Safety and feasibility of same-day discharge after endoscopic submucosal dissection: a Western multicenter prospective cohort study

BACKGROUND AND AIMS

Recent Western studies support the safety and efficacy of endoscopic submucosal dissection (ESD) for lesions throughout the GI tract. Although admission for observation after ESD is standard in Asia, a more selective approach may optimize resource utilization. We aimed to evaluate the safety and feasibility of same-day discharge (SDD) after ESD and factors associated with admission.

METHODS

This was a post hoc analysis of a multicenter, prospective cohort of patients undergoing ESD (2016-2021). The primary end points were safety of SDD and factors associated with post-ESD admission.

RESULTS

Of 831 patients (median age, 67 years; 57% male) undergoing 831 ESDs (240 performed in the esophagus, 126 in the stomach, and 465 in the colorectum; median lesion size, 44 mm), 588 (71%) were SDD versus 243 (29%) admissions. Delayed bleeding and perforation occurred in 12 (2%) and 4 (.7%) of SDD patients, respectively; only 1 (.2%) required surgery. Of the 243 admissions, 223 (92%) were discharged after ≤24 hours of observation. Interestingly, larger lesion size (>44 mm) was not associated with higher admission rate (odds ratio [OR], .5; 95% confidence interval [CI], .3-.8; P = .001). Lesions in the upper GI tract versus colon (OR, 1.7; 95% CI, 1.1-2.6; P = .01), invasive cancer (OR, 1.9; 95% CI, 1.2-3.1; P = .01), and adverse events (OR, 2.7; 95% CI, 1.5-4.8; P = .001) were independent factors for admission. Admissions were more likely performed by endoscopists with ESD volume <50 cases (OR, 2.1; 95% CI, 1.3-3.3; P = .001) with procedure time >75 minutes (OR, 13.5; 95% CI, 8.5-21.3; P < .0001).

CONCLUSIONS

SDD after ESD can be safe and feasible. Patients with invasive cancer, lesions in the upper GI tract, longer procedure times, or procedures performed by low-volume ESD endoscopists are more likely to be admitted postprocedure. Risk stratification of patients for SDD after ESD should help optimize resource utilization and enhance ESD uptake in the West. (Clinical trial registration number: NCT02989818.).

Effect of endoscopic submucosal dissection on histologic diagnosis in Barrett's esophagus visible neoplasia

BACKGROUND AND AIMS

Data are limited on the role of endoscopic submucosal dissection (ESD) as a potential diagnostic and staging tool in Barrett's esophagus (BE) neoplasia. We aimed to evaluate the frequency and factors associated with change of histologic diagnosis by ESD compared with pre-ESD histology.

METHODS

This was a multicenter, prospective cohort study of patients who underwent ESD for BE visible neoplasia. A change in histologic diagnosis was defined as "upstaged" or "downstaged" if the ESD specimen had a higher or lower degree, respectively, of dysplasia or neoplasia when compared with pre-ESD specimens.

RESULTS

Two hundred five patients (median age, 69 years; 81% men) with BE visible neoplasia underwent ESD from 2016 to 2021. Baseline histology was obtained using forceps (n = 182) or EMR (n = 23). ESD changed the histologic diagnosis in 55.1% of cases (113/205), of which 68.1% were upstaged and 31.9% downstaged. The frequency of change in diagnosis after ESD was similar whether baseline histology was obtained using forceps (55.5%) or EMR (52.2%) (P = .83). In aggregate, 23.9% of cases (49/205) were upstaged to invasive cancer on ESD histopathology. On multivariate analysis, lesions in the distal esophagus and gastroesophageal junction (odds ratio, 2.1; 95 confidence interval, 1.1-3.9; P = .02) and prior radiofrequency ablation (odds ratio, 2.5; 95% confidence interval, 1.2-5.5; P = .02) were predictors of change in histologic diagnosis.

CONCLUSIONS

ESD led to a change of diagnosis in more than half of patients with BE visible neoplasia. Selective ESD can serve as a potential diagnostic and staging tool, particularly in those with suspected invasive disease. (Clinical trial registration number: NCT02989818.).

Factors associated with complete clip closure after endoscopic mucosal resection of large colorectal polyps

BACKGROUND AND STUDY AIM : Delayed bleeding is a common adverse event following endoscopic mucosal resection (EMR) of large colorectal polyps. Prophylactic clip closure of the mucosal defect after EMR of nonpedunculated polyps larger than 20 mm reduces the incidence of severe delayed bleeding, especially in proximal polyps. This study aimed to evaluate factors associated with complete prophylactic clip closure of the mucosal defect after EMR of large polyps. METHODS : This is a post hoc analysis of the CLIP study (NCT01936948). All patients randomized to the clip group were included. Main outcome was complete clip closure of the mucosal resection defect. The defect was considered completely closed when no remaining mucosal defect was visible and clips were less than 1 cm apart. Factors associated with complete closure were evaluated in multivariable analysis. RESULTS : In total, 458 patients (age 65, 58 % men) with 494 large polyps were included. Complete clip closure of the resection defect was achieved for 338 polyps (68.4 %); closure was not complete for 156 (31.6 %). Factors associated with complete closure in adjusted analysis were smaller polyp size (odds ratio 1.06 for every millimeter decrease [95 % confidence interval 1.02-1.08]), good access (OR 3.58 [1.94-9.59]), complete submucosal lifting (OR 2.28 [1.36-3.90]), en bloc resection (OR 5.75 [1.48-22.39]), and serrated histology (OR 2.74 [1.35-5.56]). CONCLUSIONS : Complete clip closure was not achieved for almost one in three resected large nonpedunculated polyps. While stable access and en bloc resection facilitate clip closure, most factors associated with clip closure are not modifiable. This highlights the need for alternative closure options and measures to prevent bleeding.

