Repeat Endoscopic Intervention Research Articles

A140 DELAYED BLEEDING POST-ENDOSCOPIC AMPULLECTOMY FOR AMPULLARY ADENOMAS: INCIDENCE, RISK FACTORS AND MANAGEMENT OF DELAYED BLEEDING

Abstract Background The duodenal tumors of major papilla account 10% of all peri-ampullary lesions, and the majority represent adenomas, carrying malignant potential through the well-known adenoma–carcinoma sequence ([i]). Historically, surgical resection was the standard of care, but it is associated with significant risk of complications (44.7%) ([ii]). Hence, endoscopic ampullectomy became the treatment modality for selected cases. Despite the significantly lower rate of adverse events, pancreatitis and bleeding occurs in up to 25% of patients ([iii]). The rate of bleeding may be even higher, depending on periampullary lesion size and type. Factors related to delayed bleeding are poorly understood. Aims The aim of our study was to determine predicting factors for delayed post-ampullectomy bleeding. Methods We conducted a single-center retrospective study over 13 years (2010-2023). All patients who underwent an endoscopic ampullectomy were analyzed. The primary endpoint was the incidence of delayed bleeding, which was defined as a post-procedural bleeding that necessitated either a blood transfusion, ICU admission or re-intervention. Secondary outcomes included risk factors for delayed bleeding, management, and other adverse events. Results 113 patients underwent endoscopic papillectomy [mean age 66.2 ± 12.2 years; male gender 51 (45.1%)]. Mean lesion size was 27.0 ± 14.3 mm and mean procedure duration was 62.8 ± 35.6 minutes. There were 24 cases of delayed bleeding (21.2%). Of these, 6 (25%) required repeat endoscopic intervention. The average length of hospital was longer in those experiencing a delayed bleed (8.6 ± 4.9 vs 4.8 ± 2.4 days, Pampersand:003C0.001). By univariable logistic regression, the odds of delayed bleeding were greater in those with hypertension (OR 3.8, 95%CI 1.4-10.3, P=0.008) or an INR ≥ 1.2 (OR 13.3, 95%CI 3.0-58.3, P=0.001). A multivariable logistic regression analysis revealed that INR≥ 1.2 predicted delayed bleeding, with an OR of 16.1 (95%CI 3.0-85.4, P=0.001). Other adverse events included perforation (n=7, 6.3%) and pancreatitis (n=19, 16.8%). There were no deaths. Conclusions Post-ampullectomy bleeding is a common adverse event in patients undergoing ampullectomy leading to more prolonged hospital stay. History of hypertension and elevated INR above 1.2 might be related to delayed post-ampullectomy bleeding. Additional strategies to reduce post-ampullectomy bleeding should be explored. Funding Agencies None

Health-related Quality of Life in Patients With Urethral Stenosis After Radiation Treatment for Prostate Cancer

ObjectiveTo evaluate patient-reported quality of life (PRQoL) in patients presenting with membranous urethral stenosis after prostate radiotherapy. Urethral stenosis is an under-reported complication after prostate radiotherapy with a particular deficiency in PRQoL. MethodsPatients presenting with urethral stenosis after radiotherapy were retrospectively reviewed from 2004-2022. PRQoL was assessed via patient survey using the Expanded Prostate Cancer Index Composite for Clinical Practice (EPIC-CP). Results230 patients were identified at a mean age of 67.7 years and mean time to stricture diagnosis of 63.6 months’ post-radiotherapy. Of 87 patients completing the survey, 29.9% recalled being aware of urethral stenosis as a potential complication and 51.7% had documentation of urethral stenosis as a potential complication. 33.5% of patients underwent urethroplasty, 59.6% repeat endoscopic treatment and 6.1% an indwelling catheter. 64.4% of patients reported urinary dysfunction as a “moderate” or “big” problem, 66.7% reported frequent or total incontinence, 64.4% required daily pad use and 50.6% reported incontinence as either a “moderate” or “big” problem. 85.0% reported poor or absent orgasmic dysfunction and 88.5% reported erections insufficient for sexual activity. Additionally, 47.1% of patients reported rectal pain and 31.0% reported dysuria. Depressive symptoms and fatigue were reported by 41.4% and 60.9% of patients respectively. ConclusionUrethral stenosis after radiotherapy is a clinically complex entity with a broad scope of associated symptoms including high rates of patient-reported incontinence, voiding dysfunction, sexual dysfunction, pain, bowel dysfunction and depression. This multi-focal nature combined with often insidious presentation and patient unawareness creates a uniquely challenging condition to treat.

