Lady Katherine Mejia Perez

Massive bleeding after EUS-guided walled-off necrosis drainage

re 1. A, Preprocedural abdominal MRI demonstrating a large (12.3 7.4 6.4 cm) complex fluid collection with a thick outer wall surrounding ancreatic body (arrow) and suspected disruption of the pancreatic duct (arrowheads). B, EUS view demonstrating the LAMS catheter (arrow) inside the collection, and the distal end of the deployed stent (arrow). C, Upper endoscopic view showing dilation of the cystgastrostomy by f a wire-guided dilating balloon. D, Upper endoscopic view showing bleeding at the proximal end of the LAMS (gastric side). E, Arteriographic showing the deployed LAMS (arrow) and no evidence of extravasation of contrast material. F, Duodenoscopic view revealing the previously d cystgastrostomy stent on the gastric body. A hemostatic clip is seen at the site of active bleeding underneath the stent. G, EGD view demonng the gastric side of the cystgastrostomy without bleeding. H, MRI revealing nearly resolved walled-off necrosis (arrow). I, EGD views before and after (right) LAMS removal. MRI, magnetic resonance imaging; LAMS, lumen-apposing metal stent. The arrow represents the place where tent was.

Adenoma recurrence after endoscopic mucosal resection: propensity score analysis of old and new colonoscopes and Sydney recurrence tool implementation

Background and study aims  Risk factors for colorectal adenoma recurrence after endoscopic mucosal resection (EMR) have been well documented. We assessed the efficacy of the newer 190 colonoscope versus the standard 180 colonoscope for complete resection of lateral spreading lesions. Patients and methods  A single-center, retrospective study of patients who underwent EMR with Olympus 180 or 190 colonoscopes from January 1, 2010 to September 30, 2016. We included patients with lesions ≥ 20 mm and surveillance colonoscopy (SC1) after index EMR. A propensity score approach with inverse probability weighting was used to control for potential confounders. A secondary aim was to identify risk factors for recurrence and assess the applicability of the Sydney EMR recurrence tool (SERT) by grading each lesion of our cohort and analyzing associations with recurrence. Results  Two hundred ninety-one lesions met inclusion criteria for the study. Odds ratio (OR) for recurrence with the 190 colonoscope was 1.06 ( P  = .85). Adenoma size ( P  = .02) and use of argon plasma coagulation (APC; P  < .001) were risk factors for recurrence. Lesions with SERT scores > 0 had a higher recurrence risk during follow-up (32 % vs 21 %; OR 1.71; P  = .05). Lesions with SERT scores = 0 reached a plateau for recurrence at 12 and 18 months in Kaplan-Meier curves. Conclusions  The use of 190 colonoscopes did not measurably affect adenoma recurrence at SC1. Recurrence was associated with adenoma size, complementary APC for resection, and SERT scores > 0. Lesions with SERT scores = 0 that remain negative for recurrence at 18 months may return to routine surveillance.

Minimally invasive treatment of early gastrointestinal cancers

The diagnostic and therapeutic paradigm of early esophageal, gastric and colorectal cancer is shifting. Historically, surgery was the standard of care for gastrointestinal malignancies, including those at an early stage. However, it is associated with loss of function of the organ, higher morbidity, and associated costs. Endoscopic resection has evolved as a minimally invasive alternative that provides accurate histologic diagnosis, as well as curative resection for many early gastrointestinal malignancies. Endoscopic mucosal resection (EMR), endoscopic submucosal dissection (ESD), and the recently described submucosal tunneling endoscopic resection (STER) constitute some of these new resection techniques. Appropriate selection of lesions amenable for endoscopic resection is crucial when being used with curative intent. Estimation of eligibility relies entirely in an adequate pre-procedural evaluation of depth of invasion and histology, which correlate with the risk of lymph node metastasis. Adequate histopathologic examination of the resected specimen determines curability of the resection, guiding the need for further therapy. We will review the indications, outcomes, and limitations of EMR, ESD, and STER.

Collagenous Gastritis and Helicobacter pylori Infection: A Mere Coincidence?

A 21-year-old woman presented to our clinic after 7 years of abdominal pain, diarrhea, and iron-deficiency anemia. Initial upper endoscopy revealed severe inflammation and nodularity of the gastric body and active Helicobacter pylori infection. After eradication therapy, esophagogastroduodenoscopy showed gastric atrophy with nodularity resolution. Histopathology revealed scattered plasma cells, eosinophils, and collagen deposition suggestive of collagenous gastritis. H. pylori can induce proinflammatory cytokines, resulting in fibroblast upregulation. Collagenous gastritis may be caused by an inflammatory response associated with type I, II, and III collagen. Although further research is warranted, we hypothesize that chronic inflammation from H. pylori may lead to collagenous gastritis.

Closure of a persistent esophagopleural fistula by use of an atrial septal occluder device

re 1. A, Abdominal CT scan confirming the persistent esophagopleural fistula (yellow arrow), an adequately placed stent (red arrow), and a right al effusion (arrowhead). B, Esophagram showing contrast medium leaking into the right pleural space (yellow arrow). C, Upper endoscopy ling a 5-mm fistulous opening in the proximal esophagus (blue arrow). D, Side view of the chest wall demonstrating the thoracostomy window, he subtle fistulous opening (yellow arrow). E, Scheme of the atrial septal occluder device that was deployed under endoscopic guidance. Copyright by W.L. Gore & Associates, Inc. Reprinted by permission of W.L. Gore & Associates, Inc. F, Endoscopic view of the esophagus, showing the proximal of the deployed atrial occluder device covering the fistulous opening. G, Side view of the chest wall showing the deployed atrial septal occluder ring the fistulous defect. H, 4-week follow-up CT scan of the abdomen, showing device and closed defect (green arrow). I, Side view of the chest demonstrating the septal occluder covered by fibrous connective tissue (yellow arrow).