Therapeutic Endoscopy Research Articles

Epidemiology, Diagnosis, Staging and Multimodal Therapy of Esophageal and Gastric Tumors.

Simple SummaryUpper gastrointestinal tumors involve the tubular organs from the upper esophagus, the stomach, and the first part of the small intestine. Esophageal and gastric cancers are responsible for high rates of disease, morbidity, and mortality throughout the world. Diagnosis of these tumors involves a combination of clinical symptoms, endoscopy, endoscopic ultrasound, and radiological studies. Treatment depends on input from many medical doctors including gastroenterologists, surgeons, pathologists, medical oncologists, radiologists, and radiation oncologists. Treatment may include endoscopy, surgery, chemotherapy, radiation therapy, or a combination of these approaches. Future directions of diagnosis may include improvements in endoscopy, endoscopic ultrasound, blood testing, and tissue testing.Gastric and esophageal tumors are diverse neoplasms that involve mucosal and submucosal tissue layers and include squamous cell carcinomas, adenocarcinomas, spindle cell neoplasms, neuroendocrine tumors, marginal B cell lymphomas, along with less common tumors. The worldwide burden of esophageal and gastric malignancies is significant, with esophageal and gastric cancer representing the ninth and fifth most common cancers, respectively. The approach to diagnosis and staging of these lesions is multimodal and includes a combination of gastrointestinal endoscopy, endoscopic ultrasound, and cross-sectional imaging. Likewise, therapy is multidisciplinary and combines therapeutic endoscopy, surgery, radiotherapy, and systemic chemotherapeutic tools. Future directions for diagnosis of esophageal and gastric malignancies are evolving rapidly and will involve advances in endoscopic and endosonographic techniques including tethered capsules, optical coherence tomography, along with targeted cytologic and serological analyses.

Effectiveness of Solution with 5% Detergent for Cleaning Transnasal Esophagogastroduodenoscopy Lens.

Background/AimsUnsedated transnasal esophagogastroduodenoscopy (EGD) is affected by a poor scope lens-cleaning function. We have previously reported good, albeit limited, effects of an oolong tea washing solution; here, we evaluated the effectiveness of a 5% lens cleaning solution for cleaning an EGD lens. MethodsFive percent lens cleaning solution (C), 5% dimethicone solution (D), and distilled water (W) were prepared. Study I: Lenses were soiled with pork grease, washed with each washing solution, and their image quality was judged. Study II: Patients (n=996) scheduled for transnasal EGD were randomly assigned to the C- or W-group. Lens cleanliness level, washing solution volume used, and endoscopist stress due to lens contamination were determined. ResultsStudy I: The image quality of the lenses washed with (C) was significantly superior. (D) was clinically unsuitable because of spray nozzle clogging. Study II: Lens cleaning in the C-group was significantly superior (p<0.0001) and the solution volume required was significantly reduced (p<0.0001), while endoscopist stress was also lower (p<0.0001). ConclusionsFor transnasal small-caliber EGD, the present 5% lens cleaning solution provided good visibility. It features a high detergency level and is simple to formulate for therapeutic endoscopy applications, such as endoscopic submucosal dissection.

Over-the-scope-clip treatment for perforation of the duodenum after endoscopic papillectomy.

Over-the-scope-clip treatment for perforation of the duodenum after endoscopic papillectomy.

Endoscopic removal of entirely embedded esophagus-penetrating foreign bodies (with video).

Traditionally, surgery is the only choice for esophageal foreign bodies (FBs) penetrating into the mediastinum or cervical para-esophageal space. Recent progress in endoscopic techniques and devices has made it possible to perform endoscopic procedures in the mediastinum. Here, we describe a novel method to remove the entirely embedded esophagus-penetrating FBs through an endoscopic approach. Patients who underwent endoscopic removal of entirely embedded esophagus-penetrating FBs were prospectively enrolled between December 2018 and June 2020. All procedures were performed by using five major steps: localization of the FB; mucosal incision; wound debridement, myotomy, and FB exposure; FB extraction; and closure of the esophageal wound. A total of five cases of entirely embedded esophagus-penetrating FBs were evaluated, two in children and three in adults. All FBs were successfully removed and extracted using a therapeutic endoscope and a hook knife or a hybrid knife and a grasping forceps as accessories. The average procedure time was 19.0±12.4min (range 10-40min). The major surgical procedure was avoided in all patients. The average length of hospital stay was 3.8±2.5days (range 2-8days). There were no severe short-term adverse events after all procedures. During the 1month and 3months follow-up, no patient developed long-term adverse events including stenosis of the esophagus and fistula formation. Endoscopic approach was a safe and effective way to remove entirely embedded esophagus-penetrating FBs.