Symptom duration is not associated with per oral endoscopic myotomy (POEM) failure.

Per oral endoscopic myotomy (POEM) is a relatively novel technique to address achalasia; however, little is known about the efficacy of POEM for patients with long-standing achalasia. We hypothesize that patients with long-standing achalasia prior to intervention will be more recalcitrant to POEM than patients with symptoms for a short duration. We performed a retrospective analysis of patients with achalasia who received a POEM at a single institution from 2012 to 2022. Patients were grouped into cohorts based on the time of symptom duration: < 1year, 1-3years, 4-10years, > 10years. POEM failure was defined as need for repeat intervention, symptom recurrence, and a high postoperative Eckart score. Demographic and clinical data were compared between cohorts. Measures of failure multivariable logistic regression analyzed the association between symptom duration and response to POEM. During the study period, 132 patients met inclusion criteria. Patient age at surgery, sex, BMI, Charleston-Deyo Comorbidity Index, and patients with diabetes with and without end organ complications, connective tissue diseases, and patients with ulcer diseases did not differ among cohorts. Patients who have had symptoms for greater than 10years had significantly more endoscopic interventions prior to their POEM (30% vs, 60% p = 0.002). Patients in all cohorts experienced the same number of symptoms post-POEM. Manometric measurements did not vary across cohorts after POEM. Symptom recurrence, need for repeat endoscopic intervention, repeat surgical intervention, or repeat POEM also did not vary across cohorts. Having symptoms of achalasia > 10years did not increase the odds POEM failure on multivariable logistical regression. These data suggest that longer symptom duration is not associated with increased rates of POEM failure. This is promising as clinicians should not exclude patients for POEM eligibility based on duration of symptoms alone.

Do preoperative endoscopic interventions predict symptom recurrence or reintervention after peroral endoscopic myotomy?

Studies assessing outcomes of patients undergoing peroral endoscopic myotomy (POEM) after botulinum injection or dilation have had various results with respect to failure, although this has not been differentiated between lack of clinical response and recurrence. We hypothesize that patients with previous endoscopic intervention(s) are more likely to recur than treatment-naïve patients. This is a retrospective cohort study of patients that underwent POEM for achalasia at a single tertiary care center between 2011 and 2022. Patients were excluded if they had previous myotomy (POEM or Heller). The remaining patients were stratified into treatment-naïve patients (TN), those with previous botulinum injection (BTX), those with previous dilatation (BD), and those with both previous endoscopic interventions (BOTH). Primary outcome was recurrence indicated by clinical symptoms or need for repeat endoscopic intervention or surgery after originally having clinical resolution (Eckardt ≤ 3). Multivariate logistic regression using preoperative and intraoperative factors was completed to assess odds of recurrence. A total of 164 patients were included in the analysis, 90 TN, 34 BD, 28 BTX, and 12 BOTH. There were no other significant differences in demographics or in preoperative Eckardt score (p = 0.53). There was no difference in the proportion of patients that had postoperative manometry (p = 0.74), symptom recurrence (p = 0.59), surgical intervention (p = 0.16). BTX (14.3%) and BOTH (16.7%) patients had a higher rate of repeat endoscopic intervention than BD and TN patients (5.9% and 1.1%). In the logistic regression analysis, there was no association among the BTX, BD, or BOTH groups compared to the TN group. No odds ratios achieved statistical significance. There were no increased likelihood of recurrence with botulinum injection or dilatation prior to POEM, implying that they are similarly good candidates compared to treatment-naïve patients.

Executive Summary: Guidelines for the Management of Adult Acute and Acute-on-Chronic Liver Failure in the ICU: Neurology, Peri-Transplant Medicine, Infectious Disease, and Gastroenterology Considerations.

Executive Summary: Guidelines for the Management of Adult Acute and Acute-on-Chronic Liver Failure in the ICU: Neurology, Peri-Transplant Medicine, Infectious Disease, and Gastroenterology Considerations.

Long-Term Follow-up of 64 Patients With Idiopathic Subglottic Stenosis: Treatment Pathways, Outcomes, and Impact of Serial Intralesional Steroid Injections.

