Stricture Dilation Research Articles

S2374 Recurrent Strictures in a Patient With Missed Diagnosis of Eosinophilic Esophagitis

Introduction: EoE is an antigen-mediated inflammatory disorder of the esophagus that affects both children and adults. Diagnosis requires symptoms related to esophageal dysfunction and esophageal biopsy showing >15 eosinophils/hpf is confirmatory for diagnosis. Proton pump inhibitors (PPIs) are considered the first line agents for the treatment of EoE, together with elimination diet and topical corticosteroids. Nonadherence to therapy and undiagnosed disease can increase the risk of fibro-stricturing disease and food impactions. Practicing evidence-based guidelines in diagnosing and managing patients with EoE can allow standardization of care and prevent complications in patients with EoE. Case Description/Methods: A 34-year-old man presented with a longstanding history of intermittent dysphagia to solids. He had an emergent esophagogastroduodenoscopy (EGD) for food impaction about 3 years prior to presentation. No biopsies were obtained at that time, and he was prescribed a short course of PPI before discharge. On current presentation, the patient underwent an EGD which showed multiple untraversable strictures requiring dilation (Figure). Biopsy from multiple sites showed >200 eosinophils/hpf, consistent with a diagnosis of eosinophilic esophagitis (EoE). Thereafter, the patient was initiated on PPIs but had to undergo further dilations for recurrent strictures. Topical steroids were subsequently added to the therapy with satisfactory response. Discussion: Once considered rare, EoE is now a well-known entity, with an estimated prevalence of 51.6/100000 in the US. However, variability and deviations from standard therapy continues to persist among gastroenterologists. According to a national survey conducted in 2020 among 240 gastroenterologists, only 24 % were “very familiar” with the EoE guidelines and only 12 % followed EoE guidelines in their clinical practice. The current case underscores the need to standardize clinical practice related to the care of patients with EoE in order to provide quality and evidence-based care and improve overall outcomes.Figure 1.: EGD showed trachealization of the esophagus.

S2446 A Unique Endoscopic Finding in an HIV/AIDS Patient With Dysphagia

Introduction: There are many etiologies of dysphagia in patients with HIV/AIDS, including infection, structural issues, or medications. A broad differential is needed to properly diagnose and treat these patients. Here, we present a case of dysphagia in an HIV/AIDS patient related to esophageal intramural pseudodiverticulosis (EIPD). Case Description/Methods: A 58-year-old man with HIV/AIDS presented with a 2-week history of dysphagia. He had been non-compliant with highly active antiretroviral therapy (HAART), and his CD4 count at presentation was noted to be < 20. His past medical history was notable for hypertension, chronic kidney disease, Candida esophagitis, and Mallory-Weiss syndrome. He underwent an esophagogastroduodenoscopy (EGD), which revealed numerous outpouchings and white plaques in the mid esophagus (Figures 1a and b). Esophageal brushings confirmed Candida infection, and biopsies were positive for cytomegalovirus (CMV). A barium esophagram showed outpouchings throughout the esophagus, without any evidence of perforation (Figure 1c). No stricture was evident on EGD or barium esophagram. The patient was diagnosed with EIPD and treated with fluconazole, a proton pump inhibitor, and valganciclovir, with improvement in symptoms. Discussion: EIPD is characterized by the development of multiple small flask-shaped outpouchings in the esophagus. Patients with reflux esophagitis, Candida esophagitis, diabetes mellitus, HIV, and eosinophilic esophagitis are at higher risk for developing EIPD. There are approximately 250 published cases of EIPD in the literature, and the prevalence of EIPD is estimated to be 5-50 per 100,000 cases. Development of pseudodiverticula in the esophagus is suggested to be secondary to chronic inflammation, obstruction of the submucosal glands due to debris, or increased intraluminal pressure proximal to a luminal obstruction. The diagnosis is primarily made with EGD, barium esophagram, or computerized tomography. The treatment for EIPD includes treatment of underlying conditions and endoscopic dilation of strictures when they are present [1]. Our patient had several risk factors for development of EIPD such as Candida esophagitis, Mallory-Weiss syndrome, and HIV. However, a prior association between EIPD and CMV esophagitis has not been reported. Here, we highlight CMV esophagitis as a potential risk factor for development of EIPD.Figure 1.: EGD (a and b) and barium esophagram (c) findings.