Efficacy of Endoscopic Submucosal Dissection for Superficial Gastric Neoplasia in a Large Cohort in North America

BACKGROUND & AIMS

Endoscopic submucosal dissection (ESD) is a widely accepted treatment option for superficial gastric neoplasia in Asia, but there are few data on outcomes of gastric ESD from North America. We aimed to evaluate the safety and efficacy of gastric ESD in North America.

METHODS

We analyzed data from 347 patients who underwent gastric ESD at 25 centers, from 2010 through 2019. We collected data on patient demographics, lesion characteristics, procedure details and related adverse events, treatment outcomes, local recurrence, and vital status at the last follow up. For the 277 patients with available follow-up data, the median interval between initial ESD and last clinical or endoscopic evaluation was 364 days. The primary endpoint was the rate of en bloc and R0 resection. Secondary outcomes included curative resection, rates of adverse events and recurrence, and gastric cancer-related death.

RESULTS

Ninety patients (26%) had low-grade adenomas or dysplasia, 82 patients (24%) had high-grade dysplasia, 139 patients (40%) had early gastric cancer, and 36 patients (10%) had neuroendocrine tumors. Proportions of en bloc and R0 resection for all lesions were 92%/82%, for early gastric cancers were 94%/75%, for adenomas and low-grade dysplasia were 93%/ 92%, for high-grade dysplasia were 89%/ 87%, and for neuroendocrine tumors were 92%/75%. Intraprocedural perforation occurred in 6.6% of patients; 82% of these were treated successfully with endoscopic therapy. Delayed bleeding occurred in 2.6% of patients. No delayed perforation or procedure-related deaths were observed. There were local recurrences in 3.9% of cases; all occurred after non-curative ESD resection. Metachronous lesions were identified in 14 patients (6.9%). One of 277 patients with clinical follow up died of metachronous gastric cancer that occurred 2.5 years after the initial ESD.

CONCLUSIONS

ESD is a highly effective treatment for superficial gastric neoplasia and should be considered as a viable option for patients in North America. The risk of local recurrence is low and occurs exclusively after non-curative resection. Careful endoscopic surveillance is necessary to identify and treat metachronous lesions.

Endoscopic Submucosal Dissection in North America: A Large Prospective Multicenter Study

BACKGROUND AND AIMS

Endoscopic submucosal dissection (ESD) in Asia has been shown to be superior to endoscopic mucosal resection (EMR) and surgery for the management of selected early gastrointestinal cancers. We aimed to evaluate technical outcomes of ESD in North America.

METHODS

We conducted a multicenter prospective study on ESD across 10 centers in the United States and Canada between April 2016 and April 2020. End points included rates of en bloc resection, R0 resection, curative resection, adverse events, factors associated with failed resection, and recurrence post-R0 resection.

RESULTS

Six hundred and ninety-two patients (median age, 66 years; 57.8% were men) underwent ESD (median lesion size, 40 mm; interquartile range, 25-52 mm) for lesions in the esophagus (n = 181), stomach (n = 101), duodenum (n = 11), colon (n = 211) and rectum (n = 188). En bloc, R0, and curative resection rates were 91.5%, 84.2%, and 78.3%, respectively. Bleeding and perforation were reported in 2.3% and 2.9% of the cases, respectively. Only 1 patient (0.14%) required surgery for adverse events. On multivariable analysis, severe submucosal fibrosis was associated with failed en bloc, R0, and curative resection and higher risk for adverse events. Overall recurrence was 5.8% (31 of 532) at a mean follow-up of 13.3 months (range, 1-60 months).

CONCLUSIONS

In this large multicenter prospective North American experience, we demonstrate that ESD can be performed safely, effectively, and is associated with a low recurrence rate. The technical resection outcomes achieved in this study are in line with the current established consensus quality parameters and further support the implementation of ESD for the treatment of select gastrointestinal neoplasms; ClinicalTrials.gov, Number: NCT02989818.

