Paula Gil-Simon

EUS-guided transenteric gallbladder drainage with a new fistula-forming, lumen-apposing metal stent

e g ( u s p s t l a m w W t g t Laparoscopic cholecystectomy is the standard approach for patients with lithiasic acute cholecystitis. However, some are patients unsuitable for cholecystectomy because of advanced age, underlying comorbidities, or malignances: in these cases, percutaneous transhepatic gallbladder drainage is the treatment of choice up to now,3,4 with linical success rates between 56% and 100%.5,6 Nevertheless, the percutaneous approach has many drawbacks including pneumothorax, biliary peritonitis, or bleeding, reported in up to 12% of cases,5 and potential complicaions secondary to premature tube removal or dislodgeent in 0.3% to 12% of patients.7-11 Furthermore, high ates of recurrence of cholecystitis (33%) have been reorted after removal of the drainage catheter.8 The procedure is also uncomfortable for the patient, and ongoing nurse maintenance is required. Endoscopic methods for gallbladder drainage include the transpapillary approach (with plastic stents12,13 or naso-gallbladder drainage NGBD]14,15) or EUS-guided transmural gallbladder drainage. To date, there are scant data about safety and feasibility of EUS-guided transmural gallbladder drainage.16-20 In contrast, EUS-guided transenteric drainage of peripancreatic collections by using tubular stents (plastic or selfexpandable metal stents [SEMS]) has become a strengthened therapeutic procedure, replacing percutaneous or surgical drainages. However, tubular-shaped stents (plastic or metal) have disadvantages and risks, such as bile leakage or migration. Furthermore, the slow flow of bile and the small caliber of plastic stents can result in early malfunction and clogging. These inconveniences could be avoided with the recently developed self-expandable lumen-apposing metal stent AXIOS (Xlumena Inc, Moun-

Comparison between insufflation with air or carbon dioxide during the colonoscopy in sedated patients with propofol

OBJECTIVES compare the intensity of pain experienced after colonoscopy with air or with CO₂ and evaluate the safety of CO₂ in colonoscopies performed with moderate/deep sedation. MATERIALS AND METHODS individuals undergoing ambulatory colonoscopy without exclusion criteria (severe respiratory disease, morbid obesity) were randomized in air or CO₂ group. We recorded different variables prior to, during and upon completion of the colonoscopy, performing monitoring using pulse oximetry and capnography. Each patient rated, using a visual numeric scale, the intensity of post-colonoscopy pain at different moments. RESULTS 141 individuals in the air group (sex M/F 63/78, age 24-83) and the CO₂ group (sex M/F 59/70, age 24-82). No significant differences existed in the recorded variables in both groups except for the greater number of explorations performed by an endoscopist in training (TE) in the air group compared to those by a more experienced endoscopist (SE). CO2 in expired air, episodes of oxygen desaturation and of apnoea and dose of propofol, of midazolam were similar in both groups. No episodes of hypercapnea or any complication requiring cardiopulmonary resuscitation measures were recorded. The pain in the air group was significantly higher at 15 minutes and at 1, 3 and 6 hours after the endoscopy, equalising at 24 hours. After multivariant adjustment for type of doctor (TE vs. SE) the differences observed in pain intensity for each group were maintained. CONCLUSIONS a) the use of CO₂ in colonoscopy causes significantly less pain in the first 6 hours after the procedure; b) its use in patients with moderate/deep sedation is safe; and c) performance of the endoscopic technique is not modified, nor are times reduced.

Magnetic compression anastomosis through EUS-guided choledochoduodenostomy to repair a disconnected bile duct in orthotopic liver transplantation.