S1726 Eosinophilic Infiltration Causing Biliary Tree Obstruction Without Stricture

Introduction: We present an exceedingly rare case of eosinophilic cholangitis (EC) without stricture. Of the 40 cases of EC reported in the literature, fewer than 10 cases did not involve a stricture. Case Description/Methods: A 60-year-old female with no significant past medical history presented with symptoms of biliary colic for 2 days. Laboratory results were significant for elevated hepatobiliary enzymes including alkaline phosphatase of 300 IU/L and total bilirubin of 3.8 mg/dL. A hepatobiliary iminodiacetic acid scan was performed with an absence of radiotracer excretion into the biliary tract. However, a magnetic resonance cholangiopancreatography showed no obstructing stone, stricture, or lesion. A broad workup including hepatitis and autoimmune serologies was negative. The patient underwent an uncomplicated laparoscopic cholecystectomy, and direct inspection of the gallbladder confirmed significant edema. Histopathology of the gallbladder showed acute and chronic acalculous cholecystitis with eosinophilic rich infiltrates. Notably, the patient had an absolute eosinophil count of 1.2 cells/µL. She was diagnosed with eosinophilic cholangitis and treated with corticosteroids. At her one-month follow-up, her symptoms had resolved. Discussion: Eosinophilic cholangitis is a rare, self-limiting condition featuring eosinophilic invasion of the biliary tree. Laboratory values in EC reflect an obstructive process, but diagnosis is frequently delayed as both symptoms and imaging mimic multiple other biliary conditions including malignancy, primary strictures, primary sclerosing cholangitis, amongst others. Endoscopic dilation of strictures often provides a surprising diagnosis when pathology demonstrates dense infiltration of eosinophils. Although a majority of EC is associated with stricture, EC may also present with obstructive features in the absence of stricture. Likewise, peripheral eosinophilia may or may not be present. Risk factors for EC have not been established. Literature suggests that patients with pre-existing eosinophilic processes such as eosinophilic esophagitis and asthma are more likely to develop EC than the general population. There is no standard treatment, but corticosteroids have demonstrated empiric efficacy, similar to the other eosinophilic processes mentioned. Increased physician awareness of eosinophilic cholangitis will help prevent delays in diagnosis and initiation of effective medical therapy.

S2254 Use of Upadacitinib in Refractory Esophageal Lichen Planus: Endoscopic Improvement in "Planus" Sight

Introduction: Lichen planus (LP) is an inflammatory skin condition that affects oropharyngeal and esophageal mucosa. Esophageal LP (ELP) has a prevalence of 0.19% but is thought to be underdiagnosed. It presents with ulceration, exudates, rings and/or strictures. Although pathogenesis of LP is incompletely understood, the JAK signaling pathway is thought to play a role. Upadacitinib is a selective JAK1 inhibitor approved for use in ulcerative colitis. We present a case of refractory ELP with endoscopic and histologic response to upadacitinib after failing standard treatment. Case Description/Methods: A 68-year-old female with history of Sjogren’s syndrome, LP, and prior peptic stricture at the gastroesophageal junction presented with dysphagia to both liquids and solids, intermittent reflux, regurgitation, and self-limited impactions. An EGD showed esophageal stenosis, severe esophagitis, and mucosal ulceration (Figure A). Passage of the scope resulted in dilation; however, formal dilation of stenosis was not performed due to severity of esophagitis. Esophageal biopsies revealed squamous mucosa with parakeratosis, dyskeratotic cells and scattered lymphocytes consistent with ELP. Subsequently, the patient recalled having a remote history of oral lichen planus. She was started on pantoprazole 40 mg twice daily and budesonide oral slurry with limited response. With co-management by gastroenterology and dermatology, she was initiated on mycophenolate 500 mg daily and increased to 2000 mg twice a day. She continued to lack both histologic and symptomatic improvement remaining limited to a soft and liquid diet resulting in a 20lb weight loss. She was started on monotherapy with upadacitinib 30 mg twice daily. This resulted in marked symptomatic recovery with repeat endoscopy 3 months later showing dramatic macroscopic and histologic improvement (Figure B), with only some residual fibrostenotic disease remaining (Figure C). Discussion: Multimodal treatment is typically employed in ELP with medical therapy and endoscopic dilation. Systemic or topical steroids are first line, with efficacy estimated at 60-70%. Other therapies include tacrolimus, cyclosporine, mycophenolate, rituximab, adalimumab, and tofacitinib, however data for these therapies are limited. To date, there are only 2 cases reported in the literature of successful treatment of oro-esophageal LP with upadacitinib. Given profound improvement seen in our patient, upadacitinib may offer another alternative for these difficult-to-treat patients.Figure 1.: 1a. ELP on initial diagnostic endoscopy before initiation of therapy. 1b. Follow up endoscopy performed after 12 weeks of upadacitinib treatment. 1c. Lichenoid esophagitis: lymphocytic infiltrates, focal histiocytic aggregate (blue arrow) and dyskeratosis (Civatte body, red arrow).