Full-thickness resection device (FTRD) for treatment of upper gastrointestinal tract lesions: the first international experience

Background and study aims  The Full-Thickness Resection Device (FTRD) provides a novel treatment option for lesions not amenable to conventional endoscopic resection techniques. There are limited data on the efficacy and safety of FTRD for resection of upper gastrointestinal tract (GIT) lesions. Patients and methods  This was an international multicenter retrospective study, including patients who had an endoscopic resection of an upper GIT lesion using the FTRD between January 2017 and February 2019. Results  Fifty-six patients from 13 centers were included. The most common lesions were mesenchymal neoplasms (n = 23, 41 %), adenomas (n = 7, 13 %), and hamartomas (n = 6, 11 %). Eighty-four percent of lesions were located in the stomach, and 14 % in the duodenum. The average size of lesions was 14 mm (range 3 to 33 mm). Deployment of the FTRD was technically successful in 93 % of patients (n = 52) leading to complete and partial resection in 43 (77 %) and 9 (16 %) patients, respectively. Overall, the FTRD led to negative histological margins (R0 resection) in 38 (68 %) of patients. A total of 12 (21 %) mild or moderate adverse events (AEs) were reported. Follow-up endoscopy was performed in 31 patients (55 %), on average 88 days after the procedure (IQR 68-138 days). Of these, 30 patients (97 %) did not have any residual or recurrent lesion on endoscopic examination and biopsy, with residual adenoma in one patient (3 %). Conclusions  Our results suggest a high technical success rate and an acceptable histologically complete resection rate, with a low risk of AEs and early recurrence for FTRD resection of upper GIT lesions.

Effects of Blended (Yellow) vs Forced Coagulation (Blue) Currents on Adverse Events, Complete Resection, or Polyp Recurrence After Polypectomy in a Large Randomized Trial

BACKGROUND & AIMS

There is debate over the type of electrosurgical setting that should be used for polyp resection. Some endoscopists use a type of blended current (yellow), whereas others prefer coagulation (blue). We performed a single-blinded, randomized trial to determine whether type of electrosurgical setting affects risk of adverse events or recurrence.

METHODS

Patients undergoing endoscopic mucosal resection of nonpedunculated colorectal polyps 20 mm or larger (n = 928) were randomly assigned, in a 2 × 2 design, to groups that received clip closure or no clip closure of the resection defect (primary intervention) and then to either a blended current (Endocut Q) or coagulation current (forced coagulation) (Erbe Inc) (secondary intervention and focus of the study). The study was performed at multiple centers, from April 2013 through October 2017. Patients were evaluated 30 days after the procedure (n = 919), and 675 patients underwent a surveillance colonoscopy at a median of 6 months after the procedure. The primary outcome was any severe adverse event in a per patient analysis. Secondary outcomes were complete resection and recurrence at first surveillance colonoscopy in a per polyp analysis.

RESULTS

Serious adverse events occurred in 7.2% of patients in the Endocut group and 7.9% of patients in the forced coagulation group, with no significant differences in the occurrence of types of events. There were no significant differences between groups in proportions of polyps that were completely removed (96% in the Endocut group vs 95% in the forced coagulation group) or the proportion of polyps found to have recurred at surveillance colonoscopy (17% and 17%, respectively). Procedural characteristics were comparable, except that 17% of patients in the Endocut group had immediate bleeding that required an intervention, compared with 11% in the forced coagulation group (P = .006).

CONCLUSIONS

In a randomized trial to compare 2 commonly used electrosurgical settings for the resection of large colorectal polyps (Endocut vs forced coagulation), we found no difference in risk of serious adverse events, complete resection rate, or polyp recurrence. Electrosurgical settings can therefore be selected based on endoscopist expertise and preference. Clinicaltrials.gov ID NCT01936948.

EUS-guided gastroenteric anastomosis as a bridge to definitive treatment in benign gastric outlet obstruction

BACKGROUND AND AIMS

Benign gastric outlet obstruction (GOO) has typically been managed surgically. However, many patients are poor operative candidates because of comorbidities. EUS-guided gastroenterostomy (EUS-GE) using lumen-apposing metal stents (LAMSs) has previously demonstrated efficacy as a definitive treatment for benign and malignant GOO; however, limited data exist on use as a bridge to resolution of the obstruction in an attempt to avoid or delay definitive surgery.

METHODS

A retrospective series of consecutive patients who underwent EUS-GE between January 2013 and July 2019 for benign GOO at a tertiary referral center were included in the study. The primary outcome was the rate of definitive surgery; secondary outcomes included technical success and rate of adverse events.

RESULTS

During the study period, 22 patients with benign GOO underwent EUS-GE (40% female; mean age, 54.2 years). The mean procedure time was 66 minutes, and technical success was achieved in 21. Five patients developed recurrent GOO while the LAMS was in place after a mean dwell time of 228 days; 1 patient was converted to surgical GE. LAMSs were removed electively in 18 patients after GOO resolution and a mean dwell time of 270 days; 1 patient developed a recurrent GOO after LAMS removal and was converted to surgical GE. The rate of recurrent GOO after LAMS removal was 5.6%. Three severe adverse events occurred in the cohort.

CONCLUSIONS

EUS-GE was able to prevent surgery for GOO in 83.3% of cases. LAMSs needed to stay in place for a mean of 8.5 months to allow resolution of GOO, and there was a low rate of recurrent GOO (5.6%) after LAMS removal. Prospective, randomized trials comparing surgical and endoscopic anastomoses are needed in patients with benign causes of GOO.