To describe treatment pathways and long-term outcomes in 64 patients with idiopathic subglottic stenosis (iSGS), including the impact of serial intralesional steroid injection (SILSI) on degree of stenosis, need for subsequent operation, and patient-reported outcome measures. Retrospective review of 64 female patients with iSGS undergoing varied management approaches, 57 of whom underwent SILSI as at least part of their care. Treatment pathways included SILSI only, endoscopic intervention followed by SILSI only, endoscopic interventions only, endoscopic intervention followed by SILSI followed by need for repeat endoscopic intervention, open surgery, and tracheotomy. Outcomes assessed included subjectively estimated percent airway stenosis, dyspnea index (DI), modified medical research council (MMRC) dyspnea scale, voice handicap index-10 (VHI-10), number of operative and office-based procedures performed, need for subsequent operative intervention, and inter-operative interval. Treatment pathways included SILSI alone (n = 6), endoscopic intervention(s) followed by SILSI only (n = 31), SILSI followed by additional endoscopic or office-based procedures (n = 16), open surgery (n = 3), and tracheostomy (n = 4). 57 of 64 patients underwent SILSI as at least part of their treatment. Inter-operative interval was increased after starting SILSI. Of patients undergoing SILSI, those with more procedures or shorter inter-operative interval prior to SILSI were more likely to return to the operating room. Estimated stenosis, DI, MMRC, and VHI-10 decreased with SILSI. Stenosis was not correlated with DI, MMRC, or VHI-10, though DI was correlated with both MMRC and VHI-10 score. Of 57 patients undergoing SILSI, 37 did not require further operative intervention. Improvements in inter-operative interval, dyspnea, and voice were observed across patients. Randomized trials to identify which patients may benefit most from SILSI are warranted.

S2590 Endoscopic Sengstaken-Blakemore Tube Placement for Variceal Hemorrhage: A Case Series

Introduction: Management of brisk variceal bleeding is challenging and nerve-racking for both gastroenterologists and intensivists. When visibility is hampered, a Sengstaken-Blakemore (SB) tube is used to tamponade as a temporary bridge to Transjugular intrahepatic portosystemic shunt (TIPS). Traditionally, the SB tube is placed blindly, or with the help of radiography to confirm gastric balloon location. Catastrophic complications are reported with blind approach including distension of the esophagus or trachea leading to rupture. Endoscopic SB placement has been described in literature as a successful technique. We report 3 cases with successful placement of SB tubes in massive variceal hemorrhage as a bridge to TIPS. Case Description/Methods: Case 1: A 36-year-old gentleman with alcoholic cirrhosis presented with hematemesis 2 days after undergoing variceal banding. Bleeding post-banding ulcers were confirmed with endoscopy and treated with hemoclips and epinephrine. Despite the intervention, the patient had recurrence of bleeding the following day with hematemesis. Repeat endoscopic intervention was limited due to poor visibility from brisk bleeding. An SB tube was placed endoscopically, and he underwent emergent TIPS that same day. The SB tube was removed 24 hours later with no recurrence of bleeding, and he was discharged to home. Case 2: A 68-year-old gentleman with alcoholic cirrhosis and history of variceal bleeding presented with hematemesis. Emergency endoscopy found massive bleeding, however the source of bleeding could not be located. An SB tube was endoscopically placed and an emergent TIPS was performed on the same day. The SB tube was removed 24 hours later with no recurrence of bleeding. After a 10-day hospital stay, he was ultimately discharged to hospice. Case 3: A middle-aged woman presented to the hospital with active variceal bleeding. She underwent successful endoscopic SB tube placement as a bridge to TIPS. Although she also had successful placement and no rebleeding, she ultimately succumbed to her disease. Discussion: Endoscopic SB tube placement is an effective bridge to emergent TIPS due to the improved hemostasis and decreased likelihood of rebleeding. This technique also limits the complications of blind placement, such as inadvertently distending the gastric balloon in the wrong location. Therefore, gastroenterologists should consider endoscopic placement of a SB tube when other endoscopic interventions fail to achieve hemostasis in variceal hemorrhage (Figure 1).Figure 1.: Endoscopic placement of a SB tube, confirming correct placement for hemostasis.

