Alejandro L. Suarez

Low-Dose Aspirin Affects the Small Bowel Mucosa: Results of a Pilot Study With a Multidimensional Assessment

BACKGROUND & AIMS Whether low-dose aspirin (acetylsalicylic acid [ASA]) produces intestinal damage is controversial. Our aim was to determine whether the small bowel is damaged by low-dose ASA on a short-term basis. METHODS Twenty healthy volunteers (age range, 19-64 years) underwent video capsule endoscopy (VCE), fecal calprotectin, and permeability tests (sucrose and lactulose/mannitol [lac/man] ratio) before and after ingestion of 100 mg of enteric-coated ASA daily for 14 days. Video capsule images were assessed by 2 independent expert endoscopists, fully blinded to the treatment group, by using an endoscopic scale. RESULTS Post-ASA VCE detected 10 cases (50%) with mucosal damage not apparent in baseline studies (6 cases had petechiae, 3 had erosions, and 1 had bleeding stigmata in 2 ulcers). The median baseline lac/man ratio (0.021; range, 0.011-0.045) increased after ASA use (0.036; range, 0.007-0.258; P = .08), and the post-ASA lac/man ratio was above the upper end of normal (>0.025) in 10 of 20 volunteers (vs baseline, P < .02). The median baseline fecal calprotectin concentration (6.05 microg/g; range, 1.9-79.2) also increased significantly after ASA use (23.9 microg/g; range, 3.1-75.3; P < .0005), with 3 patients having values above the cutoff (>50 microg/g). Five of 10 subjects with abnormal findings at VCE also had lac/man ratios above the cutoff. Median baseline sucrose urinary excretion (70.0 mg; range, 11.8-151.3) increased significantly after ASA administration (107.0 mg; range, 22.9-411.3; P < .05). CONCLUSIONS The short-term administration of low-dose ASA is associated with mucosal abnormalities of the small bowel mucosa, which might have implications in clinical practice.

Variceal band ligation and variceal band ligation plus sclerotherapy in the prevention of recurrent variceal bleeding in cirrhotic patients: a randomized, prospective and controlled trial

BACKGROUND The combination treatment of band ligation plus sclerotherapy has been proposed to hasten variceal eradication. The aim of this study was to assess the efficacy of band ligation alone versus band ligation plus sclerotherapy in the prevention of recurrent variceal bleeding. METHODS Eighty cirrhotic patients were randomized to group I (band ligation) with 41 patients or to group II (band ligation plus sclerotherapy) with 39 patients in whom polidocanol (2%) was injected 1 to 2 cm proximal to each band. RESULTS At baseline, both groups were similar with regard to clinical, demographic and laboratory data. Mean follow-up time (standard error) for group I was 336.5 +/- 43.4 days and for group II 386.1 +/- 40.1 days (p = 0.4). No statistical differences were observed between group I and group II in relation to recurrence of bleeding (31.7% vs. 23%, p = 0.38), treatment failure (24.4% vs. 12. 8%, p = 0.18), death (39% vs. 30.8%, p = 0.44) and variceal eradication (65.8% vs. 74.4%, p = 0.40). Group II had a significantly higher number of complications than group I, 30.8% versus 7.3%, respectively (p = 0.05). The number of bleeding related deaths was higher in group I than in group II (22% vs. 10.3%, respectively; p = 0.15). CONCLUSIONS No significant difference was observed between band ligation and band ligation plus sclerotherapy in prevention of recurrent variceal bleeding. Furthermore, there was a higher incidence of complications in the latter group.

Terlipressin is more effective in decreasing variceal pressure than portal pressure in cirrhotic patients.