Clip Closure Prevents Bleeding After Endoscopic Resection of Large Colon Polyps in a Randomized Trial

BACKGROUND & AIMS

Bleeding is the most common severe complication after endoscopic mucosal resection of large colon polyps and is associated with significant morbidity and cost. We examined whether prophylactic closure of the mucosal defect with hemoclips after polyp resection reduces the risk of bleeding.

METHODS

We performed a multicenter, randomized trial of patients with a large nonpedunculated colon polyp (≥20 mm) at 18 medical centers in North America and Spain from April 2013 through October 2017. Patients were randomly assigned to groups that underwent endoscopic closure with a clip (clip group) or no closure (control group) and followed. The primary outcome, postprocedure bleeding, was defined as a severe bleeding event that required hospitalization, a blood transfusion, colonoscopy, surgery, or another invasive intervention within 30 days after completion of the colonoscopy. Subgroup analyses included postprocedure bleeding with polyp location, polyp size, or use of periprocedural antithrombotic medications. We also examined the risk of any serious adverse event.

RESULTS

A total of 919 patients were randomly assigned to groups and completed follow-up. Postprocedure bleeding occurred in 3.5% of patients in the clip group and 7.1% in the control group (absolute risk difference [ARD] 3.6%; 95% confidence interval [CI] 0.7%-6.5%). Among 615 patients (66.9%) with a proximal large polyp, the risk of bleeding in the clip group was 3.3% and in the control group was 9.6% (ARD 6.3%; 95% CI 2.5%-10.1%); among patients with a distal large polyp, the risks were 4.0% in the clip group and 1.4% in the control group (ARD -2.6%; 95% CI -6.3% to -1.1%). The effect of clip closure was independent of antithrombotic medications or polyp size. Serious adverse events occurred in 4.8% of patients in the clip group and 9.5% of patients in the control group (ARD 4.6%; 95% CI 1.3%-8.0%).

CONCLUSIONS

In a randomized trial, we found that endoscopic clip closure of the mucosal defect following resection of large colon polyps reduces risk of postprocedure bleeding. The protective effect appeared to be restricted to large polyps located in the proximal colon. ClinicalTrials.gov no: NCT01936948.

The incidence of lymph node metastasis in submucosal early gastric cancer according to the expanded criteria: a systematic review

BACKGROUND

For successful endoscopic treatment of early gastric cancer (EGC), absolute criteria for a curative en bloc resection were initially established to include predominantly differentiated mucosal lesions ≤ 2 cm in diameter without ulceration. These indications were subsequently expanded to include larger, ulcerated, and predominantly undifferentiated mucosal lesions. In addition, differentiated type adenocarcinomas ≤ 3 cm with slight submucosal invasion of < 500 µm (pT1b1) are regarded as "curative" under the expanded criteria. However, data derived from studies of surgical specimens in patients with pT1b1 EGC have yielded varying rates of lymph node metastasis (LNM).

METHOD

A systemic review was conducted using the pooled analysis to calculate the incidence of LNM in pT1b1 EGC, and to investigate whether using a cut-off value of < 300 µm would decrease the risk of LNM in patients with submucosal EGC.

RESULTS

Nineteen articles were included. 1507 patients with pT1b1 EGC met the expanded indications. The incidence of LNM was 3% (45 out of 1507 patients). In a subgroup analysis of three studies, there was no significant difference in the LNM between pT1b EGC < 300 µm and < 500 µm [3/121(2.5%) vs. 5/180 (2.8%)] (OR 0.89, 95% CI 0.22-3.54).

CONCLUSION

Overall, expanding the indications for endoscopic resection of EGC to include lesions ≤ 3 cm T1b1 is associated with a potential risk of LNM of 3%. In countries outside of Japan, we found a slightly higher risk of LNM (4.0%). These estimates of LNM should be incorporated into decisions regarding further management of patients with EGC ≤ 3 cm who are found to have slight submucosal invasion (< 500 µm) in an ESD specimen. Standardization of specimen handling and histological evaluation is essential if the Japanese results of endoscopic treatment for EGC are to be successfully applied in other parts of the world.

POEM for Achalasia

In 2008, a new treatment modality for esophageal achalasia was introduced—peroral endoscopic myotomy (POEM). POEM is a procedure performed endoscopically, which allows transection of the muscular fibers of the distal esophagus and of the lower esophageal sphincter. The procedure is therefore similar to a laparoscopic Heller myotomy without a fundoplication. Short-term studies have shown that POEM is very effective in relieving dysphagia and regurgitation, but concerns have been raised about the incidence of post-POEM gastroesophageal reflux. Prospective and randomized trials will be needed to determine the role of this new procedure in the treatment algorithm of esophageal achalasia.

POEM for Achalasia

In 2008, a new treatment modality for esophageal achalasia was introduced-peroral endoscopic myotomy (POEM). POEM is a procedure performed endoscopically, which allows transection of the muscular fibers of the distal esophagus and of the lower esophageal sphincter. The procedure is therefore similar to a laparoscopic Heller myotomy without a fundoplication. Short-term studies have shown that POEM is very effective in relieving dysphagia and regurgitation, but concerns have been raised about the incidence of post-POEM gastroesophageal reflux. Prospective and randomized trials will be needed to determine the role of this new procedure in the treatment algorithm of esophageal achalasia.