S0933 A Cooperative Approach for Treatment of Zenker's Diverticulum

INTRODUCTION: Symptomatic Zenker’s diverticulum management has changed from an open intervention to a less invasive transoral endoscopic route. At our center, both an ENT surgeon and gastroenterologist are present in the operating room when treating these lesions. An intraprocedural consensus is reached to undergo either stapler assisted rigid endoscopy or flexible endoscopic diverticulotomy without clipping with ENT guidance. We aimed to evaluate the real world efficacy with a combined gastroenterology-ENT approach. METHODS: This is a single center retrospective study of subjects who underwent a combined endoscopic diverticulotomy by a gastroenterologist and ENT specialist at Cleveland Clinic Florida between 2011 and 2019. Demographic and clinical data, intraprocedural findings/complications, postprocedural symptoms, recurrence rate and need for reintervention variables were extracted. Patients included in the study were >17 years old, with symptomatic typical single Zenker’s diverticulum confirmed with imaging or endoscopy. RESULTS: 63 subjects were identified. Patients were predominantly males (63.5%) and white (84.1%), with mean age 73.5 years (53–95). Most subjects presented dysphagia (98.4%), mostly to solids (79.4%). Other demographic and clinical data are described in Table 1. Mean diverticular size was 36.3 mm, intra- diverticular food in 30.1% and mean procedure time length of 38.4 minutes. All cases were performed as outpatient, without periprocedural complications. Technical success was achieved in all cases. Patients were followed for a mean of 3.24 months (0.1–22) post procedure. Other intra and post-procedural specifications are listed in Table 2. Fourteen patients (22.2%) had symptom recurrence, but only eight (12.7%) had a residual cricopharyngeal bar on imaging. Four patients had repeat endoscopic intervention and one opted open surgery. Hence, our approach was effective in 58 subjects (92%). CONCLUSION: A combined endoscopic approach by gastroenterology and ENT for symptomatic Zenker’s diverticulum management offered excellent technical and clinical success. This approach was safe and may have avoided elderly subjects with co-morbidities from undergoing two procedures at different times. This approach may provide better patient care than one performed by an unaccompanied ENT surgeon or gastroenterologist. Further studies will determine the long-term recurrence rate of this method of intervention.Table 1.: Demographic and clinical data at baseline for patients undergoing endoscopic Zenker’s diverticulotomyTable 2.: Intra and post-procedural specifications

S2126 Metastatic Testicular Embryonal Carcinoma Presenting as Gastrointestinal Hemorrhage

INTRODUCTION: Metastatic testicular embryonal carcinoma presenting as gastrointestinal hemorrhage is an uncommon phenomenon. While testicular cancer is the most common malignancy in males 20–35 years of age, metastases to the gastrointestinal tract occur at an incidence of less than 5%. In a young man with otherwise unexplained gastrointestinal hemorrhage, it is important to consider the possibility of underlying malignancy. CASE DESCRIPTION/METHODS: A previously healthy 27-year-old male presented with two weeks of abdominal pain and three days of melena and hematemesis. He was found to be in hemorrhagic shock with a hemoglobin of 5.3 and resuscitated aggressively with blood products and fluids. A CT abdomen/pelvis showed a large 15.1 cm × 13.9 cm × 8.6 cm hypervascular soft tissue mass with a necrotic center and multiple foci of contrast blush located adjacent to the third portion of the duodenum, extensive peritoneal and retroperitoneal lymphadenopathy, and multiple lung masses (Figure 1). Esophagogastroduodenoscopy (EGD) revealed an exophytic mass-like obstruction in the duodenum that when traversed, revealed a large cavity filled with necrotic tissue and old blood extending from the third portion of the duodenum deep into the subperitoneal space (Figure 2) with slow hemorrhage from friable tissue treated with coagulation graspers. The patient's clinical course was complicated by multiple episodes of recurrent hemorrhage requiring repeat endoscopic treatment with bipolar coagulation, epinephrine injection, and hemostatic powder application. A diagnosis of germ cell tumor was made based on scrotal US showing multiple masses and a significantly elevated beta-HCG. He was treated with chemotherapy with subsequent decrease in the size of his abdominal mass and resolution of bleeding. DISCUSSION: Testicular cancer is the most common malignancy in males 20–35 years of age, usually presenting with painless scrotal swelling. Metastases can involve retroperitoneal lymph nodes, which drain the testes. Gastrointestinal metastases are rare, and metastatic disease may not initially be considered in a young male presenting with gastrointestinal hemorrhage. This case demonstrates the importance of testicular imaging and exam should there be concern for underlying malignancy, especially if other causes of gastrointestinal hemorrhage have been ruled out. Early diagnosis and intervention may often lead to improved clinical outcomes.Figure 1.: CT abdomen showing a large heterogeneously enhancing hypervascular soft tissue mass which appears to be contiguous with the third part of the duodenum. Large necrotic central component present.Figure 2.: EGD showing duodenal lumen immediately proximal to the cavity. Note the adherent clot at the top of the abnormal tissue directly in front.Figure 3.: Necrotic cavity in duodenum.

