Sepideh Besharati

Refractory gastroparesis can be successfully managed with endoscopic transpyloric stent placement and fixation (with video).

BACKGROUND AND AIMS Medical treatment options for gastroparesis are limited. Data from studies of botulinum toxin and surgical pyloroplasty suggest that disruption of the pylorus can result in symptomatic improvement in some patients with refractory gastroparetic symptoms. The aim of this study was to determine the clinical response to transpyloric stent (TPS) placement in patients with gastroparetic symptoms refractory to standard therapy. METHODS Patients with gastroparesis refractory to medical treatment were referred for TPS placement for salvage therapy. Self-reported symptom improvement, stent migration rate, and pre- and post-stent gastric-emptying study results were collected. RESULTS A total of 30 patients with refractory gastroparesis underwent 48 TPS procedures. Of these, 25 of 48 (52.1%) were performed in patients admitted to the hospital with intractable gastroparetic symptoms. Successful stent placement in the desired location across the pylorus (technical success) was achieved during 47 procedures (98%). Most (n = 24) stents were anchored to the gastric wall by using endoscopic suturing with a mean number of sutures of 2 (range 1-3) per procedure. Clinical response was observed in 75% of patients, and all inpatients were successfully discharged. Clinical success in patients with the predominant symptoms of nausea and vomiting was higher than in those patients with a predominant symptom of pain (79% vs 21%, P = .12). A repeat gastric-emptying study was performed in 16 patients, and the mean 4-hour gastric emptying normalized in 6 patients and significantly improved in 5 patients. Stent migration was least common (48%) when stents were sutured. CONCLUSION TPS placement is a feasible novel endoscopic treatment modality for gastroparesis and improves both symptoms and gastric emptying in patients who are refractory to medical treatment, especially those with nausea and vomiting. TPS placement may be considered as salvage therapy for inpatients with intractable symptoms or potentially as a method to select patients who may respond to more permanent therapies directed at the pylorus.

Endoscopic suturing for the prevention of stent migration in benign upper gastrointestinal conditions: a comparative multicenter study

BACKGROUND AND STUDY AIMS Fully covered self-expandable metal stents (FCSEMSs) have increasingly been used in benign upper gastrointestinal (UGI) conditions; however, stent migration remains a major limitation. Endoscopic suture fixation (ESF) may prevent stent migration. The aims of this study were to compare the frequency of stent migration in patients who received endoscopic suturing for stent fixation (ESF group) compared with those who did not (NSF group) and to assess the impact of ESF on clinical outcome. PATIENTS AND METHODS This was a retrospective study of patients who underwent FCSEMS placement for benign UGI diseases. Patients were divided into either the NSF or ESF group. Outcome variables, including stent migration, clinical success (resolution of underlying pathology), and adverse events, were compared. RESULTS A total of 125 patients (44 in ESF group, 81 in NSF group; 56 benign strictures, 69 leaks/fistulas/perforations) underwent 224 stenting procedures. Stent migration was significantly more common in the NSF group (33 % vs. 16 %; P = 0.03). Time to stent migration was longer in the ESF group (P = 0.02). ESF appeared to protect against stent migration in patients with a history of stent migration (adjusted odds ratio [OR] 0.09; P = 0.002). ESF was also significantly associated with a higher rate of clinical success (60 % vs. 38 %; P = 0.03). Rates of adverse events were similar between the two groups. CONCLUSIONS Endoscopic suturing for stent fixation is safe and associated with a decreased migration rate, particularly in patients with a prior history of stent migration. It may also improve clinical response, likely because of the reduction in stent migration.

Intraprocedural fluoroscopy to determine the extent of the cardiomyotomy during per-oral endoscopic myotomy (with video).