A successful nonsurgical management of Boerhaave's syndrome

Boerhaave's syndrome consists of barogenic rupture of the esophagus, in a previously healthy esophagus. This is a rare, serious, and rapidly lethal perforation of the gastrointestinal tract. The outcome essentially depends on early diagnosis and prompt intervention. Due to the scarcity of case reports, no clear consensus exists regarding the best therapeutic approach. Surgical intervention has been mainstay of management, but with advances in therapeutic endoscopy, there has been an increasing interest in nonsurgical options. Here, we report a case of Boerhaave's syndrome in a 40-year-old male patient, diagnosed early and successfully treated nonsurgically with temporary placement of fully covered esophageal stent.

Retrospective evaluation of patients with non-varicose upper gastrointestinal bleeding

Upper gastrointestinal tract (GIS) bleeding refers to any bleeding originates from the area from upper esophagus to the proximal of the treitz ligament. It has a wide range of clinical manifestations ranging from hypovolemic shock to death. Bleeding from peptic ulcer (PU) is one of the major cause of upper GIS bleeding. Despite improvements in therapeutic endoscopy and angiography, gastrointestinal bleeding is still an important source of morbidity and mortality. Although approximately 80-85% of upper GIS bleeding stops spontaneously, supportive treatment is required. In this study, we aimed to determine the clinical, laboratory and demographic characteristics of patients with upper GIS bleeding and their relationship with major scoring systems. Two hundred thirteen patients over 18 years old that were admitted to Canakkale Onsekiz Mart University Training and Research Hospital between January 2016 and March 2020 with a diagnosis of non-variceal GIS bleeding were retrospectively enrolled to this study. Age, gender, blood group, comorbid conditions, endoscopic findings, laboratory values and medications were recorded for each patient. Prognostic scorings were calculated for each patient. The mean age of patients was 68.67±14.8 years (Male/Female: 156/57). In overall, 90.7% of patients were discharged and 7.5% of patients were transferred to intensive care unit. The mortality rate was 1.8%. Endoscopic evaluation revealed that 31.9% of patients had duodenal ulcer and 19.2% of patients had gastric ulcer. Medical treatment was applied to 84.8% of patients and 13.4% of patients received endoscopic treatments. Length of stay was significantly correlated with Rockall and Glasgow Blatchford scores. This study revealed that age, comorbid conditions and prior drug history were related to predisposition to GIS bleeding. Early diagnosis and intervention might reduce the mortality in these patients. Despite early endoscopic interventions and the improvements in endoscopic techniques GIS bleeding still associated with increased rates of morbidity and mortality.

Streaming from a Diagnostic and Therapeutic Endoscopy Room: It Is Possible at Low Cost