Increasing Rates of Surgery for Patients With Nonmalignant Colorectal Polyps in the United States

BACKGROUND & AIMS

Despite the availability of endoscopic therapy, many patients in the United States undergo surgical resection for nonmalignant colorectal polyps. We aimed to quantify and examine trends in the use of surgery for nonmalignant colorectal polyps in a nationally representative sample.

METHODS

We analyzed data from the Healthcare Cost and Utilization Project National Inpatient Sample for 2000 through 2014. We included all adult patients who underwent elective colectomy or proctectomy and had a diagnosis of either nonmalignant colorectal polyp or colorectal cancer. We compared trends in surgery for nonmalignant colorectal polyps with surgery for colorectal cancer and calculated age, sex, race, region, and teaching status/bed-size-specific incidence rates of surgery for nonmalignant colorectal polyps.

RESULTS

From 2000 through 2014, there were 1,230,458 surgeries for nonmalignant colorectal polyps and colorectal cancer in the United States. Among those surgeries, 25% were performed for nonmalignant colorectal polyps. The incidence of surgery for nonmalignant colorectal polyps has increased significantly, from 5.9 in 2000 to 9.4 in 2014 per 100,000 adults (incidence rate difference, 3.56; 95% confidence interval 3.40-3.72), while the incidence of surgery for colorectal cancer has significantly decreased, from 31.5 to 24.7 surgeries per 100,000 adults (incidence rate difference, -6.80; 95% confidence interval -7.11 to -6.49). The incidence of surgery for nonmalignant colorectal polyps has been increasing among individuals age 20 to 79, in men and women and including all races and ethnicities.

CONCLUSIONS

In an analysis of a large, nationally representative sample, we found that surgery for nonmalignant colorectal polyps is common and has significantly increased over the past 14 years.

Cohort study comparing the diagnostic yields of 2 different EUS fine-needle biopsy needles

BACKGROUND AND AIMS

Two second-generation, flexible EUS fine-needle biopsy (FNB) needles have been marketed recently in the United States. Thus far, there have been no comparative studies of the diagnostic yield of these needles. The aim of this study was to compare the diagnostic yield achieved with FNB by using 1 needle during 1 time period and the other needle during a second time period.

METHODS

Consecutive patients with solid lesions undergoing EUS-FNB by using 1 of two 22-gauge FNB needles (Franseen needle or fork-tip) at 2 different time intervals were included. The final diagnosis was based on positive pathology results. In cases of a negative pathology result, the final diagnosis was based on clinical and imaging follow-up.

RESULTS

A total of 194 lesions (97 in each group) were sampled in 179 patients. Rapid on-site evaluation (ROSE) was used in 12% of cases. The overall diagnostic yield was lower in the Franseen needle group compared with the fork-tip needle group (61/97 [63%] vs 75/97 [77%], odds ratio (OR) 2.01, 1.07-3.8; P = .027). Similarly, subanalysis of the yield for solid pancreatic masses demonstrated a lower yield with the Franseen needle (34/53 [64%] vs 40/47 [85%], OR 3.4, 9.1-8.9; P = .017). Multivariate analysis controlling for the number of passes, site, and lesion size did not have any effect on diagnostic yield. There were no adverse events in either group.

CONCLUSION

In this first, large, single-center comparative cohort study of 2 new, second-generation EUS-FNB needles of different design, the diagnostic yield when used primarily without ROSE was high in both groups but was significantly higher when a fork-tip needle was used.

Morbidity and mortality after surgery for nonmalignant colorectal polyps

BACKGROUND AND AIMS

Despite evidence that most nonmalignant colorectal polyps can be managed endoscopically, a substantial proportion of patients with a nonmalignant colorectal polyp are still sent to surgery. Risks associated with this surgery are not well characterized. We describe 30-day postoperative morbidity and mortality and explore risk factors for adverse events in patients undergoing surgical resection for nonmalignant colorectal polyps.

METHODS

We analyzed data collected prospectively as part of the National Surgical Quality Improvement Program. Our analysis included 12,732 patients who underwent elective surgery for a nonmalignant colorectal polyp from 2011 through 2014. We report adverse events within 30 days of the index surgery. Modified Poisson regression was used to estimate risk ratios and 95% confidence intervals.

RESULTS

Thirty-day mortality was .7%. The risk of a major postoperative adverse event was 14%. Within 30 days of resection, 7.8% of patients were readmitted and 3.6% of patients had a second major surgery. The index surgery resulted in a colostomy in 1.8% and ileostomy in .4% of patients. Patients who had surgical resection of a nonmalignant polyp in the rectum or anal canal compared with the colon had a risk ratio of 1.58 (95% confidence interval, 1.09-2.28) for surgical site infection and 6.51 (95% confidence interval, 4.97-8.52) for ostomy.

CONCLUSIONS

Surgery for a nonmalignant colorectal polyp is associated with significant morbidity and mortality. A better understanding of the risks and benefits associated with surgical management of nonmalignant colorectal polyps will better inform discussions regarding the relative merits of management strategies.

