Catheter-based deployment of vascular plugs for the management of challenging gastric fistulae

Video 1Case demonstrations of endoscopic vascular plug placement for challenging gastrointestinal fistulae.

Management of an iatrogenic duodenal perforation with a helical tack system in a patient with pancreatic cancer complicated by gastric outlet obstruction

Video 1Closure of an iatrogenic perforation with helical tack system and subsequent EUS-guided choledochoduodenostomy.

EUS-guided rendezvous technique for pancreas divisum

Video 1EUS-guided rendezvous technique for pancreas divisum.

Use of helical tack system for management of a high-risk fibrotic peptic ulcer

Background and Aims

GI bleeding because of peptic ulcer disease is a well-described entity in its diagnosis and management. Although hemostatic clips and thermal therapy have been the primary tools in bleeding from peptic ulcer disease, some bleeds remain refractory. New data have shown that obliteration of the underlying arterial blood flow is needed to control refractory peptic ulcer bleeding. Although this has been shown with over-the-scope clips, we present a case where GI bleeding is controlled via a helical tack system. Although there are several available tools that can be used for treatment of upper GI bleeds, there remains a need for devices that can be used when standard methods of closure, such as with clips, cannot be performed because of a challenging location or friable mucosa. The aim of this video case is to demonstrate the use of a novel helical tack system as a salvage technique in the treatment of challenging upper GI bleeds.

Methods

One case of a bleeding GI ulcer that was refractory to standard endoscopic clips was identified.

Results

In this case, the ulcer closure was achieved using the helical tack system. There were no adverse events. The patient did not require additional surgical or endoscopic interventions.

Conclusions

The helical tack system is a novel device that may be useful as a salvage method for the cessation of GI bleeds refractory to standard clips. Additional comparative studies are needed to better understand the advantages and disadvantages of this system relative to other closure tools.

Initial multicenter experience using a novel endoscopic tack and suture system for challenging GI defect closure and stent fixation (with video)

BACKGROUND AND AIMS

Closure of endoscopic resection defects can be achieved with through-the-scope clips, over-the-scope clips, or endoscopic suturing. However, these devices are often limited by their inability to close large, irregular, and difficult-to-reach defects. Thus, we aimed to assess the feasibility and safety of a novel through-the-scope, suture-based closure system developed to overcome these limitations.

METHODS

This was a retrospective multicenter study involving 8 centers in the United States. Primary outcomes were feasibility and safety of early use of the device. Secondary outcomes were assessment of need for additional closure devices, prolonged procedure time, and technical feasibility of performing the procedure with an alternative device(s).

RESULTS

Ninety-three patients (48.4% women) with mean age 63.6 ± 13.1 years were included. Technical success was achieved in 83 patients (89.2%), and supplemental closure was required in 24.7% of patients (n = 23) with a mean defect size of 41.6 ± 19.4 mm. Closure with an alternative device was determined to be impossible in 24.7% of patients because of location, size, or shape of the defect. The use of the tack and suture device prolonged the procedure in 8.6% of cases but was considered acceptable. Adverse events occurred in 2 patients (2.2%) over a duration of follow-up of 34 days (interquartile range, 13-93.5) and were mild and moderate in severity. No serious adverse events or procedure-related deaths occurred.

CONCLUSIONS

The novel endoscopic through-the-scope tack and suture system is safe, efficient, and permits closure of large and irregularly shaped defects that were not possible with established devices.

Novel dilation technique and stent selection to reduce periprocedural adverse events in left hepaticogastrostomy

Video 1Video demonstration of left hepaticogastrostomy with the assistance of an angioplasty balloon.

Use of a novel helical tack system for the management of challenging upper gastrointestinal defects

Background and Aims

Methods

Results

Conclusions

Assessment of Video Capsule Endoscopy in the Management of Acute Gastrointestinal Bleeding During the COVID-19 Pandemic

IMPORTANCE

Evaluation of acute gastrointestinal (GI) bleeding using invasive endoscopic procedures comprising the standard of care (SOC)-upper endoscopy and colonoscopy-can expose the endoscopy staff to SARS-CoV-2. Video capsule endoscopy (VCE) does not generate aerosols and only requires 1 person to manage the procedure.