Sa2065 THE NOVEL USE OF A BIODEGRADABLE EXTRACELLULAR MATRIX MEMBRANE FOR THE TREATMENT OF REFRACTORY BENIGN ESOPHAGEAL STRICTURES: FIRST REPORTED CASE SERIES

The natural history of recurrent benign esophageal stricture (RBES) remains uncertain. Various therapeutic options for the treatment of RBES including dilation, incisional therapy, injection of steroids, and use of self-expandable metal stents (SEMS) have been reported. However, the efficacy of these interventions remains unclear with a wide clinical range of stricture resolution rates between 20% to 63.6%. We devised a novel endoscopic technique that utilizes a biodegradable scaffold membrane composed of porcine extracellular matrix (ECM) to reinforce soft tissue repair. It is an acellular matrix that serves as a temporary reinforcement while it is assimilated into the host tissue and replaced with native, site-specific tissue to reduce scarring. Our study aims to assess the efficacy of this technique in improving RBES. Five patients with RBES underwent therapeutic endoscopic intervention involving the placement of the ECM membrane. Patients underwent incisional therapy of the stricture to expose the submucosa with or without concurrent dilation, followed by trans-endoscopic placement of the ECM membrane across the stenosis. The ECM membrane was anchored in place by endoclips, followed by a fully covered esophageal SEMS placement over the membrane to help stabilize the membrane and prevent migration with food intake. A median follow-up period was 60 days (range 1 to 112 days) to remove the esophageal SEMS and evaluate response to therapy. We reviewed the outcomes of ECM placement in regard to stricture resolution with the need for, and frequency of repeat endoscopic intervention before and after the ECM application. Our study noted a complete stricture resolution rate of 40% (2 out of 5 patients). The mean frequency of therapeutic intervention procedures with the use of balloon and Savary wire-guided dilations, incisional therapy, steroid injection and esophageal SEMS before ECM application was every 5.2 weeks, which reduced to every 8.4 weeks with the use of dilation alone after the ECM application. The mean number of therapeutic procedures pre and post ECM application were 4 and 2.8, respectively. With this new technique, we noted an absolute decrease in the frequency of the therapeutic procedure by 3.2 weeks and an absolute decrease in the mean number of interventions by 1.2. Our study presents a novel use of the ECM membrane for the treatment of RBES that may reduce both the frequency and the number of repeat interventions. Further prospective studies with a larger cohort and a longer-term follow up is required to evaluate the potential of this new technique.

Preoperative Biliary Drainage With Self-Expanding Metal Biliary Stents During Neoadjuvant Chemotherapy for the Treatment of Pancreatic Adenocarcinoma Reduces the Need for Repeat Endoscopic Intervention

Introduction: Neoadjuvant chemotherapy for pancreatic adenocarcinoma is on the rise in both resectable and borderline resectable tumors. Recent evidence suggests improved outcomes in these patient populations. Studies have also shown the superiority of self-expanding metal biliary stents in the preoperative period for resectable head of the pancreas tumors but there has been no comparison of plastic vs. self-expanding metal biliary stents (SEMS) in patients undergoing neoadjuvant chemotherapy. Methods: We conducted a retrospective chart review comparing number of repeat ERCPs prior to surgery, hospital length of stay and surgical complications in patients undergoing preoperative biliary drainage and neoadjuvant chemotherapy and ultimately, a pancreaticoduodenectomy for the treatment of pancreatic adenocarcinoma. Thirteen patients underwent both preoperative endoscopic biliary drainage and neoadjuvant chemotherapy prior to pancreaticoduodenectomy, 5 received plastic biliary stents while 8 received SEMS. The primary endpoint was need for repeat ERCP prior to surgery. Secondary endpoints such as surgical complications and length of hospital stay after surgery were also evaluated. Results: Patients who underwent biliary drainage with SEMS had significantly less need for repeat ERCP compared to patients whom received plastic stents, 12.5% vs 80%, p-value 0.0114. There was no difference in procedural based complications. There was no significant difference in post-operative hospital length in either group, 9.4 days (plastic) vs 11.8 days (SEMS). No surgical complications were identified in either group. Conclusion: This retrospective chart review suggests that SEMS for preoperative biliary drainage significantly reduces the need for repeat ERCP in patients receiving neoadjuvant chemotherapy for pancreatic adenocarcinoma prior to pancreaticoduodenectomy. Though health care cost associated with need for repeat ERCP was not calculated, one could infer reducing the number of ERCP procedures prior to surgery would lessen the financial burden on both the patient and the healthcare system. This study is limited due to the patient population size however with an increased use of neoadjuvant chemotherapy in both resectable and borderline resectable head of the pancreas tumors there will likely be a larger patient population for further investigation..