Peroral endoscopic myotomy using FlushKnife BT: a single-center series

BACKGROUND AND STUDY AIMS

Peroral endoscopic myotomy (POEM) is an evolving new treatment strategy for achalasia. Although several kinds of electrosurgical knives have been used in performing POEM, the best device has yet to be determined. The FlushKnife BT is a waterjet-emitting short needle-knife with a small ball tip (BT) that offers the potential to perform all aspects of POEM with a single device. In this study, we evaluated the safety and efficiency of the FlushKnife BT for POEM.

PATIENTS AND METHODS

 A total of 54 consecutive patients with achalasia and other spastic esophageal motility disorders, such as jackhammer esophagus or distal esophageal spasm, who underwent POEM between January 2016 and August 2016, were included in this retrospective study.

RESULTS

 The median operation time was 73.0 minutes (range 39 - 184 minutes). All procedures were completed using only the FlushKnife BT without changing to any other electrosurgical instrument. The median number of additional submucosal injections with an injection needle was 0 (range 0 - 1). Endoscopic vessel sealing was performed a mean of 3 times (range 0 - 7). The median number of bleeding episodes requiring treatment with hemostatic forceps was 0 (range 0 - 5). There were no significant adverse events. Seven of 52 patients (13.5 %) reported symptoms of gastroesophageal reflux disease such as heartburn or acid reflux at 3 month follow-up.

CONCLUSIONS

 The FlushKnife BT enabled POEM to be performed with very few device exchanges, either for re-injection or to control intraoperative bleeding. In this uncontrolled case series, the ability of the FlushKnife BT to perform nearly all aspects of the POEM procedure seems to make it particularly well suited to this procedure.

Use of a lumen-apposing metal stent to treat GI strictures (with videos)

BACKGROUND AND AIMS

Benign GI strictures occur typically in the esophagus and pyloric channel but can occur anywhere in the GI tract and at anastomotic sites. Such strictures can be treated with dilation, incisional therapy, steroid injection, and stents. Our aim was to describe the use of a lumen-apposing metal stent (LAMS) to treat short, benign GI strictures.

PATIENTS AND METHODS

Consecutive patients who underwent LAMS placement for various benign strictures at 2 tertiary care centers from August 2014 to November 2015 were reviewed retrospectively. The main outcome measures were technical success, clinical success, stent migration, and adverse events.

RESULTS

Twenty-five patients (7 males, 18 females) with a median age of 54 years (33-85 years) underwent 28 LAMS placements to treat various benign strictures. The location of the strictures included esophagogastric anastomoses (n=4), gastrojejunal anastomoses (n=13), pylorus (n=6), vertical banded gastroplasty (n=1), and ileocolonic anastomosis (n=1). Twenty patients had been previously treated with dilation alone (9 patients with ≥3 dilations), 11 patients with dilation and steroid injection, 2 patients with additional needle-knife therapy, and 1 patient with placement of a traditional fully covered self-expandable metal stent. A 15-mm internal diameter LAMS was placed in all patients; 3 patients had been treated previously with a 10-mm LAMS. Technical success was achieved in all patients, whereas clinical success was achieved in 15 of 25 patients (60%) who completed a minimum of 6 months of follow-up after placement. Median stent dwell time was 92 days (range, 3-273 days). Stent migration was seen in 2 of 28 stent placements (7%). Four of 25 patients (16%) developed 5 moderate adverse events (pain requiring removal, 2; new stricture formation, 2; bleeding, 1). Median follow-up was 301 days after stent placement. Study limitations include the small, select group of patients, the retrospective study design, and short follow-up.

CONCLUSIONS

LAMS placement for benign GI strictures is technically easy and safe with low migration rates and may be an option to treat selected patients with short-length strictures.

A meta-analysis of endoscopic ultrasound-fine-needle aspiration compared to endoscopic ultrasound-fine-needle biopsy: diagnostic yield and the value of onsite cytopathological assessment

Background The diagnostic yield of endoscopic ultrasound (EUS) guided fine-needle aspiration (FNA) is variable, and partly dependent upon rapid onsite evaluation (ROSE) by a cytopathologist. Second generation fine-needle biopsy (FNB) needles are being increasingly used to obtain core histological tissue samples. Aims Studies comparing the diagnostic yield of EUS guided FNA versus FNB have reached conflicting conclusions. We therefore conducted a systematic review and meta-analysis to compare the diagnostic yield of FNA with FNB, and specifically evaluating the diagnostic value of ROSE while comparing the two types of needles. Methods We searched several databases from inception to 10 April 2016 to identify studies comparing diagnostic yield of second generation FNB needles with standard FNA needles. Risk ratios (RR) were calculated for categorical outcomes of interest (diagnostic adequacy, diagnostic accuracy, and optimal quality histological cores obtained). Standard mean difference (SMD) was calculated for continuous variables (number of passes required for diagnosis). These were pooled using random effects model of meta-analysis to account for heterogeneity. Meta-regression was conducted to evaluate the effect of ROSE on various outcomes of interest. Results Fifteen studies with a total of 1024 patients were included in the analysis. We found no significant difference in diagnostic adequacy [RR 0.98 (0.91, 1.06), (I² = 51 %)]. Although not statistically significant (P = 0.06), by meta-regression, in the absence of ROSE, FNB showed a relatively better diagnostic adequacy. For solid pancreatic lesions only, there was no difference in diagnostic adequacy [RR 0.96 (0.86, 1.09), (I² = 66 %)]. By meta-regression, in the absence of ROSE, FNB was associated with better diagnostic adequacy (P = 0.02). There was no difference in diagnostic accuracy [RR 0.99 (0.95, 1.03), (I² = 27 %)] or optimal quality core histological sample procurement [RR 0.97 (0.89, 1.05), (I² = 9.6 %)]. However, FNB established diagnosis with fewer passes [SMD 0.93 (0.45, 1.42), (I² = 84 %)]. The absence of ROSE was associated with a higher SMD, i. e., in the presence of an onsite pathologist, FNA required relatively fewer passes to establish the diagnosis than in the absence of an onsite pathologist. Conclusions There is no significant difference in the diagnostic yield between FNA and FNB, when FNA is accompanied by ROSE. However, in the absence of ROSE, FNB is associated with a relatively better diagnostic adequacy in solid pancreatic lesions. Also, FNB requires fewer passes to establish the diagnosis.