BACKGROUND/AIMS Terlipressin decreases portal pressure. However, its effects on variceal pressure have been poorly investigated. This study investigated the variceal, splanchnic and systemic hemodynamic effects of terlipressin. METHODS Twenty cirrhotic patients with esophageal varices grade II-III, and portal pressure > or =12 mmHg were studied. Hepatic venous pressure gradient, variceal pressure and systemic hemodynamic parameters were obtained. After baseline measurements, in a double-blind administration, 14 patients received a 2mg/iv injection of terlipressin and six patients received placebo. The same measurements were repeated 60 min later. RESULTS No demographic or biochemical differences were observed in basal condition between groups. Terlipressin produced significant decreases in intravariceal pressure from 20.9+4.9 to 16.3+/-4.7 mmHg (p<0.01, -21+/- 16%), variceal pressure gradient from 18.9+/-4.8 to 13.5+/-6.0 mmHg (p<0.01, -28+/-27%), estimated variceal wall tension from 78+/-29 to 59+/-31 mmHg x mm (p<0.01, -27+/-22%), and hepatic venous pressure gradient from 19.4+/-4.5 to 16.8+/-5 mmHg (p<0.01, -14+/-12%) at 60 min. The change in variceal pressure after 60 min of terlipressin administration was greater than the change in wedge hepatic venous pressure (-4.7 mmHg vs -0.5 mmHg, respectively, p<0.0001). Terlipressin also caused significant decreases in heart rate and cardiac index and increases in mean arterial pressure and peripheral vascular resistance. CONCLUSIONS Our results demonstrate that terlipressin produces significant and prolonged decreases in variceal pressure and variceal wall tension and has intrinsic effects on portal pressure and systemic hemodynamics. Variceal pressure provides a better assessment of the effects of terlipressin administration on esophageal varices than hepatic venous pressure gradient.

Patients with ascites have higher variceal pressure and wall tension than patients without ascites.

OBJECTIVE:It has been suggested that ascites is a risk factor for variceal bleeding. Recently, it has been demonstrated that total paracentesis decreases variceal pressure. However, no data are available showing the basal variceal pressure in patients with and without ascites.METHODS:We studied 76 cirrhotic patients, 49 with and 27 without ascites. Variceal pressure was measured by direct puncture. Variceal size, variceal pressure gradient, and variceal wall tension were also obtained.RESULTS:No demographic differences were observed between the groups. Child score was higher (9.7 ± 1.5 vs 7.8 ± 2.1, p < 0.001) and serum albumin lower (2.6 ± 0.6 vs 3.0 ± 0.7 mg %, p < 0.02) in ascitic than in nonascitic patients, respectively. Variceal pressure and variceal pressure gradient were significantly higher in patients with ascites than in those without ascites (25.0 ± 6 vs 20.4 ± 4.6 mm Hg, p < 0.001 and 18.75 ± 4.7 vs 13.70 ± 4.1 mm Hg, p < 0.0001, respectively). The variceal wall tension was significantly higher in patients with ascites (71.0 ± 25.1 mm Hg/mm) than in those without ascites (55.1 ± 22.1 mm Hg/mm, p < 0.03). No relationship was observed between variceal pressure gradient and liver function. Ascites patients included in Child-Pugh grade A+B presented a similar variceal pressure to Child C patients (18.5 ± 4.2 vs 19.3 ± 5.7 mm Hg, respectively, p = ns). In addition, no relationship was observed between variceal pressure gradient and etiology of cirrhosis.CONCLUSION:Our results demonstrate that patients with ascites have significantly higher variceal pressure and wall tension than patients without ascites. These results suggest that patients with ascites may be at risk for variceal bleeding.

Sphincter of Oddi Manometry: Reproducibility of Measurements and Effect of Sphincterotomy in the EPISOD Study