Single-operator cholangioscopy in a patient with prior pancreaticoduodenectomy.

A 64-year-old woman with a history of Gardner syndrome requiring classic pancreaticoduodenectomy for an ampullary adenoma 10 years prior presents for follow-up of adenomatous tissue at the hepaticojejunal anastomosis ([Fig. 1]) with an intraductal extension of adenomatous tissue ([Fig. 2]). She previously underwent endoscopic mucosal resection (EMR) of the adenomatous tissue and intraductal radiofrequency ablation (RFA) ([Fig. 3]). After EMR and RFA, the patient developed a stricture at the hepaticojejunal anastomosis. Subsequently, stricture dilations at the anastomosis were performed. The decision was made to perform cholangioscopy to evaluate for intraductal extension of adenomatous tissue ([Video 1]). A modified therapeutic upper endoscope (1T; GIF-1TH190 Olympus, Center Valley, Pennsylvania, United States) was used and advanced to the anastomosis. Cholangioscopy showed intraductal extension of adenomatous tissue. Cholangioscopy-directed biopsies were obtained. Pathology revealed tubular adenoma without high grade dysplasia. Repeat intraductal RFA is planned.

Balloon dilation and electrodestruction for colorectal anastomosis strictures

AIM: to assess results of balloon dilatation (BD) and electric destruction (ED) for strictures of colorectal anastomoses.PATIENTS AND METHODS: the prospective cohort study included 69 patients with colorectal anastomotic strictures. Thirty-two of them underwent endoscopic balloon dilatation, 37 — electric destruction of scar tissue using a spherical monopolar electrode.RESULTS: the recurrence rate of the anastomotic stricture in the BD group was 3 times higher than after ED (OR = 2.9; 95% CI: 0.7–11.1; p = 0.04). The independent factor of stricture recurrence was the extent of stricture &gt; 11 mm (OR = 11.8; 95% CI: 1,57–123,5; p = 0.02).CONCLUSION: electric destruction and balloon dilatation are effective and safe methods for strictures of colorectal anastomoses. The independent factor recurrence risk of the stricture was the extent of the scar narrowing more than 11 mm long.

Economic burden of complications and readmission following oesophageal cancer surgery.

Oesophageal cancer is the seventh most prevalent malignancy globally, and the sixth most common cause of cancer-related death. Oesophageal cancer is also one of the most costly cancers to treat. The aim of this study was to assess the financial impact of post-operative morbidity and hospital readmissions following oesophagectomy for oesophageal cancer. A retrospective analysis was performed on a prospectively maintained database of patients with oesophageal cancer who underwent an oesophagectomy at a single centre between July 2014 and June 2019 (N= 56). Readmission costs were also assessed in this cohort for 12 months post-operatively. The total median cost for oesophagectomy in this cohort was AU$57 250. Major complications occurred in 40% of patients, with a median total admission cost of AU$74 606, significantly higher than patients with either minor or no complications (median admission cost of AU$52 713, P< 0.001). Patients whose operation was complicated by an anastomotic leak had a higher median admission cost than those without a leak (AU$104 328 and AU$54 972 respectively, P< 0.001). Cost centres representing the greatest proportion of costs were theatre resources and surgical ward care (medical and nursing). A total of 110 readmissions in 25 patients were recorded in the 12 months post-operatively, the majority for gastroscopy and dilatation of anastomotic stricture. Post-oesophagectomy morbidity greatly increases cost of care. In addition to the clinical benefits, interventions to minimize post-operative complications are likely to result in substantial cost savings.

Endoscopic therapy using a self-expandable metallic stent with an anti-migration system for postorthotopic liver transplantation anastomotic biliary stricture.