BACKGROUND An adequate myotomy on the gastric side is considered essential to optimize outcomes in patients undergoing per-oral endoscopic myotomy (POEM). An objective method to measure the length of gastric myotomy has not yet been reported. OBJECTIVE To evaluate a new method of precisely determining the length of the submucosal tunnel below the esophagogastric junction (EGJ) using intraprocedural fluoroscopy. DESIGN Single-center cohort study. SETTING Academic tertiary care center. PATIENTS Twenty-four consecutive patients who underwent POEM for management of achalasia. INTERVENTIONS A radiopaque marker (endoscopic clip placed at the EGJ or fluoroscopically guided placement of a 19-gauge needle on the skin) was used to mark the EGJ. The endoscope was inserted to the most distal aspect of the submucosal tunnel and, using fluoroscopy, the distance between the radiopaque marker and the tip of the endoscope was measured. MAIN OUTCOME MEASUREMENTS Technical success, procedural impact, duration of technique, and adverse events. RESULTS Technical success was achieved in 100% of patients. The submucosal tunnel was extended in 5 patients (20.8%) with a mean extension of 1.4±.5 cm. The mean increase in procedure time was 4 minutes with the endoscopic clip and 2 minutes with the 19-gauge needle. There were no adverse events associated with this technique. LIMITATIONS Need for fluoroscopy. Absence of available criterion standard. CONCLUSIONS Intraprocedural fluoroscopy was an efficient and safe method of objectively documenting the extent of gastric myotomy during POEM. This may benefit those investigating the anatomic and physiologic changes that occur during the myotomy and those early in their experience performing POEM.

Stylet slow-pull versus standard suction for endoscopic ultrasound-guided fine-needle aspiration of solid pancreatic lesions: a multicenter randomized trial

BACKGROUND AND STUDY AIM Standard endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) procedures involve use of no-suction or suction aspiration techniques. A new aspiration method, the stylet slow-pull technique, involves slow withdrawal of the needle stylet to create minimum negative pressure. The aim of this study was to compare the sensitivity of EUS-FNA using stylet slow-pull or suction techniques for malignant solid pancreatic lesions using a standard 22-gauge needle. PATIENTS AND METHODS Consecutive patients presenting for EUS-FNA of pancreatic mass lesions were randomized to the stylet slow-pull or suction techniques using a 22-gauge needle. Both techniques were standardized for each pass until an adequate specimen was obtained, as determined by rapid on-site cytology examination. Patients were crossed over to the alternative technique after four nondiagnostic passes. RESULTS Of 147 patients screened, 121 (mean age 64 ± 13.8 years) met inclusion criteria and were randomized to the stylet slow-pull technique (n = 61) or the suction technique (n = 60). Technical success rates were 96.7 % and 98.3 % in the slow-pull and suction groups, respectively (P > 0.99). The sensitivity for malignancy of EUS-FNA was 82 % in the slow-pull group and 69 % in the suction group (P = 0.10). The first-pass diagnostic rate (42.6 % vs. 38.3 %; P = 0.71), acquisition of core tissue (60.6 % vs. 46.7 %; P = 0.14), and the median (range) number of passes to diagnosis (2 1 2 3 vs. 1 1 2; P = 0.71) were similar in the slow-pull and suction groups, respectively. CONCLUSIONS The stylet slow-pull and suction techniques both offered high and comparable diagnostic sensitivity with a mean of 2 passes required for diagnosis of solid pancreatic lesions. The endosonographer may choose either technique during FNA.

Intraoperative determination of the adequacy of myotomy length during peroral endoscopic myotomy (POEM): The double-endoscope transillumination for extent confirmation technique (DETECT)

BACKGROUND AND STUDY AIMS Precise identification of the gastroesophageal junction (GEJ) is a challenging prerequisite for adequate length of an esophageal myotomy. Multiple standard methods to identify the GEJ have been described; however, a more objective modality is needed to ensure effective peroral endoscopic myotomy (POEM). PATIENTS AND METHODS In the double-endoscope transillumination for extent confirmation technique (DETECT), an ultraslim gastroscope is passed to the most distal aspect of the submucosal tunnel created during POEM. A regular gastroscope is advanced into the stomach, and the visualization of transillumination from the ultraslim gastroscope enables identification of the extent of the submucosal tunnel. RESULTS A total of 10 patients underwent POEM with DETECT. Initial submucosal tunneling was performed based on a determination of the GEJ location via standard methods. DETECT indicated the tunnel extent to be inadequate in 50% of patients, and the tunnel was extended a further 1 to 2cm. The mean initial tunnel length was 15.4cm, with a mean initial myotomy length of 11.9cm. DETECT was performed in less than 10 minutes without complications. CONCLUSION DETECT is an objective method for determining the adequacy of the submucosal tunnel length during POEM.