OBJECTIVE

To examine the safety of VCE for the initial evaluation of GI bleeding at the peak of the COVID-19 pandemic to identify signs of active bleeding while minimizing patient and personnel exposure, saving personal protective equipment, and avoiding invasive or unnecessary procedures.

DESIGN, SETTING, AND PARTICIPANTS

A multicenter (UMass Memorial Medical Center and Louisiana State University Health Sciences Center) retrospective cohort study including 146 patients with COVID-19 who received VCE as the first-line diagnostic modality was conducted from March 15 to June 15, 2020, compared with SOC in January 2020 for evaluation of GI bleeding. The association between treatment and outcomes was estimated using multivariable regression adjusting for potential confounders. Propensity score matching was used to verify the results.

MAIN OUTCOMES AND MEASURES

The primary end point was detection of active bleeding or stigmata of recent bleeding. Secondary end points included the number of patients requiring any invasive procedures, number of additional procedures, rates of rebleeding and rehospitalization, transfusion requirements, and mortality.

RESULTS

Among 146 patients, 92 (63.0%) were men; mean (SD) age was 64.93 (14.13) years in the COVID-19 group and 61.33 (13.39) years in the SOC group. Active bleeding or stigmata of recent bleeding was observed in 44 (59.5%) patients in the COVID-19 group compared with 18 (25.0%) in the SOC group (adjusted odds ratio, 5.23; 95% CI, 2.23 to 12.27). Only 36 patients (48.7%) in the COVID-19 group required any invasive procedure during the hospitalization compared with 70 (97.2%) in the SOC group (adjusted odds ratio, 0.01; 95% CI, 0.001 to 0.08). The mean (SD) number of invasive procedures was 0.59 (0.77) per patient in the COVID-19 group compared with 1.18 (0.48) per patient in the SOC group (adjusted difference, -0.54; 95% CI, -0.77 to -0.31). Both approaches appeared to be safe and there was no significant difference in transfusion requirements, rebleeding, rehospitalization, or in-hospital mortality. No mortality was attributed to GI bleeding in either group.

CONCLUSIONS AND RELEVANCE

In this cohort study, first-line diagnostic evaluation of acute GI bleeding using VCE appeared to be a safe and useful alternative to the traditional approach of upper endoscopy and colonoscopy. Use of VCE was associated with increased detection of active bleeding and a reduced number of invasive procedures and unnecessary exposure of personnel to SARS-CoV-2 and use of personal protective equipment.

Proton pump inhibitors increase the severity of hepatic encephalopathy in cirrhotic patients

BACKGROUND

Liver cirrhosis is the late stage of hepatic fibrosis and is characterized by portal hypertension that can clinically lead to decompensation in the form of ascites, esophageal/gastric varices or encephalopathy. The most common sequelae associated with liver cirrhosis are neurologic and neuropsychiatric impairments labeled as hepatic encephalopathy (HE). Well established triggers for HE include infection, gastrointestinal bleeding, constipation, and medications. Alterations to the gut microbiome is one of the leading ammonia producers in the body, and therefore may make patients more susceptible to HE.

AIM

To investigate the relationship between the use of proton pump inhibitors (PPIs) and HE in patients with cirrhosis.

METHODS

This is a single center, retrospective analysis. Patients were included in the study with an admitting diagnosis of HE. The degree of HE was determined from subjective and objective portions of hospital admission notes using the West Haven Criteria. The primary outcome of the study was to evaluate the grade of HE in PPI users versus non-users at admission to the hospital and throughout their hospital course. Secondary outcomes included rate of infection, gastrointestinal bleeding within the last 12 mo, mean ammonia level, and model for end-stage liver disease scores at admission.