Impact of EUS-guided fine-needle biopsy sampling with a new core needle on the need for onsite cytopathologic assessment: a preliminary study

BACKGROUND AND AIMS

FNA is the primary method of EUS tissue acquisition. In an attempt to improve our yield of EUS-guided tissue acquisition, we compared fine-needle biopsy (FNB) sampling without rapid onsite evaluation (ROSE) with FNA with ROSE and assessed the concordance of FNA and FNB sampling.

METHODS

This was a retrospective review of prospectively collected data from consecutive patients. Patients underwent FNB sampling and FNA of the same single lesion, with the same needle gauge and number of passes. FNA with ROSE was performed with a standard FNA needle. FNB sampling was performed with a new dedicated core needle. FNA samples were assessed with ROSE, and a final interpretation was provided by cytopathology staff; FNB samples were analyzed by surgical pathologists, each not made aware of the other's opinion.

RESULTS

Thirty-three patients underwent 312 passes in 42 different lesions. A diagnosis of malignancy was more likely with FNB sampling than with FNA (72.7% vs 66.7%, P = .727), although statistical significance was not reached. FNA and FNB sampling had similar sensitivities, specificities, and accuracies for cancer (81.5% vs 88.9%, 100% vs 100%, and 84.8% vs 90.9%, respectively). FNB sampling provided qualitative information not reported on FNA, such as degree of differentiation in malignancy, metastatic origin, and rate of proliferation in neuroendocrine tumors.

CONCLUSIONS

FNB sampling without ROSE using a dedicated core needle performed as well as FNA with ROSE in this small cohort, suggesting that FNB sampling with this new core needle may eliminate the need for an onsite cytopathologic assessment, without loss of diagnostic accuracy.

EUS-guided gastroenterostomy is comparable to enteral stenting with fewer re-interventions in malignant gastric outlet obstruction

BACKGROUND AND AIMS

Endoscopic enteral stenting (ES) in malignant gastric outlet obstruction (GOO) is limited by high rates of stent obstruction. EUS-guided gastroenterostomy (EUS-GE) is a novel procedure that potentially offers sustained patency without tumor ingrowth/overgrowth. The aim of this study is to compare EUS-GE with ES in terms of (1) symptom recurrence and need for re-intervention, (2) technical success (proper stent positioning as determined via endoscopy and fluoroscopy), (3) clinical success (ability to tolerate oral intake without vomiting), and (4) procedure-related adverse events (AEs).

METHODS

Multicenter retrospective study of all consecutive patients who underwent either EUS-GE at four centers between 2013 and 2015 or ES at one center between 2008 and 2010.

RESULTS

A total of 82 patients (mean age 66-years ± 13.5 and 40.2% female) were identified: 30 in EUS-GE and 52 in ES. Technical and clinical success was not significantly different: 86.7% EUS-GE versus 94.2% ES (p = 0.2) and 83.3% EUS-GE versus 67.3% ES (p = 0.12), respectively. Symptom recurrence and need for re-intervention, however, was significantly lower in the EUS-GE group (4.0 vs. 28.6%, (p = 0.015). Post-procedure mean length of hospitalization was comparable at 11.3 days ± 6.6 for EUS-GE versus 9.5 days ± 8.3 for ES (p = 0.3). Rates and severity of AEs (as per the ASGE lexicon) were also similar (16.7 vs. 11.5%, p = 0.5). On multivariable analysis, ES was independently associated with need for re-intervention (OR 12.8, p = 0.027).

CONCLUSION

EUS-GE may be ideal for malignant GOO with comparable effectiveness and safety to ES while being associated with fewer symptom recurrence and requirements for re-intervention.