Long-Term Effectiveness, Safety and Mortality Associated with the Use of TC-325 for Malignancy-Related Upper Gastrointestinal Bleeds: A Multicentre Retrospective Study

Background and Study AimsMalignant-related upper gastrointestinal bleeding (MRUGIB) is difficult to treat by conventional endoscopic methods. We sought to determine the efficacy, safety and mortality associated with the use of TC-325 for the treatment of MUGIB.Patients and MethodsThis is a multicentre, retrospective study at the University of Calgary and University of Ottawa performed between January 1, 2010, and July 30, 2016. TC-325 use was identified via staff polling, product order forms and endoscopic records review. Once identified, patient charts and online records were examined to identify MRUGIB cases and to assess our primary and secondary endpoints.OutcomesThe primary outcome was hemostasis at seven days. Secondary outcomes include immediate hemostasis, early hemostasis, hemostasis at 14 days, 30-day mortality, adverse events related to TC-325 therapy and the need for repeat endoscopic intervention, surgery or transarterial embolization.ResultsTwenty-five patients were identified. The median age was 62 years (interquartile range [IQR] 52.5–76), and most were male (64%). TC-325 was the primary treatment modality in 20 patients (80%). Hemostasis was 88%, 89%, 58% and 50% at 24 hours, 72 hours, 7 days and 14 days, respectively. Five patients underwent repeat endoscopy, two patients required surgical intervention, and transarterial embolization was not required. Twelve patients died by 30 days (48%). There were no complications directly attributed to the use of TC-325.ConclusionsTC-325 is effective for achieving and maintaining hemostasis in patients with malignancy-related upper gastrointestinal bleeding, and most patients do not require additional interventions. The 30-day mortality risk in this group of patients is high.

Burden of Disease for Urethral Stricture Managed by Repeat Endoscopic Treatment vs Single Endoscopic Treatment or Urethroplasty in the Veterans Affairs Population

IntroductionMale urethral stricture disease is a challenging urological condition that affects nearly a third of men 65 years old or older. Management options include dilation and urethrotomy as well as urethroplasty, an open approach with increased morbidity and durability. Presently optimal management remains debated. In this study we focus on emergent procedures required by male patients in the Veterans Health Administration after stricture treatment as an indicator of clinically significant complications, comparing treatment approaches. MethodsWe performed an institutional review board approved, retrospective, cohort study of male veterans with urethral stricture from 2005 to 2014. Our independent variable was immediate or delayed urethroplasty or continued endoscopic treatments. Our dependent variable was a stricture related procedure performed in the emergent or urgent care setting. We used a binary logistic regression model to model the likelihood of an adverse outcome as predicted by treatment type. ResultsIn our cohort of 9,632 patients 1.8% underwent immediate urethroplasty and 3% underwent delayed urethroplasty. Of the operated men 5.3% had an adverse outcome (5% following delayed urethroplasty or continued endoscopic treatments and 1% after immediate urethroplasty, p = 0.04). On multivariate analysis repeat endoscopy and delayed urethroplasty trended toward worsening odds of adverse outcomes (p = 0.07 and p = 0.08, respectively). ConclusionsIn the Veterans Health Administration system men who undergo repeated scheduled endoscopic treatments for urethral stricture may be at increased risk for emergent procedures, even if they eventually progress to urethroplasty, compared to men who undergo urethroplasty immediately after a failed endoscopic intervention.

EUS-guided drainage of peripancreatic fluid collections with lumen-apposing metal stents and plastic double-pigtail stents: comparison of efficacy and adverse event rates

