Lea Fayad

EUS-guided Gastrojejunostomy Versus Laparoscopic Gastrojejunostomy: An International Collaborative Study

Introduction: Endoscopic ultrasound–guided gastrojejunostomy (EUS-GJ) with placement of a lumen-apposing metal stent is a minimally invasive and efficacious procedure for gastric outlet obstruction (GOO) patients not amenable to surgery. Laparoscopic gastrojejunostomy (Lap-GJ) has traditionally been the standard of care. No direct comparison between EUS-GJ and Lap-GJ has been described. Our aim was to compare the clinical outcomes, success rate, and adverse events (AE) of EUS-GJ with Lap-GJ. Methods: Patients with GOO from 4 academic centers in 3 countries were included. Technical success was defined as successful creation of a gastrojejunostomy. Clinical success was defined as the ability to tolerate a diet postprocedure. Results: Data were collected on 54 patients. A total of 25 patients underwent EUS-GJ (male n=11, mean age 63.9 y) and 29 patients underwent Lap-GJ (male n=22, mean age 75.8 y). Technical success was achieved in 29 (100%) Lap-GJ group patients and 23 (88%) in the EUS-GJ group (P=0.11). AEs occurred in 41% (n=12) of patients in the Lap-GJ group and 12% (n=3) in the EUS-GJ group (P=0.0386). According to the Clavien-Dindo Classification, the Lap-GJ group AEs were grade I (n=4), grade II (n=5), grade III (n=2), and grade V (n=1); the EUS-GJ AEs were grade II (n=2) and grade V (n=1). Conclusions: Although the EUS-GJ group contained more complex patients, efficacy was similar between the groups. AEs were significantly lower in the EUS-GJ group. EUS-GJ is a safe and efficacious, minimally invasive option for patients with GOO.

Cost-effectiveness analysis comparing lumen-apposing metal stents with plastic stents in the management of pancreatic walled-off necrosis

BACKGROUND AND AIMS EUS-guided transmural drainage is effective in the management of pancreatic walled-off necrosis (WON). A lumen-apposing metal stent (LAMS) has recently been developed specifically for the drainage of pancreatic fluid collections that shows promising results. However, no cost-effectiveness data have been published in comparison with endoscopic drainage with traditional plastic stents (PSs). Our aim here was to compare the cost-effectiveness of LAMSs to PSs in the management of WON. METHODS A decision tree was developed to assess both LAMSs and PSs over a 6-month time horizon. For each strategy, after the insertion of the respective stents, patients were followed for subsequent need for direct endoscopic necrosectomy, adverse events requiring unplanned endoscopy, percutaneous drainage (PCD), or surgery using probabilities obtained from the literature. The unit of effectiveness was defined as successful endoscopic drainage without the need for PCD or surgery. Costs in 2016 U.S.

The Forgotten Fundus—Response to - Obesity Treatment with Botulinum Toxin-A Is Not Effective: a Systematic Review and Meta-analysis

were based on inpatient institutional costs. Sensitivity analyses were performed. An a priori willingness-to-pay threshold of U.S.

Peroral endoscopic myotomy is effective and safe in non-achalasia esophageal motility disorders: an international multicenter study

50,000 was established. RESULTS LAMSs were found to be more efficacious than PSs, with 92% and 84%, respectively, of the patients achieving successful endoscopic drainage of WON. LAMSs, however, were more costly: the average cost per patient of U.S.

EUS-guided gastroenterostomy in management of benign gastric outlet obstruction

20,029 compared with U.S.

Plastic stents are more cost-effective than lumen-apposing metal stents in management of pancreatic pseudocysts

15,941 for PSs. The incremental cost-effectiveness ratio favored LAMSs at U.S.

Endoscopic ultrasound-guided transjejunal rendezvous access to the common bile duct

49,214 per additional patient successfully treated. Sensitivity analyses confirmed the robustness of the results. CONCLUSION LAMSs are more effective but also more costly than PSs in managing WON. Data from high-quality, adequately controlled, prospective, randomized trials are needed to confirm our findings.

EUS-guided gastroenterostomy: a multicenter study comparing the direct and balloon-assisted techniques