<i>Background and Aims</i>: Before the covid-19 pandemic, medicine was practice and taught almost entirely face-to-face. The new normal, presented us with an opportunity to change the paradigm. Previously, live video transmission was only possible with the use of satellites, that were too expensive to be use regular bases. Now it is possible to broadcast live cases, from anywhere around de world, at a relative low cost. <i>Methodology</i>: This is a descriptive study to show the experience in transmissions of endoscopy live procedures from endoscopy rooms of different centers of Latin America ascribed to the Latin American Training Center (LAGE-TC) adapting virtual transmission technologies for a diagnostic and therapeutic endoscopy, to broadcast cases in real-time through the internet. <i>Results</i>: From April 2020 to July 31^th, 2020 we have made transmissions every week, for each center, being Tuesdays designated for transmissions from Manizales in Colombia from the Unión de Cirujanos SAS (Dr Lázaro Arango M), Wednesdays from San Borja Arriaran, in Santiago de Chile (fellows training center of Latin America and from where the LAGE-TC is born) (Drs. Claudio Sergio Navarrete Garcia- Cecilia Castillo T, Carlos Barrientos- Ignacio Robles and Arturo Valle) and from San Juan in Argentina (Dr Marcelo Ponce), on Thursdays from Santa Fé Argentina (Dr. Hugo Imcof), and the Clínica del Norte in Barranquilla - Colombia (Drs. Jesús Rodríguez and Álvaro Jalal). Transmissions have also been made from other centers in Santiago de Chile, Mendoza (Dr Jorge Isaguirre) and Cordoba (Dra Jackelina Gobelet) in Argentina, and in Bucaramanga - Colombia (Dr Eduardo Valdivieso – Fundación Ildetecsa). 23 live broadcasts of cases from all the named cities in Latin America have been made, almost all from one center and being seen by the other centers already named as initial tests. One of the last meetings was held simultaneously between the Latin American Training Center in Santiago de Chile and the Hospital de San Juan in Argentina. The transmissions were done with good quality of video and sound, at a relative low cost. <i>Conclusion</i>: The study shows in detail different ways in which an endoscopy room can be adapted to perform live broadcasts with elements easy to get and at low cost, with good quality images. The adaptation of this technology will allow live transmission of medical classes, conferences with large audience, consultation form experts on line in other units, cities or countries, to improve medical knowledge and care.

Management of Chronic Fistula Using the Cardiac Septal Defect Occluder

Therapeutic endoscopy plays a critical role in the management of gastrointestinal (GI) fistulas. Innovative endoscopic approaches have revolutionized the treatment of GI fistulas; however, current endoscopic treatment modalities require multiple sessions and are associated with highly variable success rates and safety profi les. Due to these currently limitations, the off -label use of cardiac septal defect occluders (CSDOs) has emerged as a promising device to treatment GI fi stulas, with early studies suggesting it to be a technically feasible, effective, and safe treatment. Therefore, we believe CSDO devices may be a preferred option for the management of refractory GI fistulas.

Advances and caveats in modern achalasia management.

Achalasia is a rare esophageal motility disorder characterized by the incomplete relaxation of the lower esophageal sphincter (LES) and impaired peristaltic activity. The advent of high-resolution manometry (HRM) and the rapidly evolving role of therapeutic endoscopy have revolutionized the approach to the diagnosis and management of achalasia patients in the last decade. With advances in HRM technology and methodology, fluoroscopy and EndoFlip, achalasia can be differentiated into therapeutically meaningful phenotypes with a high degree of accuracy. Further, the newest treatment option, per-oral endoscopic myotomy (POEM), has become a staple therapy following the last 10 years of experience, and recent randomized trials appear to show no difference between POEM, graded pneumatic dilatation and surgical Heller myotomy in terms of short- and long-term efficacy or complication rate. On the other hand, how treatment outcomes are measured as well as the risk of reflux following therapy remain areas of contention. This review aims to summarize the recent advancements in achalasia testing and therapy, describes the recent randomized clinical trials as well as their potential setbacks, and touches on the future of personalizing achalasia treatment.

Forward: A new kind of endoscopists for advanced therapeutic endoscopy

Forward: A new kind of endoscopists for advanced therapeutic endoscopy

Colon capsule endoscopy in patients with chronic respiratory disease during the COVID‐19 pandemic