Background/Aims The reproducibility of sphincter of Oddi manometry (SOM) measurements and results of SOM after sphincterotomy has not been studied sufficiently. The aim of our study is to evaluate the reproducibility of SOM and completeness of sphincter ablation. Methods The recently published Evaluating Predictors and Interventions in sphincter of Oddi dysfunction (EPISOD) study included 214 subjects with post-cholecystectomy pain, and fit the criteria of sphincter of Oddi dysfunction type III. They were randomized into 3 arms, irrespective of manometric findings: sham (no sphincterotomy), biliary sphincterotomy, and dual (biliary and pancreatic). Thirty-eight subjects had both biliary and pancreatic manometries performed twice, at baseline and at repeat endoscopic retrograde cholangiopancreatography after 1–11 months. Sham arm was examined to assess the reproducibility of manometry, and the treatment arms to assess whether the sphincterotomies were complete (elevated pressures were normalized). Results Biliary and pancreatic measurements were reproduced in 7/14 (50%) untreated subjects. All 12 patients with initially elevated biliary pressures in biliary and dual sphincterotomy groups normalized after biliary sphincterotomy. However, 2 of 8 subjects with elevated pancreatic pressures in the dual sphincterotomy group remained abnormal after pancreatic sphincterotomy. Paradoxically, normal biliary pressures became abnormal in 1 of 15 subjects after biliary sphincterotomy, and normal pancreatic pressures became abnormal in 5 of 15 patients after biliary sphincterotomy, and in 1 of 9 after pancreatic sphincterotomy. Conclusions Our data suggest that SOM measurements are poorly reproducible, and question whether we could adequately perform pancreatic sphincterotomy.

Adjunctive radiofrequency ablation for the endoscopic treatment of ampullary lesions with intraductal extension (with video)

Background and study aims: Catheter-based radiofrequency ablation (RFA) delivered during endoscopic retrograde cholangiopancreatography (ERCP) may represent a viable treatment option for intraductal extension of ampullary neoplasms, however, clinical experience with this modality is limited. After ampullary resection, 4 patients with intraductal extension underwent adjunctive RFA of the distal bile duct. All patients received a temporary pancreatic stent to reduce the risk of pancreatitis, as well as a plastic biliary stent to prevent biliary obstruction. Three patients were treated for adenoma and 1 for adenoma with a focus of adenocarcinoma. During a short follow-up period, 3 patients experienced complete eradication of the target lesion, whereas the patient with a focus of adenocarcinoma had progression to overt invasive cancer. There were no immediate adverse events. One patient developed a post-RFA bile duct stricture, which has required additional endoscopic therapy. Catheter-based RFA of ampullary lesions that extend up the bile duct is technically feasible. Additional research is necessary to understand the risks and long-term benefits of this technique.

Impact of Endotracheal Intubation on Interventional Endoscopy Unit Efficiency Metrics at a Tertiary Academic Medical Center.

OBJECTIVES:Measures for evaluating interventional endoscopy unit efficiency have not been adequately validated, especially in reference to the involvement of anesthesia services for endoscopy. Primary aim was to compare process measures/metrics of interventional endoscopy unit efficiency between intubated and non-intubated patients. Secondary aim was to assess variables associated with the need for endotracheal intubation.METHODS:The prospectively collected endoscopy unit metrics database at UF Health was reviewed for procedures performed in the interventional endoscopy unit for 6 months. Parameters included hospital-mandated metrics available from the database.RESULTS:A total of 1,421 patients underwent 1,635 interventional endoscopic procedures and 271/1,421 patients (19.1%) were intubated. There was no significant difference between intubated and non-intubated cohorts with respect to age, gender, BMI, ASA Score, Mallampati Score, or the Charlson Comorbidity Index. Patients undergoing endoscopic retrograde cholangiopancreatography (ERCP) were more frequently intubated than those undergoing non-ERCP procedures (41.3 vs. 12.4%, P<0.0001). Inpatients comprised 48.3% of all intubated patients, whereas only 29.2% of non-intubated patients were inpatients (P<0.0001). Most patients (159/271, 58.7%) were intubated per anesthesiologist preference. All process efficiency metrics were significantly prolonged in the intubated compared with the non-intubated patient cohort, except the time interval between successive procedures. Multivariate analysis revealed that patients with an anesthesiologist who had performed a greater number of total endoscopic sedations were less likely to be intubated than patients with an anesthesiologist who had performed fewer total procedures (P=0.0066).CONCLUSIONS:Endotracheal intubation negatively impacts efficiency metrics in an interventional endoscopy unit. Careful assessment for the need for intubation should be emphasized.