Dear Editor, We congratulate Bustamante et al. on his meticulous review of the effectiveness of gastric injections of botulinum toxin-A (BTA) as primary treatment for obesity. [1] In reporting the results of their meta-analysis, the authors conclude that BTA therapy alone is not effective for the primary treatment of obesity. However, after reviewing the individual studies, we wonder if there are potential alternative explanations for their conclusions. We propose that interventions directed at paralyzing the stomach to induce satiety and a delay in gastric emptying are only effective when BTA is injected into the fundus. Of the four randomized controlled studies the authors describe, two studies injected BTA or saline into the gastric antrum—with no significant difference in absolute weight loss at 16 weeks in one trial, and a statistically insignificant higher absolute weight loss in the second trial. The third study injected into the antrum and distal gastric body, again with no significant weight loss at 6 months. The final and only study with significantly higher absolute weight loss and BMI reduction was when BTA was injected into the antrum and fundus. BTA is a neurotoxin that acts pre-synaptically to block the release of acetylcholine at the neuromuscular junction, resulting in an inhibitory effect on smooth muscle tone in the gastrointestinal tract, i.e., relaxation. It has been used successfully in the treatment of disorders with inappropriate or prolonged contraction such as achalasia, sphincter of oddi spasm, and anal fissures. [2] Unfortunately, most studies hypothesized that injection of BTA into the antrum would reduce passage of gastric contents into the duodenum by inhibiting the antral pump, which is likely not the case. BTA injection into the fundus likely causes weight loss by two modalities. The first is by retarding gastric emptying which emerged from the initial observation that obese individuals have rapid gastric emptying that contributes to their overeating. The second is related to gastric accommodation which is primarily a feature of the fundus and mediated via a vagal reflex pathway. Impaired accommodation results in early satiety and hence reduced per oral intake. Foschi et al. eloquently demonstrated this in his study by a decrease in gastric emptying and reduction in maximal gastric capacity for solids following BTA injection to the antrum and fundus [3]. Garcia-Compean et al. performed a similar trial with BTA injection into the antrum. However, there was no difference in weight loss or gastric emptying measured via scintigraphy at 8 weeks implying that the area of interest for injection may be the fundus [4]. Even though the authors were diligent in their search of the literature and meticulously analyzed the varying doses used across the studies, they appeared to not recognize that the location of BTA injection had a compelling effect on the ultimate weight loss outcome. We defer in our conclusion of the literature that BTA injection does indeed induce weight loss, but only when injected into the gastric fundus. We need an adequately powered double-blind randomized control trial looking at weight loss outcomes, gastric volume tomaximum satiety, and gastric emptying within three groups: * Vivek Kumbhari vkumbhari@gmail.com

Endoscopic Sleeve Gastroplasty (ESG) Is a Reproducible and Effective Endoscopic Bariatric Therapy Suitable for Widespread Clinical Adoption: a Large, International Multicenter Study

Background and study aims  The efficacy of per oral endoscopic myotomy (POEM) in non-achalasia esophageal motility disorders such as esophagogastric junction outflow obstruction (EGJOO), diffuse esophageal spasm (DES), and jackhammer esophagus (JE) has not been well demonstrated. The aim of this international multicenter study was to assess clinical outcomes of POEM in patients with non-achalasia disorders, namely DES, JE, and EGJOO, in a large cohort of patients. Patients and methods  This was a retrospective study at 11 centers. Consecutive patients who underwent POEM for EGJOO, DES, or JE between 1/2014 and 9/2016 were included. Rates of technical success (completion of myotomy), clinical response (symptom improvement/Eckardt score ≤ 3), and adverse events (AEs, severity per ASGE lexicon) were ascertained . Results  Fifty patients (56 % female; mean age 61.7 years) underwent POEM for EGJOO (n = 15), DES (n = 17), and JE (n = 18). The majority of patients (68 %) were treatment-naïve. Technical success was achieved in all patients with a mean procedural time of 88.4 ± 44.7 min. Mean total myotomy length was 15.1 ± 4.7 cm. Chest pain improved in 88.9 % of EGJOO and 87.0 % of DES/JE ( P  = 0.88). Clinical success was achieved in 93.3 % of EGJOO and in 84.9 % of DES/JE ( P  = 0.41) with a median follow-up of 195 and 272 days, respectively. Mean Eckardt score decreased from 6.2 to 1.0 in EGJOO ( P  < 0.001) and from 6.9 to 1.9 in DES/JE ( P  < 0.001). A total of 9 (18 %) AEs occurred and were rated as mild in 55.6 % and moderate in 44.4 %. Conclusion  POEM is effective and safe in management of non-achalasia esophageal motility disorders, which include DES, JE, and EGJOO.

Overtube-Assisted EUS-Guided Access of the Common Bile Duct in a Patient With Roux-en-Y Gastric Bypass Anatomy

Background and study aims  Endoscopic ultrasound-guided gastroenterostomy (EUS-GE) in malignant gastric outlet obstruction (GOO) appears to be promising; however, its role in benign GOO is unclear. The aim of this study was to ascertain the clinical efficacy and safety of EUS-GE in benign GOO. Patients and methods  This was an international retrospective series involving 5 tertiary centers. Consecutive patients who underwent EUS-GE between 1/2013 – 10/2016 for benign GOO were included. The primary endpoint was the rate of clinical success defined as ability to tolerate oral intake without vomiting. Secondary endpoints included technical success and rate of adverse events (AE). Results  Overall, 26 patients (46.2 % female; mean age 57.7 ± 13.9 years) underwent EUS-GE for benign GOO due to strictures from chronic pancreatitis (n = 11), surgical anastomosis (n = 6), peptic ulcer disease (n = 5), acute pancreatitis (n = 1), superior mesentery artery syndrome (n = 1), caustic injury (n = 1), and hematoma (n = 1). Technical success was achieved in 96.2 %. Dilation of the lumen apposing metal stent was performed in 13/25 (52 %) with a mean maximum diameter of 14.6 ± 1.0 mm. Mean procedure time was 44.6 ± 26.1 min. Clinical success was observed in 84.0 % with a mean time to oral intake of 1.4 ± 1.9 days and a median follow-up of 176.5 (IQR: 47 – 445.75) days. Rate of unplanned re-intervention was 4.8 %. 3 AE were noted including 2 misdeployed stents and 1 gastric leak needing surgical intervention following elective GE stent removal. Conclusions  EUS-GE is a promising treatment for benign GOO. Larger and prospective data are needed to further validate this novel endoscopic technique in treating benign GOO of various etiologies.