Dear Editor, We read with interest the article by MacLeod et al. [1]. The authors suggest that colon capsule endoscopy (CCE) could be a useful tool for triaging emergency colonoscopy during the COVID-19 pandemic. The literature for CCE in patients with chronic respiratory disease, who comprise one of the COVID-19 high-risk groups [2], is limited. We carried out a retrospective study of CCE in patients with chronic respiratory disease up to May 2020, the first wave of the COVID-19 pandemic in Japan. Thirty-one patients (18 men and 13 women with a mean age of 65.2 ± 15.1 years) with chronic respiratory disease who underwent CCE at our hospital were included. The diagnoses of these patients were pulmonary emphysema in seven patients, bronchial asthma in seven patients, chronic bronchitis in six patients, sleep apnoea syndrome in two patients, pulmonary tuberculosis (old and latent) in eight patients and nontuberculous mycobacteriosis in one patient. The reasons for the procedure were as follows: screening in seven patients, positive for a faecal occult blood test in four patients, lower abdominal pain in five patients, diarrhoea in two patients, abnormal bowel movement in five patients, narrowing of the stool column in one patient, follow-up for Crohn's disease in one patient, suspicion of irritable bowel syndrome in three patients and accumulation of positron emission tomography in the transverse colon in one patient. The overall total colorectal detection rate using CCE was 90.3% (28/31). Polyps were detected in 54.8% of patients by CCE (17/31 cases), and a significant finding (polyp lesion of 6 mm or more) was observed in 64.7% (11/17 cases). Colonoscopy (CS) was performed in 45.1% (14/31). The positive predictive value was 100% (17/17 patients) and the negative predictive value (13/14 patients) was 92.9%. Histopathological examination by therapeutic endoscopy using CS with personal protective equipment revealed six cases of adenoma, six cases of hyperplasia, one case of carcinoma in situ and no advanced cancer. There were no adverse events, such as retention, in any patient and no evidence of SARS-Cov-2 infection in healthcare professionals. There is a report suggesting the possibility of colon CT examination [3] and positron emission tomography [4] as an alternative method during the COVID-19 pandemic. However, CCE is free from radiation exposure and the only examination that can be performed at home without coming to hospital during the pandemic. CCE is expensive, it costs the national health insurance adaptation of Japan approximately ￥30 000 at a 30% burden. However, it can be easily inferred that in patients with chronic respiratory disease it is more cost-effective than the medical cost of ventilators and extracorporeal membrane oxygenation in intensive care units if they become seriously ill with SARS-Cov-2 infection. Also, in Japan, CCE was adopted by the national health insurance plan for chronic obstructive pulmonary disease from March 2020. Our study results suggest that CCE in patients with chronic respiratory disease avoids unnecessary CS and may reduce the risk of SARS-Cov-2 infection by CS in approximately 60% of the patients. All patients consented to data collection, analysis and dissemination. The author participated in the interpretation of study results, and in the drafting, critical revision, and approval of the final version of the manuscript. I declare no conflict of interests. This study was approved by the ethics committee. The data that support the findings of this study are openly available in [repository name e.g. “figshare”] at 10.6084/m9.figshare.13278059.

Clinical Practice Guideline for the Management of Antithrombotic Agents in Patients Undergoing Gastrointestinal Endoscopy

Antithrombotic agents, including antiplatelet agents and anticoagulants, are increasingly used in South Korea. The management of patients using antithrombotic agents and requiring gastrointestinal endoscopy is an important clinical challenge. Although clinical practice guidelines (CPGs) for the management of patients receiving antithrombotic agents and undergoing gastrointestinal endoscopy have been developed in the Unites States, Europe, and Asia Pacific region, it is uncertain whether these guidelines can be adopted in South Korea. After reviewing current CPGs, we identified unmet needs and recognized significant discrepancies in the clinical practice among regions. This is the first CPG in Korea providing information that may assist endoscopists in the management of patients on antithrombotic agents who require diagnostic or elective therapeutic endoscopy. This guideline was developed through the adaptation process as an evidence-based method, with four guidelines retrieved by systematic review. Eligible guidelines were evaluated according to the Appraisal of Guidelines for Research and Evaluation II process, and 13 statements were established using a grading system. This guideline was reviewed by external experts before an official. It will be revised as necessary to cover changes in technology, evidence, or other aspects of clinical practice.

Massive impact of coronavirus disease 2019 pandemic on gastroenterology and hepatology departments and doctors in Spain.