BACKGROUNDEndoscopic therapy using multiple plastic stents (MPSs) is the standard therapy for postorthotopic liver transplantation (p-OLT) anastomotic biliary stricture (ABS). However, this approach demands repeated procedures. Recent studies using fully covered self-expandable metallic stents (FCSEMS) have shown encouraging results, but migration occurs in 10% to 40% of cases. The objective of this retrospective study was to evaluate the efficacy of endoscopic treatment using FCSEMS with an anti-migration system (Am-FCSEMS) in patients with p-OLT ABS.AIMTo evaluate the efficacy of endoscopic treatment using an Am-FCSEMS in patients with p-OLT ABS.METHODSThis study was conducted in a private tertiary care centre in São Paulo, Brazil and was approved by our institution's Human Research Committee. From April 2018 to October 2020, regardless of previous endoscopic treatment (MPS or FCSEMS), 17 patients with p-OLT ABS and indications for endoscopic therapy were included in this study. The exclusion criteria were pregnancy, nonanastomotic biliary or hilar stricture, hepatic artery stenosis/thrombosis, isolated biliary fistulae, a distance shorter than 2 cm from the stricture to the hepatic hilum, and patient refusal. The primary endpoint was the efficacy of p-OLT ABS endoscopic treatment using an Am-FCSEMS that remained in place for a 12-mo period. Biliary sphincterotomy was performed in patients with native papilla, and an Am-FCSEMS (10 mm in final diameter and 60 or 80 mm in length) was placed (HanarostentTM MI Tech, Co). Balloon stricture dilation was performed only if necessary to introduce the stent.RESULTSThree patients were excluded due to loss to follow-up before stent removal. Among the 14 patients included and followed, 7 were women, and the average age was 56 years (range: 28-76). The average period of Am-FCSEMS placement was 362 ± 109 d. Technical success occurred in all 14 patients (100%). There were no cases of distal stent migration. Complete resolution of the stricture occurred in 13/14 patients (92.85%). Adverse events occurred in 3/14 patients (21.42%): 2 patients with mild acute pancreatitis (14.28%) and 1 patient (7.14%) with stent dysfunction (occlusion by biliary sludge and stones, which was treated endoscopically without the need for stent removal). No deaths occurred related to therapy. All stents were removed using foreign body forceps or snares without difficulty. After Am-FCSEMS removal, all 13 patients who had ABS resolution were followed-up for an average of 411 ± 172 d, and there was no stricture recurrence or need for further endoscopic therapy.CONCLUSIONIn this retrospective study, endoscopy therapy using an Am-FCSEMS for p-OLT ABS was safe and effective, with a high stricture resolution rate that was probably due to the absence of stent migration.

Adverse Respiratory Events After Pediatric Endoscopic Airway Surgeries.

Perioperative risk stratification of pediatric patients undergoing airway intervention remains crucial in identifying those at a higher risk of requiring postoperative intensive care unit (ICU) care. Here we determined the likelihood of and possible risk factors for developing perioperative adverse respiratory events (PAREs) requiring ICU care after various pediatric endoscopic airway surgeries (EASs). We conducted a retrospective chart review of pediatric patients who were aged <18 years and underwent EAS between 2015 and 2021. Early postoperative adverse events within 24 h of surgery were recorded and analyzed. Overall, 99 patients who underwent EAS were included. The age at the time of the intervention ranged from 8 months to 18years. Fifty-eight patients, median age was 4.83 years, underwent papilloma debulking with no high likelihood of PARE in this patient subgroup (OR = 0.48; 0.16-1.44). Twenty-five patients, median age was 9.72years, underwent balloon dilation of laryngotracheal stenosis with no increase in the likelihood of PARE in this patient population (OR = 2.02; 0.65-6.28). Early postoperative respiratory events occurred in 16 patients (16.2%). Most of these events (75%) manifested within 4 h after surgery. In a univariate analysis, intervention at the level of the subglottis or 2 or more laryngeal subsites increased the risk of PARE (OR = 6.57; 1.11-12.52 and OR = 3.73; 1.93-22.34, respectively). In a multivariate analysis, only intervention in the subglottic area maintained its effect (OR = 6.84; 1.82-25.65). Respiratory adverse events following pediatric EAS are not uncommon, and the majority are encountered shortly after surgery. Intervention in the subglottic area was an independent predictor of PARE.