This video can be viewed directly from the GIE website or by using the QR code and your mobile device. Download a free QR code scanner by searching “QR Scanner” in your mobile device’s app store. Figure 1. A, Balloon cholangiogram through the naked EUS-guided choledoch nected choledochocholedochostomy (arrowhead). A covered self-expandable magnet insertion at ERCP. B, Magnets across the disconnected segment with t magnetic compression anastomosis. D, Retrograde retrieval of coupled magne

Cumulative risks of stent migration and gastrointestinal bleeding in patients with lumen-apposing metal stents

BACKGROUND Delayed gastrointestinal (GI) bleeding and stent migration are known adverse events which may occur following placement of lumen-apposing metal stents (LAMSs). METHODS All consecutive patients who underwent LAMS placement between May 2011 and June 2017 at a single tertiary medical center were included. Demographics and procedural details were prospectively collected. Post-procedure follow-up and outcome measures were retrospectively collected. The cumulative risks of migration and LAMS-related GI bleeding were estimated using the life-table method. Risk predictors were assessed using Cox proportional hazards models. RESULTS We analyzed 250 patients (64.8 % men; median age 71.6 [interquartile range (IQR) 57.9 - 83.6]). Median follow-up was 78.5 days (IQR 31 - 246.5 days). Thirty-four stent migrations (13.6 %) occurred (5 symptomatic). On multivariable analysis, associations with migration included nasocystic drains (hazard ratio [HR] 6.5, 95 % confidence interval [CI] 2.2 - 19.3), pancreatic fluid collections (PFCs; HR 4.2, 95 %CI 1.8 - 10.1), and double-pigtail stents (HR 2.4, 95 %CI 1.2 - 4.9). Migration risk at 12 months was 25.5 % (95 %CI 17.9 % - 35.7 %) and was higher for PFCs 48.9 % (33.4 % - 66.9 %) than other indications 8.4 % (4.9 % - 17.5 %; P < 0.001). LAMSs placed for longer durations (i. e. enteral anastomoses, biliary and gallbladder drainage) presented an 8.4 % cumulative risk at 2 years. There were 13 LAMS-related GI hemorrhages (5.2 %), two of them fatal, presenting a median of 3 days (IQR 1 - 9 days) after deployment. The cumulative risk of bleeding at 12 months was 6.9 % (3.6 % - 12.7 %). CONCLUSIONS LAMS migration occurs in 1 out of 7 cases and is most common when treating PFCs. Bleeding related to LAMS placement occurs much less commonly but can be life-threatening.

Natural orifice transluminal endoscopic surgery salvage of direct EUS-guided gastrojejunostomy

Lumen-apposing metal stents (LAMSs) can be used for gastrojejunostomy (GJ) under natural orifice transluminal endoscopic surgery (NOTES) or EUS guidance. EUS-GJ requires both LAMS flanges to be properly placed. Proximal flange misplacement during LAMS deployment into the small bowel or the gallbladder has occasionally been salvaged by a bridging tubular SEMS. However, the only 2 reported instances of distal LAMS flange misplacement during EUS-GJ resulted in procedural failure. We report a successful NOTES approach to salvage distal LAMS flange misplacement during EUS-GJ. An 80-year-old woman with metastatic pancreatic cancer and a biliary SEMS experienced symptoms of gastric outlet obstruction 4.5 months after diagnosis. Guidewire insertion across a stricture in the third part of the duodenum failed. She was not a surgical candidate, and direct EUSGJ was chosen. Loops of small bowel were initially distended with saline solution injection through a 22-gauge needle before

Mo1837 Efficacy of Immunotherapy and Alergen-Molecular-Study-Led Diet Treatments in Eosinophilic Esophagitis

BACKGROUNDA B=4.97; C=3.27; p=0.04), but no differences were observed between groups B and C (p=0,17). Regarding endoscopic findings, inflammatory features were significantly decreased after histological remission (furrows A=75%; B=72.7%; C=22.4%; p=0.003; exudates A=50%; B=48.5%; C=6.7%; p=0.01), but not fibrostenotic features ( rings A=71.4%; B=56.3%; C=53.3%; p=0.37; stricture A=10.7%; B=6.1%; C=6.7%; p=0.78). Mucosal edema was common at baseline and persistent regardless of histological remission (A=78.6%; B= 81.8%; C=66.7%; p=0.5). CONCLUSIONS: EoE clinical activity significantly decreased after different therapeutic interventions, with no differences between patients showing eosinophilia remission or persistence after therapy. Histological remission was correlated with significant decrease of inflammatory endoscopic features, but not of fibrostenotic findings. Mucosal edema was mostly persistent regardless of histological remission, suggesting it might belong to the fibrotic remodelling spectrum. Characteristics of the groups