Variability in management of ERCP-related contrast media reaction

drainage of uncomplicated pancreatic pseudocysts. Surg Endosc 2014;28:2877-83. 5. Mukai S, Itoi T, Moriyasu F. Interventional endoscopy for the treatment of pancreatic pseudocyst and walled-off necrosis (with videos). J Hepatobiliary Pancreat Sci 2014;21:E75-85. 6. Mukai S, Itoi T, Baron TH, et al. Plastic stent versus biflanged metal stent placement under EUS guidance for the treatment of walled-off necrosis: a single center retrospective analysis. Endoscopy 2015;47:47-55. 7. Mukai S, Itoi T, Sofuni A, et al. Expanding endoscopic interventions for pancreatic pseudocyst and walled-off necrosis. J Gastroenterol 2015;50(21):1-20. http://dx.doi.org/10.1016/j.gie.2015.07.001

Emerging techniques and efficacy of endoscopic esophageal reconstruction and lumen restoration for complete esophageal obstruction

Background and study aims: Complete esophageal obstruction (CEO) is a rare occurrence characterized by progressive esophageal stricture, which eventually causes lumen obliteration. With recent advances in flexible endoscopy, various innovative techniques exist for restoring luminal continuity. The primary aim of this study was to assess the efficacy and safety of patients undergoing combined antegrade-retrograde endoscopic dilation for CEO at our institution. The secondary aim was to review and highlight emerging techniques, outcomes, and adverse events after endoscopic treatment of CEO. Patients and methods: Our electronic endoscopy database was retrospectively reviewed to identify patients who underwent combined antegrade and retrograde endoscopy for CEO. Patient and procedural data collected included gender, age, technical success, pre- and post-dysphagia scores, and adverse events. Results: Six patients (67 % male, mean age 71.6 years [range 63 – 80]) underwent technically successful esophageal reconstruction with combined antegrade-retrograde endoscopy. All patients noted improvement in dysphagia with mean pre-procedure dysphagia score of 4 reduced to 1.33 (range 0 – 3) post-procedure. There were no adverse events and mean follow-up time was 17.3 months (range 3 – 48). Conclusions: Combined antegrade and retrograde endoscopic therapy for CEO is feasible and safe. We present our experience with endoscopic management of complete esophageal obstruction, and highlight emerging techniques, outcomes and adverse events related to this minimally invasive modality.

Techniques and efficacy of flexible endoscopic therapy of Zenker's diverticulum.

Zenkers diverticulum (ZD) is an abnormal hypopharyngeal pouch often presenting with dysphagia. Treatment is often sought with invasive surgical management of the diverticulum being the only mode of definitive therapy. Primarily done by an open transcervical approach in the past, nowadays treatment is usually provided by otolaryngologists using a less invasive trans-oral technique with a rigid endoscope. When first described, this method grew into acceptance quickly due to its similar efficacy and vastly improved safety profile compared to the open transcervical approach. However, the main limitation with this approach is that it may not be suitable for all patients. Nonetheless, progress in the field of natural orifice endoscopic surgery over the last 10-20 years has led to the increase in utilization of the flexible endoscope in the treatment of ZD. Primarily performed by interventional gastroenterologists, this approach overcomes the prior limitation of its surgical counterpart and allows adequate visualization of the diverticulum independent of the patients body habitus. Additionally, it may be performed without the use of general anesthesia and in an outpatient setting, thus further increasing the utility of this modality, especially in elderly patients with other comorbidities. Today, results in more than 600 patients have been described in various published case series using different techniques and devices demonstrating a high percentage of clinical symptom resolution with low rates of adverse events. In this article, we present our experience with flexible endoscopic therapy of Zenkers diverticulum and highlight the endoscopic technique, outcomes and adverse events related to this minimally invasive modality.