P7.06: Endovascular Thrombectomy in a Chronic Upper Cava Syndrome Due to Long Term Home Parenteral Nutrition. New Hope to Extend Life Support

Introduction: Chronic Intestinal Pseudo Obstruction(CIPO) refers to a heterogeneous group of disorders characterized by symptoms of intestinal obstruction, without evidence of mechanical lesion and is a cause of chronic intestinal failure. Loss of vascular accesses by thrombosis has become the current main indication for intestinal transplant. Materials and Methods: A 28-year-old female patient with a history of myopathic CIPO received Home Parenteral Nutrition(HPN) for 25 years, developing central venous accesses thrombosis. As a consequence of a chronic upper cava syndrome with occlusion of the right jugular and subclavian-axillary vein, an invalidating headache and inability to maintain dorsal decubitus due to retroocular pain evolves overtime, but worsen with HPN infusion, limiting the volume and calories provided. A multidisciplinary case discussion concluded that although chronic, an endovascular thrombectomy should be attempted to improve quality of life and to satisfy nutritional needs. Results: A vascular computer tomography(CT) scan with 3D reconstruction and a digital venography were performed showing complete occlusion of the right jugular, axillary and subclavian(where a picc-line was placed as last access) veins and a partial occlusion of the proximal superior vena cava(SVC) and occlusion of the right iliac vein. An angioplasty trough the right humeral, axillary, innominate trunk axis and superior vena cava using 6 & 9mm balloons was performed. Balloon dilatation of multiple venous strictures was done, followed by placement of two stents, one into the right subclavian vein and SVC, and the other into left subclavian vein, with restitution of venous blood flow. Anticoagulation with Rivaroxaban and Clopidrogel was started. On the 5th postoperative day a new onset of acute pain, paresthesia were reported, followed by edema in the right upper limb. A Doppler ultrasound was positive for an acute thrombosis, confirmed by CT scan. A new phlebography and mechanical thrombectomy using the ASPIREX device followed by a new angioplasty of a partial distal stenosis was done. A new stent implantation into humeral, axillary, and subclavian veins was performed. Outcome was favorable with complete resolution of the symptoms; being discharged on day 6. The patient currently is asymptomatic, receiving HPN without complications. Conclusion: This case is an example of the management of deep venous thrombosis secondary to the chronic use of HPN. A comprehensive multidisciplinary approach is mandatory due to its complexity, requiring to be performed by trained and expert interventionists, to successfully provide new alternatives to extend the possibility for their life support or avoid contraindications to transplant. Peripheral venous hemodynamic is not a common procedure however, is the cornerstone to treat this complication achieving in many cases the recovery of venous blood flow delaying the need of intestinal transplantation.

A Simulation Study to Investigate the Usefulness of a Novel Stricture Tool for Training Wire Guided Balloon Dilation

Abstract Background and Aims The training in esophageal stricture dilation is difficult to obtain and have few simulation models. The aim of the study was to evaluate a novel stricture simulation for training a wire-guided, controlled radial expansile (CRE) balloon dilation. Methods The study was a pretest–posttest design without a control group involving a novel simulation device for esophageal stricture. The training session involved 12 final year gastroenterology fellows from five different centers. The trainees received 2 hours of education sessions featuring didactic content, a live demonstration of step-by-step demonstration of wire-guided CRE balloon dilation and a study material on the procedure. The simulation device used was a single-use hose pipe along with a red color nonhardening modeling clay with a 5.0-to-8.0-mm hole in the center. Results All the trainees and instructor uniformly rated the model as excellent or good with simulation device being mild stiffer in haptics than of the real tissue. The mean (%) pretest scores of 39 (21.6%) improved significantly to 160 (88.8%) in mean (%) posttest questionnaire (p &lt; 0.05). There was a significant improvement in the questionnaire of the dilation procedure after the simulation training episode. Conclusion The novel stricture simulation model had good performance evaluation and can be used to train CRE balloon dilation procedure.

Scheduled endoscopic treatment of biliary anastomotic and nonanastomotic strictures after orthotopic liver transplantation

Biliary strictures after liver transplantation are associated with significant morbidity and mortality. Although various endoscopic treatment strategies are available, consensus on a particular strategy is lacking. Moreover, the influence of endoscopic therapy on overall survival has not been studied. This retrospective study aimed to evaluate the impact of scheduled endoscopic dilatation of biliary strictures after orthotopic liver transplantation on therapeutic success, adverse events, and survival. Between 2000 and 2016, patients with post-transplant anastomotic and nonanastomotic strictures were treated with balloon dilatation at defined intervals until morphologic resolution and clinical improvement. The primary clinical endpoint was overall survival, whereas secondary outcomes were technical and sustained clinical success, adverse events, treatment failure, and recurrence. Overall, 165 patients with a mean follow-up of 8 years were included; anastomotic and nonanastomotic strictures were diagnosed in 110 and 55 patients, respectively. Overall survival was significantly higher in patients with anastomotic strictures than in those with nonanastomotic strictures (median, 17.6 vs 13.9 years; log-rank: P< .05). Sustained clinical success could be achieved significantly more frequently in patients with anastomotic strictures (79.1% vs 54.5%, P< .001), and such patients showed significantly superior overall survival (19.7 vs 7.7 years; log-rank: P< .001). Sustained clinical success and the presence of nonanastomotic strictures were independently associated with better and worse outcomes (P< .05), respectively. Scheduled endoscopic treatment of biliary anastomotic and nonanastomotic strictures after liver transplantation is effective and safe, with high success rates. The implementation of this strategy controls symptoms and significantly improves survival.