Significant human and material resources have been diverted to coronavirus disease 2019 (COVID-19). Healthcare workers are at high risk of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection. We assess the impact of the COVID-19 pandemic on gastroenterology and hepatology departments and specialists in Spain. This study involves a nationwide survey addressing the impact of COVID-19 on resources, procedures, and physicians of gastroenterology and hepatology departments in 81 hospitals representative of the Spanish National Health Service. Overall, 41.8% of hospital beds and 40.7% of gastroenterology and hepatology beds were allocated to COVID-19 patient care, as well as 24.8% of gastroenterologists and 58.3% of residents. Outpatient visits, abdominal ultrasounds, and endoscopies were reduced by 81.8-91.9%. Nine large university hospitals had 75% and 89% reductions in therapeutic endoscopies and hepatocellular carcinoma surgery, respectively, with cancelation of elective liver transplant and transjugular intrahepatic portosystemic shunt. Prevalence of infected physicians was 10.6% and was dependent on regional population incidence (r=0.74, P=0.001), with 11% hospitalized and one physician dying. Up to 63.4% of physicians may have been infected before or shortly after Spain entered lockdown, 57% of them having recently performed endoscopies. Adequate protection was acknowledged in >80% hospitals, but only 2.9% performed regular SARS-CoV-2 testing. The impact of the COVID-19 pandemic on healthcare delivery has been massive. A wave of gastroenterology-related complications is expected because of resource diversion. Gastroenterologists have a high prevalence of infection, although they may have been infected during a first phase of lower awareness and protection. Regular SARS-CoV-2 screening, adequate protection, and quick reorganization of healthcare resources are still needed.

Clinical Impact of Universal Screening for COVID-19 before Therapeutic Endoscopy

Abstract Introduction The Coronavirus pandemic (COVID-19) has led to drastic change in gastrointestinal (GI) endoscopy practice. Endoscopy is an aerosol-generating procedure. COVID-19 testing prior to endoscopy can reduce transmission by delaying non-emergency endoscopies in positive patients. There is scarcity of literature to support such protocols. We aimed to study the clinical impact of universal testing for COVID-19 before therapeutic endoscopy. Methods This is retrospective analysis of prospectively maintained data. All patients requiring therapeutic endoscopy were enrolled between June 15 to July 15, 2020. Clinical profile, indication, endoscopic intervention, and outcome of patients tested positive for COVID-19 real-time polymerase chain reaction (RT PCR) or CT chest suggestive of CO-RADS 3 or more were included for analysis. Results Out of 772 patients scheduled for endoscopic interventions, 26 (3.34%) patients had COVID-19 infection with mean age (range) of 48.19 (3–75) years. Eight (30.8%) were females. Of them, seven (26.9%) patients underwent emergency endoscopy, and another seven (26.9%) patients underwent endoscopy after minimum of 2 weeks waiting period. Two deaths were seen in patients who underwent emergency interventions which were unrelated to endoscopy. One patient, who was planned for endoscopic ultrasound (EUS) for choledocholithiasis, developed acute biliary pancreatitis in the waiting period. Conclusion We suggest use of universal testing for COVID-19 by RT-PCR before endoscopic intervention. Endoscopy can be postponed for 2 weeks with marginal risk of adverse events during the waiting period in nonemergency indications. However, this approach needs to be tailored as per local needs, resources availability, and indication of endoscopy.

Recommendations for the return to scheduled diagnostic and therapeutic endoscopy during the COVID-19 pandemic

The Committee on Flexible Endoscopy of the AAC, which is permanently engaged in advising and assisting surgeons who perform gastrointestinal endoscopy during the SARS-Cov-2 pandemic, drew up the following recommendations for the return to the scheduled activity, based on the experiences shared by different international scientific societies and renowned national centers dedicated to flexible endoscopy.

Bleeding After Elective Interventional Endoscopic Procedures in a Large Cohort of Patients With Cirrhosis.

INTRODUCTION:Elective therapeutic endoscopy is an important component of care of cirrhotic patients, but there are concerns regarding the risk of bleeding. This study examined the incidence, risk factors, and outcomes of bleeding after endoscopic variceal ligation (EVL), colonoscopic polypectomy, and endoscopic retrograde cholangiopancreatography with sphincterotomy in cirrhotic patients.METHODS:A cohort study of patients with cirrhosis who underwent the above procedures at a single center between 2012 and 2014 was performed. Patients with active bleeding at the time of procedure were excluded. Patients were followed for 30 days to assess for postprocedural bleeding and for 90 days for mortality.RESULTS:A total of 1,324 procedures were performed in 857 patients (886 upper endoscopies, 358 colonoscopies, and 80 endoscopic retrograde cholangiopancreatograpies). After EVL, bleeding occurred in 2.8%; after polypectomy, bleeding occurred in 2.0%; and after sphincterotomy, bleeding occurred in 3.8%. Independent predictors of bleeding after EVL and polypectomy included younger age and lower hemoglobin. For EVL, bleeding was also associated with infection and model for end-stage liver disease-Na. International normalized ratio was associated with bleeding in univariate analysis only, and platelet count was not associated with bleeding in any procedure. Bleeding after EVL was associated with 29% 90-day mortality, and bleeding after polypectomy was associated with 14% mortality. Of the 3 patients with postsphincterotomy bleeding, none were outliers regarding their baseline characteristics.DISCUSSION:In patients with cirrhosis, bleeding occurs infrequently after elective therapeutic endoscopy and is associated with younger age, lower hemoglobin, and high mortality. Consideration of these risk factors may guide appropriate timing and preprocedural management to optimize outcomes.