Evaluation of Peritumoral Fibrosis in Metastatic Colorectal Adenocarcinoma to the Liver Using Digital Image Analysis

Objectives It is challenging to separate peritumoral fibrosis from fibrosis due to chronic liver disease in mass-directed liver biopsies. We evaluated the distance that peritumoral fibrosis extends from metastatic colorectal adenocarcinoma in liver. Methods Peritumoral and distant uninvolved liver trichrome stains from 25 cases were analyzed using digital image analysis. Fibrosis was quantitated at concentric intervals from each tumor and in uninvolved liver. Results There was a 3.9 fold (range 0.9-18.6) median increase in fibrosis in the first 0.5 mm of peritumoral liver compared to distant liver. Fibrosis levels returned to baseline at median 2.5 mm (interquartile range 1.5-5.0 mm) from tumor. Conclusions Fibrosis is markedly increased in peritumoral liver. Fibrosis levels returned to baseline by 5 mm from tumor in approximately 75% of cases. Pathologists should be cautious of fibrosis in mass-directed liver biopsies without at least 5 mm of liver tissue distal to the mass.

Predictors of incomplete optical colonoscopy using computed tomographic colonography.

Background/Aims: Optical colonoscopy (OC) is the primary modality for investigation of colonic pathology. Although there is data on demographic factors for incomplete OC, paucity of data exists for anatomic variables that are associated with an incomplete OC. These anatomic variables can be visualized using computed tomographic colonography (CTC). We aim to retrospectively identify variables associated with incomplete OC using CTC and develop a scoring method to predict the outcome of OC. Patients and Methods: In this case–control study, 70 cases (with incomplete OC) and 70 controls (with complete OC) were identified. CTC images of cases and controls were independently reviewed by a single CTC radiologist. Demographic and anatomical parameters were recorded. Data was examined using descriptive linear statistics and multivariate logistic regression model. Results: On analysis, female gender (80% vs 58.6% P = 0.007), prior abdominal/pelvic surgeries (51.4% vs 14.3% P < 0.001), colonic length (187.6 ± 30.0 cm vs 163.8 ± 27.2 cm P < 0.001), and number of flexures (11.4 ± 3.1 vs 8.4 ± 2.9 P < 0.001) increased the risk for incomplete OC. No significant association was observed for increasing age (P = 0.881) and history of severe diverticulosis (P = 0.867) with incomplete OC. A scoring system to predict the outcome of OC is proposed based on CTC findings. Conclusion: Female gender, prior surgery, and increasing colonic length and tortuosity were associated with incomplete OC, whereas increasing age and history of severe diverticulosis were not. These factors may be used in the future to predict those patients who are at risk of incomplete OC.

Tu1229 Endoluminal Functional Lumen Imaging Probe (EndoFLIP) During Peroral Endoscopic Myotomy (POEM) for Achalasia Predicts Postoperative Clinical Success: A Multicenter Case-Control Study

Background: Anorectal manometry is useful in evaluating and planning treatment in patients with fecal incontinence (FI) and other disorders of defecation. Traditional water perfusion techniques are limited to 4 to 8 radial measurements obtained via a pullback technique. Three-dimensional high resolution anorectal manometry (3D HRAM) employs solid state micro transducers and can obtain 257 data points during resting, squeeze, and bear down (simulated defecation) sequences. Data are then reconstructed into a 3D format showing functional anatomy. While differences are known to exist between patients with FI and obstruction, patients with mixed disorders (of FI and obstruction) are less well described Objective: To determine physiologic differences between groups of female patients with FI, obstructed defecation, and mixed disorders. In addition to known parameters of mean resting pressure and maximal squeeze pressure, relationships between rectoanal pressure differential and percent anal relaxation were sought among the groups. Methods Retrospective chart review of 50 female patients undergoing 3D HRAM between 1/1/ 13 and 6/1/14. Physiologic values including mean resting, and maximal squeeze pressures, percent anal relaxation, and rectoanal pressure differential were recorded. Analysis of variance test, and linear regression analysis was performed as appropriate. Results:Women with mixed defecatory disorders had sphincter pressure profiles that were significantly different from patients with pure FI or obstruction (table). While rectoanal pressure differential was not different among the groups, patients with mixed disorders had a significant linear relationship between rectoanal pressure differential and percent anal relaxation that was not seen among the pure FI or obstructed groups (figure). Conclusion: Mixed defecatory disorders are associated with a unique physiologic profile that can be characterized using 3D HRAM. The mixed defecatory group demonstrates relationships between physiologic parameters that are not seen the incontinent or obstructed groups. This data will be helpful in the planning treatment regimens.