Predictive factors for the success of endoscopic dilation of esophageal caustic stricture: the experience of a French tertiary reference center.

Predictors of the efficacy of endoscopic dilation for caustic esophageal stricture have been poorly studied. All patients undergoing an endoscopic dilation for an esophageal caustic stricture between 1990 and 2015 in a French national reference center were included. Success of dilation was defined by self-food autonomy without the need for reconstructive esophageal surgery. During the study period, 894 patients were admitted after caustic ingestion. Among them, 101 patients developed esophageal stricture and 92 patients were eligible for analysis (missing data in 8 cases, 1 patient died before endoscopic dilation). In this cohort (median age 42years, women 53%, strong alkali 74%, suicide attempt 77%, hydrostatic balloon use 93%), the overall success rate of dilation was 57% with a median number of 3 dilation sessions (274 sessions, range 1-17). Factors predicting the success of the procedure were: non-inflammatory stricture or non-inflammatory intercalated mucosa between stricture (88% vs 47%, p = 0.001), a single stricture versus 2 or more strictures (69% vs 47% vs 33%, respectively, p = 0.04), a stricture of less than 5cm (70% vs 27%, p < 0.001) and the existence of mild/ moderately tight or very tight stricture (70% vs 21% of success, p < 0.001). Perforation rate was 6.5% (18/274) requiring emergency surgery in 2 cases. Several characteristics of caustic esophageal strictures are significantly associated with the success rate of endoscopic dilation. Our data may be useful for customizing treatment strategies in patients with a caustic stricture.

Implementation of Image-Guided Brachytherapy for Pediatric Vaginal Cancers: Feasibility and Early Clinical Results.

Simple SummaryBrachytherapy is one of the cornerstones of the treatment of pediatric vaginal tumors in combination with surgery and chemotherapy from a conservative perspective. In this retrospective series, we present our experience with 3D pulsed dose rate brachytherapy for the treatment of children with vaginal tumors. Our results show that this treatment has good compliance and provides an excellent local control rate. The toxicity rate is also favorable, with gynecological toxicities being the most frequent. Given the rarity of these diseases, their management should be entrusted to expert centers.Background: Brachytherapy (BT) has a major role in pediatric cancers of the lower genital tract, as part of a multimodal organ conservative strategy. Scarce data are available on the location of image-guided BT. Methods: Medical records of all consecutive girls treated in our center between 2005 and 2020 for a vaginal tumor with exclusive image-guided PDR-BT were retrospectively examined, with a focus on treatment parameters, patient compliance, and clinical outcome, including analysis of local control, survival and late toxicity rates. Results: Twenty-six patients were identified, with a median age of 25 months. Histological types were rhabdomyosarcoma, malignant germ cell tumor (MGCT) and clear cell adenocarcinoma in 18 (69%), 7 (27%) and 1 (4%) patients, respectively. Ten (33%) patients had prior surgery and 25 (96%) received chemotherapy prior to BT. The median prescribed dose was 60 Gy through pulses of 0.42 Gy. Global compliance was satisfactory, but three (12%) patients required replanning because of applicator displacement. After a median follow-up of 47.5 months, one patient with MGCT referred for salvage treatment of a local recurrence had a local and metastatic relapse. The local control rate probability was 96% at the last follow-up. Late toxicity rates ≥ grade 2 and ≥ grade 3 were reported in 23% and 11%, respectively, with gynecological toxicities being the most frequent side effect. Two patients required dilatation for vaginal stenosis. Conclusions: PDR-BT allowed similar local control compared to the historical low-dose rate technique. An indirect comparison suggests fewer treatment-related toxicities by integrating image guidance and optimization capabilities, but longer follow-up is necessary. Due to the rarity of the disease and the technical aspects of BT in these very young patients, referral to specialized high-volume centers is recommended.

