Tom Moreels

An international multicenter study comparing EUS-guided pancreatic duct drainage with enteroscopy-assisted endoscopic retrograde pancreatography after Whipple surgery

BACKGROUND AND AIMSnEndoscopic management of post-Whipple pancreatic adverse events (AEs) with enteroscopy-assisted endoscopic retrograde pancreatography (e-ERP) is associated with high failure rates. EUS-guided pancreatic duct drainage (EUS-PDD) has shown promising results; however, no comparative data have been done for these 2 modalities. The goal of this study is to compare EUS-PDD with e-ERP in terms of technical success (PDD through dilation/stent), clinical success (improvement/resolution of pancreatic-type symptoms), and AE rates in patients with post-Whipple anatomy.nnnMETHODSnThis is an international multicenter comparative retrospective study at 7 tertiary centers (2 United States, 2 European, 2 Asian, and 1 South American). All consecutive patients who underwent EUS-PDD or e-ERP between January 2010 and August 2015 were included.nnnRESULTSnIn total, 66 patients (mean age, 57 years; 48% women) and 75 procedures were identified with 40 in EUS-PDD and 35 in e-ERP. Technical success was achieved in 92.5% of procedures in the EUS-PDD group compared with 20% of procedures in the e-ERP group (OR, 49.3; Pxa0< .001). Clinical success (per patient) was attained in 87.5% of procedures in the EUS-PDD group compared with 23.1% in the e-ERP group (OR, 23.3; Pxa0< .001). AEs occurred more commonly in the EUS-PDD group (35% vs 2.9%, Pxa0< .001). However, all AEs were rated as mild or moderate. Procedure time and length of stay were not significantly different between the 2 groups.nnnCONCLUSIONSnEUS-PDD is superior to e-ERP in post-Whipple anatomy in terms of efficacy with acceptable safety. As such, EUS-PDD should be considered as a potential first-line treatment in post-pancreaticoduodenectomy anatomy when necessary expertise is available.

Cerebrovascular events in inflammatory bowel disease patients treated with anti-tumour necrosis factor alpha agents.

BACKGROUND AND AIMSnCerebrovascular accidents [CVA] have rarely been reported in inflammatory bowel disease [IBD] patients treated with anti-tumour necrosis alpha [anti-TNF alpha] agents. Our aim here was to describe the clinical course of CVA in these patients.nnnMETHODSnThis was a European Crohns and Colitis Organisation [ECCO] retrospective observational study, performed as part of the CONFER [COllaborative Network For Exceptionally Rare case reports] project. A call to all ECCO members was made to report on IBD patients afflicted with CVA during treatment with anti-TNF alpha agents. Clinical data were recorded in a standardised case report form and analysed for event association with anti-TNF alpha treatment.nnnRESULTSnA total of 19 patients were identified from 16 centres: 14 had Crohns disease, four ulcerative colitis and one IBD colitis unclassified [median age at diagnosis: 38.0 years, range: 18.6-62.5]. Patients received anti-TNF alpha for a median duration of 11.8 months [range: 0-62] at CVA onset; seven had previously been treated with at least one other anti-TNF alpha agent. Complete neurological recovery was observed in 16 patients. Anti-TNF alpha was discontinued in 16/19 patients. However, recurrent CVA or neurological deterioration was not observed in any of the 11 patients who received anti-TNF alpha after CVA [eight resumed after temporary cessation, three continued without interruption] for a median follow-up of 39.8 months [range: 5.6-98.2].nnnCONCLUSIONnThese preliminary findings do not unequivocally indicate a causal role of anti-TNF alpha in CVA complicating IBD. Resuming or continuing anti-TNF alpha in IBD patients with CVA may be feasible and safe in selected cases, but careful weighing of IBD activity versus neurological status is prudent.