Transmural drainage with double-pigtail plastic stents (DPPSs) was the mainstay of endoscopic therapy for symptomatic peripancreatic fluid collections (PPFCs) until the introduction of lumen-apposing covered self-expanding metal stents (LAMSs). Currently, there are limited data regarding the efficacy and adverse event rate of LAMSs compared with DPPSs. A retrospective analysis of EUS-guided PPFC drainage at a single tertiary care center between 2008 and 2015 was performed. Patients were classified based on drainage method: DPPSs and LAMSs. Adverse event rates, unplanned endoscopic procedures/necrosectomies, and PPFC resolution within 6 months were recorded. Significant bleeding was defined as necessitating transfusion or requiring endoscopic treatment/radiographic embolization. Subsequent endoscopic procedures were defined as unplanned procedures; stent removals were excluded. A total of 103 patients met inclusion criteria (84 DPPSs, 19 LAMSs). PPFCs were classified as walled-off necrosis (WON) in 23 (14 DPPSs, 9 LAMSs). There were significantly more bleeding episodes in the LAMS group (4 [19%]: 2 splenic artery pseudo-aneurysms, 1 collateral vessel bleed, 1 intracavitary variceal bleed; P= .0003) than in the DPPS group (1 (1%]: stent erosion into the gastric wall). One perforation occurred in the DPPS group.Unplanned repeat endoscopy was more frequent in the LAMS group (10% vs 26%, P= .07). Among retreated LAMS patients in with WON, 5 (56%) had obstruction by necrotic debris. In patients for whom follow-up was available, 67 of 70 (96%) with DPPSs and 16 of 17 (94%) with LAMSs had resolution of PPFCs within 6 months (P= .78). DPPSs and LAMSs are effective methods for treatment of PPFCs. In our cohort, use of LAMSs was associated with significantly higher rates of procedure-related bleeding and greater need for repeat endoscopic intervention.

Endoscopic diverticulotomy using Ligasure™

Abstract Introduction Endoscopic treatment of Zenker diverticulum is considered feasible, effective and safe. The use of the Ligasure™ vessel sealer provides adequate and quick dissection of tissue, achieving effective haemostasis. Patients and methods Retrospective, descriptive study of all patients with Zenker diverticulum who were treated by endoscopic diverticulotomy using Ligasure™. The procedure was performed in the endoscopy unit under deep sedation controlled by the endoscopist. Patients were subsequently admitted for observation and, after discharge, were followed-up in the outpatient clinic. Results Eight patients, 5 women and 3 men, mean age 78 ± 15 years, 25% ASA I, 36% ASA II, 14% ASA III and 25% ASA IV. Main symptom: dysphagia. Diverticula size: 1–7 cm. Technical success: 100%. Complications: one patient with upper gastrointestinal bleeding. Average stay: 24 h. Seven patients: asymptomatic; one patient with partial improvement, requiring repeat endoscopic intervention. Surgery and morbidity and mortality: 0%. Conclusion The treatment of Zenker diverticulum by endoscopic diverticulotomy using the Ligasure™ vessel sealer is highly effective, fast and safe, and could be considered the treatment of choice.

A decade of day-case endoscopically guided stent placement in malignant oesophagogastric strictures.

Self-expanding metal stents (SEMSs) are the palliative treatment of choice for rapid symptomatic relief in patients with malignant dysphagia. Increasingly endoscopically guided insertion is performed as a day case and without the need for fluoroscopic guidance. This consecutive case series reports 11-year experience of endoscopically guided SEMS insertion in a large UK specialist oesophagogastric unit. Patients undergoing stent insertion for malignant dysphagia between 2003 and 2014 were identified from a prospectively maintained database. Data on patient demographics, tumour characteristics, indications, technique of insertion, complications, and need for re-intervention were abstracted and then corroborated by retrospective review of electronic case records. A total of 362 patients with a median age of 76years underwent primary SEMS insertion under endoscopic guidance. Repeat endoscopic intervention was required in 26 patients within 30days and 59 patients within 90days of primary insertion, giving Kaplan-Meier estimated re-intervention rates of 7.7% and 20.3%, respectively. Higher tumours were associated with need for repeat intervention (p=0.014). The most frequent repeat intervention was insertion of a new stent, most commonly for stent migration or tumour overgrowth. Out of 252, 222 (88.1%) patients referred through a rapid access pathway were stented as day cases, and the 30-day readmission rate in this cohort did not differ significantly from patients stented as inpatients (p=0.774). Three (0.8%) patients suffered a perforation, and there was a single procedure-related death. This large consecutive case series demonstrates that endoscopically guided SEMS insertion in malignant dysphagia can be performed efficiently as a day case with low complication, readmission, and re-intervention rates.

Endoscopic ultrasound-assisted gastrointestinal hemostasis: an evolving technique.