Effectiveness of Endoscopic Dilatation for Corrosive Oesophageal Strictures

Objective: The objective of study was to determine the efficacy after endoscopic dilatation in patients of corrosive intake. Study Design: It was descriptive case series Setting: Research was conducted at Medical Unit-III, Services Hospital, Lahore. Duration: Duration of study was 6 months from 1st November 2016 to 30th April 2017. Material and Methods: This study involved 150 patients of age 18-65 years with corrosive intake and dysphagia score ≥ 2. A written informed consent was taken from each patient. Results: Total 150 patients were added in the study. Out of these, 118 patients (78.7%) were females while 32 (21.3%) were males. The age of patient ranged from 18 to 48 years with a mean of 26.72 ±5.61. One hundred thirty two patients (88 %) showed improvement in dysphagia while 18 patients (12 %) did not show any improvement. Efficacy calculated by chi- square test which showed p-value of .000 (statistically significant) Conclusion: 150 patients with dysphagia score ≥ 2 were added in study and dilated with Savary-Gilliard dilator. 132 patients showed improvement in dysphagia with p-value of .ooo (statistically significant).

Pediatric endoscopy across multiple clinical settings: Efficiency and adverse events.

BACKGROUNDEndoscopic procedures are becoming increasingly important for the diagnosis and treatment of gastrointestinal disorders during childhood, and have evolved from a more infrequent inpatient procedure in the operating room to a routine outpatient procedure conducted in multiple care settings. Demand for these procedures is rapidly increasing and thus there is a need to perform them in an efficient manner. However, there are little data comparing the efficiency of pediatric endoscopic procedures in diverse clinical environments. We hypothesized that there are significant differences in efficiency between settings.AIMTo compare the efficiency and examine adverse effects of pediatric endoscopic procedures across three clinical settings.METHODSA retrospective chart review was conducted on 1623 cases of esophagogastroduodenoscopy (EGD) or combined EGD and colonoscopy performed between January 1, 2014 and May 31, 2018 by 6 experienced pediatric gastroenterologists in three different clinical settings, including a tertiary care hospital operating room, community hospital operating room, and free-standing pediatric ambulatory endoscopy center at a community hospital. The following strict guidelines were used to schedule patients at all three locations: age greater than 6 mo; American Society of Anesthesiologists class 1 or 2; normal craniofacial anatomy; no anticipated therapeutic intervention (e.g., foreign body retrieval, stricture dilation); and, no planned or anticipated hospitalization post-procedure. Data on demographics, times, admission rates, and adverse events were collected. Endoscopist time (elapsed time from the endoscopist entering the operating room or endoscopy suite to the next patient entering) and patient time (elapsed time from patient registration to that patient exiting the operating room or endoscopy suite) were calculated to assess efficiency.RESULTSIn total, 58% of the cases were performed in the tertiary care operating room. The median age of patients was 12 years and the male-to-female ratio was nearly equal across all locations. Endoscopist time at the tertiary care operating room was 12 min longer compared to the community operating room (63.3 ± 21.5 min vs 51.4 ± 18.9 min, P < 0.001) and 7 min longer compared to the endoscopy center (vs 56.6 ± 19.3 min, P < 0.001). Patient time at the tertiary care operating room was 11 min longer compared to the community operating room (133.2 ± 39.9 min vs 122.3 ± 39.5 min, P < 0.001) and 9 min longer compared to the endoscopy center (vs 124.9 ± 37.9 min; P < 0.001). When comparing endoscopist and patient times for EGD and EGD/colonoscopies among the three locations, endoscopist, and patient times were again shorter in the community hospital and endoscopy center compared to the tertiary care operating room. Adverse events from procedures occurred in 0.1% (n = 2) of cases performed in the tertiary care operating room, with 2.2% (n = 35) of cases from all locations having required an unplanned admission after the endoscopy for management of a primary GI disorder.CONCLUSIONPediatric endoscopic procedures can be conducted more efficiently in select patients in a community operating room and endoscopy center compared to a tertiary care operating room.

Curative balloon dilation of a severe esophageal stricture in a pig

AbstractA 3‐month‐old, Yorkshire cross barrow was evaluated for diarrhoea and vomiting, which were observed intermittently during and after consumption of feed and water. Weight loss, despite good appetite, was also reported. Abdominal radiographs demonstrated stomach distention and gas within the duodenal lumen. Thickening of the pyloric antrum and proximal duodenum were noticed using abdominal ultrasonography. Esophageal endoscopy demonstrated severe reduction of the aborad esophageal lumen, which precluded endoscopic evaluation of the stomach. A severe esophageal stricture was diagnosed. Medical management using omeprazole and dietary changes did not alleviate the clinical signs. The esophageal stricture was successfully resolved by balloon dilation performed under general anaesthesia using fluoroscopy. The pig started to gain weight, developed normally, and was successfully harvested 3 months later. The balloon dilation was curative and is presented as an option for cases of severe porcine gastric ulceration and esophageal stricture that are refractory to nutritional and medical management.

