). Laparoscopic GBP is associated with increased risk of GJS. Endoscopic dilation of GJS is an effective treatment with minimal risk. Radiographic studies appear to have poor specificity for diagnosis of GJS and have a low positive predictive value. EGD should be performed in all suspected cases of GJS.

ERCP Evaluation and Treatment for Pancreaticobiliary Complications Following Pancreaticoduodenectomy (PDE/Whipple's Resection)

Background: Ductal anastomotic stricturing not infrequently follows PDE, especially with long-term survival, and may be approached endoscopically. The success and outcome of endoscopic intervention in this setting has been little reported. Patients (Pts) and Methods: From 1/1993 to 6/2006, 39 pts were identified in a prospective ERCP database as having undergone a total of 65 attempted ERCPs in PDE pts. Pts had undergone PDE a median of 39.5 months earlier (1-396 months) and indications for the surgery included chronic pancreatitis (n = 9), pancreatic cancer (n = 9), ampullary adenoma (n = 8), cholangioca (n = 5), neuroendocrine tumor (n = 4), or other (n = 4). The indications for ERCP were biliary (jaundice, colic, cholangitis, abnormal LFTs) in 23/39 (59%) and pancreatic (pancreatitis, pancreatic-type pain, pseudocyst, steatorrhea) in 16/39 (41%). ERCPs were performed with standard side-viewing endoscopes, pediatric colonoscopes, or prototype oblique-viewing enteroscopes and standard or special long-length accessories. Results: Success for planned interventions was achieved in 29/43 attempts (67%) for biliary indications and 10/21 attempts (48%) for pancreatic indications. Total biliary interventions included stent placement (n = 17), balloon dilation (n = 9), stone extraction (n = 7) and diathermic stricture release (n = 6). Total pancreatic interventions included stent placement (n = 8), balloon dilation (n = 3), diathermic stricture release (n = 1) and pseudocyst drainage (n = 1). Successful cannulation of the desired duct depended on endoscopic access to the afferent jejunal limb and was independent of the type of PDE (conventional with antrectomy (n = 21) or with pylorus preservation (n = 18)). In follow-up, of the 24 pts who underwent successful endoscopic intervention, 10 pts (42%) required an average of 2.9 (range 2-7) re-interventions. Minimum follow-up of 6 months after the final intervention was determined in 22/24 pts (92%) who had undergone successful cannulation and endoscopic treatment. 18 of these 22 (81%) pts were alive and 14/22 (64%) pts were asymptomatic. Four pts continued to have symptoms despite patent anastomoses at endoscopy. Four pts have died from progressive cancer. Of the 15 unsuccessful ERCP pts, 8 have undergone additional procedures including PTC (3 pts) or surgical revision (5 pts). Two pts have died and 5 continue to be followed. Conclusions: Endoscopic intervention in the setting of Whipple's resection for a variety of indications can often be achieved with positive outcome, especially for biliary indications. The approach to and the identification of the pancreatic anastomosis is technically challenging resulting in failure in >50%.

Endoscopic retrograde cholangiopancreatography in chronic pancreatitis.

Endoscopic retrograde cholangiopancreatography (ERCP) plays an important diagnostic and therapeutic role in the management of chronic pancreatitis. New techniques are being developed which should further improve outcomes of endoscopic intervention. The ultimate role of these therapeutic interventions for chronic pancreatitis awaits prospective randomized data demonstrating their efficacy and safety in comparison to surgery. Until such time, these often difficult techniques should be performed by experienced endoscopists with significant experience in pancreatic disease, ideally within the context of controlled clinical trials.