Therapeutic enteroscopy using a new single-balloon enteroscope: a case series

Background and study aims: Balloon-assisted enteroscopy allows therapeutic intervention in the small bowel, and even of the biliopancreatic system in patients with altered anatomy. However, the conventional single-balloon enteroscope (SBE) has limited therapeutic use because of its small-caliber working channel and the lack of an additional water jet channel. The new single-balloon enteroscope prototype XSIF-180JY has been developed to overcome these problems. We present experience with use of the new SBE prototype during 14 therapeutic endoscopy procedures, which illustrates its advantages. Patients and methods: During a 2-month period, 16 SBE procedures were performed (2 antegrade, 2 retrograde and 12 ERCP procedures) using the XSIF-180JY prototype, 14 of which were done with therapeutic intent. Results: The XSIF-180JY SBE allowed deep enteroscopy with balloon dilation and multiple intestinal polypectomies. Moreover, 14 ERCP procedures were successfully performed in 12 patients with Roux-en-Y altered anatomy. Sphincterotomy, balloon dilation, stone extraction and 7 Fr plastic stent placement were performed through the 3.2-mm working channel. The additional water jet was useful for flushing away stone fragments from the intrahepatic bile ducts and the retrieval basket and for flushing away blood from a bleeding sphincterotomy. No complications related to the enteroscope were encountered. Conclusions: The new therapeutic XSIF-180JY SBE permitted therapeutic enteroscopy and ERCP through its 3.2-mm working channel and the additional water jet channel proved useful in flushing away biliary stones and blood without the need to clear the working channel. This newly developed SBE has the advantage of a larger working channel and an additional water jet, improving therapeutic enteroscopy.

What is the advantage of a passive bending segment in balloon enteroscopy-assisted ERCP?

Yane et al. recently published an article on the usefulness of short-type singleballoon enteroscope (SBE) prototypes to perform balloon enteroscope-assisted endoscopic retrograde cholangiopancreatography (ERCP) [1]. They used three different short-type SBEs (152 cm), and two of these were equipped with passive bending and force transmission (SIFY0004-V01 and SIF-Y0015) to perform ERCP in patients with Billroth II gastrectomy, pancreaticoduodenectomy, shortlimb Roux-en-Y gastrectomy, and hepaticojejunostomy. Factors determining therapeutic success were type of surgical reconstruction, second attempt ERCP, and the use of a transparent cap [1]. However, the possible advantage of the passive bending segment with force transmission is not mentioned. A passive bending segment may help to overcome sharp angulations when introducing an endoscope into a tortuous intestinal limb, an endoscopic feature that is difficult to measure [2]. We recently performed a successful SBEassisted ERCP using the SIF-Y0011 prototype in a patient with long-limb Roux-enY gastric bypass. The SIF-Y0011 prototype is a 200 cm long SBE with a 3.2mm working channel and a passive bending segment with force transmission near the 20 cm marker. A 43-year-old woman was referred for urgent SBE-assisted ERCP because of biliary leak from the cystic stump after recent cholecystectomy. She had undergone bariatric longlimb Roux-en-Y gastric bypass 1 year earlier. We performed the initial ERCP using the SIF-Y0011 prototype, and treated the biliary leak with sphincterotomy and placement of a 7 Fr plastic stent in the common bile duct. The patient recovered well from the biliary leak. Abdominal radiography 3 months later confirmed the presence of the biliary stent, which we tried to remove using the conventional SIF-Q180 SBE without the passive bending feature. However, after trying for 60 minutes to remove the stent, we were not able to reach the major papilla through the tortuous afferent limb. We rescheduled the procedure using the SIF-Y0011 prototype, which allowed us to reach the papilla and pull out the plastic biliary stent, which had been in place for 7 months. The direct advantage of a passive bending segment with force transmission is difficult to measure in a single endoscopy procedure. However, this case clearly illustrates the benefit of the passive bending feature of the SBE to overcome difficult intestinal angulations. We attempted three SBE-assisted ERCP procedures in the same patient with longlimb Roux-en-Y gastric bypass, and only those performed using the SIF-Y0011 SBE were successful, illustrating the usefulness of passive bending with force transmission. Reaching the biliary tract remains a challenge in patients with altered anatomy, especially in long-limb Roux-en-Y [3]. New developments in balloon enteroscopy aim to increase the success rate of therapeutic ERCP [4]. Passive bending with force transmission represents another endoscopic improvement [2]. It would be interesting to know whether Yane et al. also studied the role of passive bending in their recently published series [1]. Competing interests