An international experience with single-operator cholangiopancreatoscopy in patients with altered anatomy

Background and study aims The utility of digital single- operator cholangiopancreatoscopy (D-SOCP) in surgically altered anatomy (SAA) is limited. We aimed to evaluate the technical success and safety of D-SOCP in patients SAA. Patients and methods Patients with SAA who underwent D-SOCP between February 2015 and June 2020 were retrospectively evaluated. Technical success was defined as completing the intended procedure with the use of D-SOCP. Results Thirty-five patients underwent D-SOCP (34 D-SOC, 1 D-SOP). Bilroth II was the most common type of SAA (45.7 %), followed by Whipple reconstruction (31.4 %). Twenty-three patients (65.7 %) patients had prior failed ERCP due to the presence of complex biliary stone (52.2 %). A therapeutic duodenoscope was utilized in the majority of the cases (68.6 %), while a therapeutic gastroscope (22.7 %) or adult colonoscope (8.5 %) were used in the remaining procedures. Choledocholithiasis (61.2 %) and pancreatic duct calculi (3.2 %) were the most common indications for D-SOCP. Technical success was achieved in all 35 patients (100 %) and majority (91.4 %) requiring a single session. Complex interventions included electrohydraulic or laser lithotripsy, biliary or pancreatic stent placement, stricture dilation, and target tissue biopsies. Two mild adverse events occurred (pancreatitis and transient bacteremia). Conclusions In SAA, D-SOCP is a safe and effective modality to diagnose and treat complex pancreatobiliary disorders, especially in cases where standard ERCP attempts may fail.

P-38 Proper size and timing of endoscopic dilation in anastomotic stricture after near-total esophagectomy

The size or timing of endoscopic dilatation for anastomotic stricture after near-total esophagectomy is not clear. The purpose of this study is to find out the target size and the timing of endoscopic dilatation for stenosis after near-total esophagectomy.

Improved outcomes in proximal gastric bypass surgery following the transition from a conventional circular stapling to an augmented linear stapling protocol

Abstract Objective Bariatric techniques for bypass surgery evolve constantly. Switching from one well-established protocol to another in a running surgical teaching program is challenging. We analyzed clinical outcomes, safety and costs at a single bariatric center transitioning from circular to an augmented linear bypass protocol. Methods Between 2011 and 2018, 454 patients were included in this retrospective study. The circular bypass protocol (CIRC; n=177) was primarily used between 2011–2012. Between 2013–2015 the transition occurred. Thereafter, the augmented linear protocol (aLIN; n=277) was primarily utilized. Results Overall, mean preoperative BMI dropped from 42.2 kg/m2 to 29.6 kg/m2 after 5 years with no difference between groups. Operation times were significantly shorter in the aLIN-group, compared with CIRC-patients at 108 (±32) vs. 120 (±34) minutes (P&amp;lt;0.001), respectively. The reoperation rate was significantly higher in the CIRC vs. aLIN group at n=65 (36%) vs. n=35 (13%; P&amp;lt;0.001), respectively. Specifically, revision due to internal hernia occurred much more frequently in the CIRC-group, n=36 (20%) vs. n=12 (4%; P&amp;lt;0.001). Moreover, reoperation due to gastrojejunostomy-leakage and endoscopic dilatation for anastomotic stenosis was more common in the CIRC vs. aLIN group (P&amp;lt;0.001). Adjusted overall cost per case was lower in aLIN-patients at 15,403 (±7,848) vs. CIRC-patients at 18,525 (±7,850) Swiss Francs (P&amp;lt;0.001). Overall profit was 2,555 ± 4,768 vs. 1,455 ± 5,638 Swiss Francs in the aLIN vs. CIRC-group, respectively (P=0.026). Conclusion This study showed improved clinical outcomes while also secondarily improving financial performance after a gradual transition from a circular stapling protocol to an augmented linear stapling protocol in proximal gastric bypass surgery. The technical transition in this study proves, that if a new technique is superior in terms of safety and postoperative morbidity, it will also be financially beneficial.