Clinical Practice Guideline for the Management of Antithrombotic Agents in Patients Undergoing Gastrointestinal Endoscopy.

Antithrombotic agents, including antiplatelet agents and anticoagulants, are increasingly used in South Korea. The management of patients using antithrombotic agents and requiring gastrointestinal endoscopy is an important clinical challenge. Although clinical practice guidelines (CPGs) for the management of patients receiving antithrombotic agents and undergoing gastrointestinal endoscopy have been developed in the Unites States, Europe, and Asia Pacific region, it is uncertain whether these guidelines can be adopted in South Korea. After reviewing current CPGs, we identified unmet needs and recognized significant discrepancies in the clinical practice among regions. This is the first CPG in Korea providing information that may assist endoscopists in the management of patients on antithrombotic agents who require diagnostic or elective therapeutic endoscopy. This guideline was developed through the adaptation process as an evidence-based method, with four guidelines retrieved by systematic review. Eligible guidelines were evaluated according to the Appraisal of Guidelines for Research and Evaluation II process, and 13 statements were established using a grading system. This guideline was reviewed by external experts before an official. It will be revised as necessary to cover changes in technology, evidence, or other aspects of clinical practice.

Peroral traction-assisted natural orifice trans-anal flexible endoscopic rectosigmoidectomy followed by intracorporeal colorectal anastomosis in a live porcine model.

BACKGROUNDCompared to traditional open surgery, laparoscopic surgery has become a standard approach for colorectal cancer due to its great superiorities including less postoperative pain, a shorter hospital stay, and better quality of life. In 2007, Whiteford et al reported the first natural orifice trans-anal endoscopic surgery (NOTES) sigmoidectomy using transanal endoscopic microsurgery. To date, all cases of NOTES colorectal resection have included a hybrid laparoscopic approach with the use of established rigid platforms. AIMTo introduce a novel technique of peroral external traction-assisted transanal NOTES rectosigmoidectomy followed by intracorporeal colorectal end-to-end anastomosis by using only currently available and flexible endoscopic instrumentation in a live porcine model.METHODSThree female pigs weighing 25-30 kg underwent NOTES rectosigmoid resection. After preoperative work-up and bowel preparation, general anesthesia combined with endotracheal intubation was achieved. One dual-channel therapeutic endoscope was used. Carbon dioxide insufflation was performed during the operation. The procedure of trans-anal NOTES rectosigmoidectomy included the following eight steps: (1) The rectosigmoid colon was tattooed with India ink by submucosal injection; (2) Creation of gastrostomy by directed submucosal tunneling; (3) Peroral external traction using endoloop ligation; (4) Creation of rectostomy on the anterior rectal wall by directed 3 cm submucosal tunneling; (5) Peroral external traction-assisted dissection of the left side of the colon; (6) Trans-anal rectosigmoid specimen transection, where an anvil was inserted into the proximal segment after purse-string suturing; (7) Intracorporeal colorectal end-to-end anastomosis using a circular stapler by a single stapling technique; and (8) Closure of gastrostomy using endoscopic clips. All animals were euthanized immediately after the procedure, abdominal exploration was performed, and the air-under-water leak test was carried out. RESULTSThe procedure was completed in all three animals, with the operation time ranging from 193 min to 259 min. Neither major intraoperative complications nor hemodynamic instability occurred during the operation. The length of the resected specimen ranged from 7 cm to 13 cm. With the assistance of a trans-umbilical rigid grasper, intracorporeal colorectal, tension-free, end-to-end anastomosis was achieved in the three animals.CONCLUSIONPeroral traction-assisted transanal NOTES rectosigmoidectomy followed by intracorporeal colorectal end-to-end anastomosis is technically feasible and reproducible in an animal model and is worthy of further improvements.