Gastrointestinal bleeding can range from grossly visible blood in stool or vomitus to microscopic bleed. However, any kind of bleeding can lead to potential life-threatening consequences. A small proportion of patients with gastrointestinal bleeding remain refractory to initial endoscopic hemostasis. While some are successfully managed by repeat endoscopic intervention, a few fail to respond or are not amenable to endoscopic hemostasis. As of now, the next level of intervention is passed on to either surgeons or interventional radiologists. There is new evidence suggesting the increased utility of endoscopic ultrasound (EUS) in diagnosis and treatment of culprit vascular lesions across the gut. In addition, EUS-assisted technique has also been used in the primary prevention of bleeding from gastroesophageal varices. In this review article, we have summarized case series and reports describing the use of EUS-assisted hemostasis. Indications, techniques, complications and success rates reported are discussed. While most of the authors describe their experience with primary and secondary treatment of gastric varices, treatment of other gastrointestinal lesions with EUS assisted hemostatic techniques is also discussed.

Diverticulotomía endoscópica utilizando Ligasure™

IntroductionEndoscopic treatment of Zenker diverticulum is considered feasible, effective and safe. The use of the Ligasure™ vessel sealer provides adequate and quick dissection of tissue, achieving effective haemostasis. Patients and methodsRetrospective, descriptive study of all patients with Zenker diverticulum who were treated by endoscopic diverticulotomy using Ligasure™. The procedure was performed in the endoscopy unit under deep sedation controlled by the endoscopist. Patients were subsequently admitted for observation and, after discharge, were followed-up in the outpatient clinic. ResultsEight patients, 5 women and 3 men, mean age 78±15 years, 25% ASA I, 36% ASA II, 14% ASA III and 25% ASA IV. Main symptom: dysphagia. Diverticula size: 1-7cm. Technical success: 100%. Complications: one patient with upper gastrointestinal bleeding. Average stay: 24h. Seven patients: asymptomatic; one patient with partial improvement, requiring repeat endoscopic intervention. Surgery and morbidity and mortality: 0%. ConclusionThe treatment of Zenker diverticulum by endoscopic diverticulotomy using the Ligasure™ vessel sealer is highly effective, fast and safe, and could be considered the treatment of choice.

Durability of Memokath™ urethral stent for stabilisation of recurrent bulbar urethral strictures – medium‐term results

To examine the durability after 3 months deployment of a urethral (Memokath™) stent in conjunction with endoscopic treatment of recurrent bulbar urethral strictures, as repeated endoscopic treatment of urethral strictures can cause worsening of underlying spongiofibrosis. Prospective series of 22 patients with recurrent bulbar strictures requiring repeat endoscopic treatment were included. The median age was 38 years and the mean stricture length was 2.4 cm. The median number of previous dilatation or direct visual internal urethrotomy (DVIU) procedures was three with a mean time to stricture recurrence of 2 months. After endoscopic dilatation or DVIU, the urethral (Memokath™) stent was deployed and left situ for 3 months. Re-stricture rates were examined with uroflowmetry at 3, 6 and 12 months and confirmed with 17-F cystoscopy at 1 year after stent removal. A telephone survey was conducted at >1-year follow-up. Five of the 22 (22%) patients had stricture recurrence after stent removal. In all, 17/22 (78%) patients remained stricture-free at a median (range) follow-up of 23 (9-31) months. Uroflowmetry showed significantly improved flow rates, which were sustained at 12 months after stent removal. On Kaplan-Meier analysis, there was a significant delay (23 vs 2 months) in stricture or symptom recurrence after stent removal. The medium term results of temporary urethral stent placement are encouraging with 78% of patients remaining stricture-free at a median follow-up of 23 months.

Repeat Transurethral Manipulation of Bulbar Urethral Strictures is Associated With Increased Stricture Complexity and Prolonged Disease Duration

We examined the association of previous transurethral manipulation with stricture complexity and disease duration among men referred for bulbar urethral reconstruction. We retrospectively reviewed the records of 340 consecutive urethroplasties performed by a single surgeon between July 2007 and October 2010. Only men treated with initial open surgery for bulbar strictures were included in analysis, thus excluding those with hypospadias, lichen sclerosus, pelvic radiation, prior urethroplasty, incomplete data, or pure penile or posterior urethral stenosis. Cases were divided into 2 groups based on the history of transurethral treatment for urethral stricture before urethroplasty, including group 1-0 or 1 and group 2-2 or greater treatments. Of 101 patients with bulbar urethral stricture and all data available 50 and 51 underwent 0 to 1 and 2 or greater previous transurethral treatments, respectively. Repeat transurethral manipulation was strongly associated with longer strictures and the need for complex reconstruction. Repeat transurethral manipulation of bulbar urethral strictures was also associated with an eightfold increase in disease duration between stricture diagnosis and curative urethroplasty. Repeat transurethral manipulation of bulbar strictures is associated with increased stricture complexity and a marked delay to curative urethroplasty.