RESULTS

The HE grade at admission using the West Haven Criteria was 2.3 in the PPI group compared to 1.7 in the PPI nonuser group (P = 0.001). The average length of hospital stay in PPI group was 8.3 d compared to 6.5 d in PPI nonusers (P = 0.046). Twenty-seven (31.8%) patients in the PPI user group required an Intensive Care Unit admission during their hospital course compared to 6 in the PPI nonuser group (16.7%) (P = 0.138). Finally, 10 (11.8%) patients in the PPI group expired during their hospital stay compared to 1 in the PPI nonuser group (2.8%) (P = 0.220).

CONCLUSION

Chronic PPI use in cirrhotic patients is associated with significantly higher average West Haven Criteria for HE compared to patients that do not use PPIs.

Covalent immunochemical membrane labeling of viable cells with K698-T708, a simian virus 40 tumor antigen-derived peptide

The process of covalent immunochemical linking of viable cell membranes with a Simian Virus 40 (SV40) tumor antigen-derived undecapeptide, K(698)PPTPPPEPET(708) (KT), is described. The principle applied was the reaction of the lysine residue, K 698, of the undecapeptide with the succinimidyl moiety of a heterobifunctional linker molecule, N-succinimidyl-3-(2-pyridyldithio)propionate (SPDP) or sulfosuccinimidyl(4-iodo-acetyl)aminobenzoate (sulfo-SIAB). Thereby, upon release of N-hydroxy-succinimide, the rest of the linker molecule reacts covalently with the epsilon-NH2 group of lysine. Upon release of pyridyl-2-thion or hydrogen iodide, respectively, the second reactive moiety of the linker is then ready to form a covalent bond with SH-groups of cell membrane compounds. As a result, KT is covalently linked onto the cell membrane by an -SS- or an -S-bond, respectively. Binding is prevented by treatment of the candidate cells with iodoacetamide, an SH-reactive compound. This artificial cell membrane epitope can be demonstrated by surface immunofluorescence and by binding to immunomagnetic beads loaded with PAb1605, a KT-specific monoclonal antibody. Quantitation by cytofluorimetry shows some 10(4) KT molecules bound per cell, a number that is in the range of the number of SV40 tumor antigen molecules of genuine SV40-transformed mammalian cells.

Relationship of intestinal obstruction to serial plasma carcinoembryonic antigen levels

Since it has been suggested that colonic obstruction due to carcinoma may play a role in elevations of circulating carcinoembryonic antigen, serial plasma carcinoembryonic antigen levels were studies in 19 patients with intestinal obstruction due to tumor and nontumor causes. Regardless of cause, eight of ten patients with colonic obstruction did not show decreased carcinoembryonic antigen levels after decompression. Two patients with postoperative carcinoembryonic antigen reductions of greater than 40 per cent had ascite removed at operation. Removal of a large volume of carcinoembryonic antigen-rich ascites was thought to contribute to the fall in circulating carcinoembryonic antigen. Six patients with small intestinal obstruction and one patient with large and small intestinal obstruction did not show a reduction in postdecompression carcinoembryonic antigen levels. One patient with Crohn's disease who underwent ileal resection and one with intestinal obstruction due to carcinoma of the ovary who underwent resection at the time of decompression had a greater than 40 per cent reduction in postoperative carcinoembryonic antigen levels. Inflamed intestinal and carcinoma of the ovary are known sources of carcinoembryonic antigen and their removal could explain the decrease in carcinoembryonic antigen. Rehydration, as monitored by plasma osmolality and protein concentration, did not explain changes in plasma carcinoembryonic antigen. Thus, it appears that carcinoembryonic antigen production may play a more significant role in the regulation of circulating carcinoembryonic antigen than the physiopathologic processes associated with obstruction.

Evaluation of domicilliary management of protein-calorie malnutrition

An approach to tackle protein-calorie malnutrition through domiciliary management is described. Children suffering from moderate and severe protein-calorie malnutrition were managed using a food supplement containing low cost locally available foodstuffs and nutrition education. An evaluation showed that the anthropometric improvement was closely associated with better concepts in nutrition and improved dietary practices following nutrition education. Parents of children suffering from kwashiorkor had better knowledge and practice compared with those of marasmus.