Efficacy of Endoscopically Created Bypass Anastomosis in Treatment of Afferent Limb Syndrome: A Single-Center Study

Afferent limb syndrome is a postoperative complication of gastrointestinal surgery, resulting from obstruction of a biliary-enteric limb. Surgery has been the cornerstone of treatment for this condition, but advances in endoscopic and percutaneous techniques could offer less-invasive options. Creation of an internal endoscopic anastomosis between the obstructed afferent limb and an adjacent gastrointestinal lumen can relieve symptoms and might provide a long-term solution. We report the efficacy of endoscopic treatment of afferent limb syndrome using lumen-apposing self-expandable metal stents to create 3 types of enteric anastomoses: a jejunojejunostomy, 2 gastrojejunostomies, and a duodenuojejunostomy in patients who developed afferent limb obstruction following a resection for pancreaticobiliary cancer.

Conversion of Percutaneous Cholecystostomy to Internal Transmural Gallbladder Drainage Using an Endoscopic Ultrasound-Guided, Lumen-Apposing Metal Stent

Patients with acute cholecystitis sometimes require placement of percutaneous cholecystostomy catheters, either as a bridge to surgery or as primary therapy. In patients who cannot undergo surgery, subsequent removal of the catheter can lead to recurrence of cholecystitis, whereas leaving the drain in place can cause adverse events. We investigated internalization of percutaneous cholecystostomy drainage catheters, using endoscopic ultrasound (EUS)-guided placement of lumen-apposing metal stents (LAMS) as an alternative treatment strategy. Seven patients (median age, 57 years; 6 men) underwent EUS-guided cholecystoenterostomy for internalization of gallbladder drainage with EUS-guided placement of a 10- or 15-mm LAMS. All had initially been treated with placement of a percutaneous cholecystostomy catheter for cholecystitis and were later deemed unfit for cholecystectomy. Technical success was achieved in all patients in 1 endoscopic session, with subsequent removal of all percutaneous drains. Two patients required placement of self-expandable metal stents within the LAMS to successfully bridge the gallbladder and gastrointestinal lumen. No adverse events occurred after a median follow-up of 2.5 months. EUS-guided cholecystoenterostomy using a LAMS is therefore a viable option for internal gallbladder drainage in patients who have a percutaneous cholecystostomy catheter and are poor candidates for cholecystectomy.

Gastro-pancreaticojejunostomy for treatment of pancreatic ductal obstruction in a post-Whipple procedure patient

We report a case of a woman with a medical history of classic Whipple surgery who underwent endoscopic ultrasound (EUS)-guided pancreatic drainage due to smouldering acute pancreatitis secondary to an obstructing pancreatic ductal stone. A gastro-pancreaticojejunostomy anastomosis was created anterogradely, with dilation of both the anastomoses in the same procedure, with subsequent decompression of the pancreatic duct. Endoscopic retrograde pancreatography (ERP) is often impossible to perform in patients with post-Whipple procedure anatomy due to inaccessibility to the pancreaticojejunostomy anastomosis. EUS-guided pancreatic drainage may be offered in these patients in whom the pancreatic duct cannot be accessed at ERP. It has been used as a platform for access to and drainage of the pancreatic duct either by rendezvous or transmural drainage. However, only one of four patients achieve successful completion of the rendezvous procedure. There are limited data regarding safety and long-term outcome of this procedure, as well as scant guidelines on the optimal time for leaving stents in place. We believe definitive endoscopic therapy should be attempted, whenever possible, after relief of obstruction. In our case, we expect that stent occlusion is inevitable and that long-term drainage is possible due to drainage occurring between the stent and the stone.

EUS-guided gastroenterostomy: the first U.S. clinical experience (with video)

BACKGROUND AND AIMS

There are limitations to enteral self-expandable metal stents and surgical gastrojejunostomy in the treatment of patients with gastric outlet obstruction (GOO). EUS-guided gastroenterostomy (EUS-GE) is a novel procedure that potentially offers long-lasting luminal patency without the risk of tumor ingrowth and/or overgrowth, while avoiding the morbidity of a surgical procedure. The aims of this study were to report the first U.S. clinical experience with EUS-GE in terms of technical success, clinical success, and adverse events and to detail the technical aspects of performing EUS-GE.

METHODS

This was a retrospective study from two tertiary-care centers. EUS-GE was performed by using either the direct EUS-GE or balloon-assisted EUS-GE technique. Technical success was defined as adequate positioning and deployment of the stent as determined endoscopically and radiologically. Clinical success was defined as the patient's ability to tolerate oral intake without vomiting.

RESULTS

A total of 10 patients underwent attempted EUS-GE. Malignant GOO was present in 3 patients, whereas benign obstruction was found in the remaining 7. One patient had complete GOO and underwent successful direct EUS-GE. In the remaining 9 patients, balloon-assisted EUS-GE was attempted and was successful in 8. Thus, technical success occurred in 9 patients (90%). There were no procedure-related adverse events. Mean procedure time was 96 minutes (range 45-152 minutes), and mean length of hospital stay was 2.2 days. Clinical success with resumption of solid oral intake was achieved in all 9 patients (100%) who underwent successful EUS-GE. A total of 8 patients were able to tolerate almost a normal diet and/or full diet, and 1 patient tolerated a soft diet. There was no symptom recurrence during a mean follow-up period of 150 days.

CONCLUSIONS

EUS-GE is a promising new technique for the treatment of symptoms of benign and malignant GOO. Prospective, multicenter trials are needed to confirm these results.