Gastrointestinal bleeding in patients with pancreatic cancer: Causes and haemostatic treatments.

Gastrointestinal bleeding is a rare but severe complication of pancreatic ductal adenocarcinoma. The purpose of this study was to describe the causes and treatments of non-postoperative gastrointestinal bleeding in patients with pancreatic ductal adenocarcinoma, and explore the parameters associated with therapeutic effectiveness. This was a single-centre observational retrospective study (2000-2017) with data collected from the prospectively coded diagnostic hospital's database system including patients with pancreatic ductal adenocarcinoma who had a gastrointestinal bleeding episode. Effectiveness of haemostatic treatment was assessed according to transfusion requirements and immediate and long-term haemostatic efficacy; the latter defined as no bleeding recurrence. The population included 72 patients with pancreatic ductal adenocarcinoma who had 94 episodes of gastrointestinal bleeding. The main causes of gastrointestinal bleeding were gastroduodenal tumour invasion (56.4%) and oesophageal variceal bleeding due to left-sided portal hypertension (19.1%). In cases of gastrointestinal bleeding caused by tumour invasion, the main treatment was therapeutic endoscopy (41.5%). Among patients who had gastrointestinal bleeding by tumour invasion treated by endoscopy or radiation therapy, haemostatic immediate efficacy rates were 70.6% and 100%, respectively. Bleeding recurrence rates were 35.3% and 25.0%, for patients treated by endoscopy or radiation therapy, respectively, for a first episode of gastrointestinal bleeding by tumour invasion. Transfusion requirements, before and after treatment, were not different in patients treated by haemostatic radiation therapy for gastrointestinal bleeding by tumour invasion compared to other treatments (odds ratio 0.3, 95% CI (0.06-1.59); p = 0.16). The median survival after all-cause gastrointestinal bleeding was 2.72 months (1.43-4.01). Gastroduodenal tumour invasion was the main cause of gastrointestinal bleeding in patients with pancreatic ductal adenocarcinoma; haemostatic radiation therapy is a potential interesting option for gastrointestinal bleeding treatment in this context.

Retrospective multicenter study on endoscopic treatment of upper GI postsurgical leaks

Therapeutic endoscopy plays a critical role in the management of upper GI (UGI) postsurgical leaks. Data are scarce regarding clinical success and safety. Our aim was to evaluate the effectiveness of endoscopic therapy for UGI postsurgical leaks and associated adverse events (AEs) and to identify factors associated with successful endoscopic therapy and AE occurrence. This was a retrospective, multicenter, international study of all patients who underwent endoscopic therapy for UGI postsurgical leaks between 2014 and2019. Two hundred six patients were included. Index surgery most often performed was sleeve gastrectomy (39.3%), followed by gastrectomy (23.8%) and esophagectomy (22.8%). The median time between index surgery and commencement of endoscopic therapy was 16 days. Endoscopic closure was achieved in 80.1% of patients after a median follow-up of 52 days (interquartile range, 33-81.3). Seven hundred seventy-five therapeutic endoscopies were performed. Multimodal therapy was needed in 40.8% of patients. The cumulative success of leak resolution reached a plateau between the third and fourth techniques (approximately 70%-80%); this was achieved after 125 days of endoscopic therapy. Smaller leak initial diameters, hospitalization in a general ward, hemodynamic stability, absence of respiratory failure, previous gastrectomy, fewer numbers of therapeutic endoscopies performed, shorter length of stay, and shorter times to leak closure were associated with better outcomes. Overall, 102 endoscopic therapy-related AEs occurred in 81 patients (39.3%), with most managed conservatively or endoscopically. Leak-related mortality rate was 12.4%. Multimodal therapeutic endoscopy, despite being time-consuming and requiring multiple procedures, allows leak closure in a significant proportion of patients with a low rate of severe AEs.