Oral budesonide in gastrointestinal and liver disease: A practical guide for the clinician: Optimising therapy with budesonide

Oral budesonide is a second‐generation steroid that allows local, selective treatment of the gastrointestinal tract and the liver, minimizing systemic exposure. The results of randomized trials comparing budesonide versus placebo or active comparators have led to expert recommendations that budesonide be used to treat mild or moderate active ileocecal Crohns disease, microscopic colitis (including both collagenous and lymphocytic colitis), ulcerative colitis, and non‐cirrhotic autoimmune hepatitis. The mechanism of budesonide action obviates the need for dose tapering due to safety reasons after induction therapy. Where low‐dose budesonide is used to maintain remission, usually in microscopic colitis, it does not appear to have adverse safety implications other than slight reductions in cortisol levels on rare occasions. As a gut‐selective and liver‐selective corticosteroid, budesonide offers an appealing alternative to conventional systemic glucocorticoids in diseases of these organs.

Comparative analysis of ESD versus EMR in a large European series of non-ampullary superficial duodenal tumors

Background and study aimsu2002 The choice of endoscopic submucosal dissection (ESD) or endoscopic mucosal resection (EMR) in non-ampullary superficial duodenal tumors (NASDTs) is challenging and the benefits of ESD remain unclear. The aim was to comparatively analyze the feasibility, outcomes and safety of these techniques in these lesions. Patients and methods u2002This is an observational and retrospective study. All consecutive patients presenting with NASDTs who underwent EMR or ESD between 2005 and 2017 were included. The following main outcomes were comparatively evaluated: en-bloc and complete (R0) resection rates, and local recurrence. Secondary outcomes were perforation and delayed bleeding. Resultsu2002 One hundred sixty-six tumors in 150 patients (age: 66 years, range: 31u200a–u200a83, 42.7u200a% males) were resected by ESD (nu200a=u200a37) or EMR (nu200a=u200a129) and included. The median procedure time (81 vs. 50u200amin, P u200a=u200a0.007) and tumor size (25 vs. 20u200amm, P u200a=u200a0.01) were higher in the ESD group.u200aThe global malignancy rate was 50.3u200a%. There were no differences in en-bloc resection (29.7u200a% vs. 44.2u200a%, P u200a=u200a0.115), complete resection (19.4u200a% vs. 35.5u200a%, P u200a=u200a0.069), and local recurrence (14.7u200a% vs. 16.7u200a%, P u200a=u200a0.788) rates. Tumor size was associated with recurrence (28 vs. 20u200amm, P u200a=u200a0.008), with a median follow-up of 6.5 months. Focal recurrence (nu200a=u200a22, 13.3u200a%) was treated endoscopically in 86.4u200a%. En-bloc resection in the ESD group was comparable in large (u200a≥u200a20u200amm) and small lesions (27.6u200a% vs. 37.5u200a%, P u200a=u200a0.587), while this outcome decreased significantly in large lesions resected by EMR (17.4u200a% vs. 75u200a%, P u200a<u200a0.001). Nine perforations were confirmed in 6 lesions (16.2u200a%) resected by ESD and 3 (2.3 %) by EMR ( P u200a=u200a0.001). Endoscopic therapy was successful in all but 1 patient (88.9u200a%) presenting with a delayed perforation. Conclusionsu2002 ESD may be an alternative to EMR and surgery in selected NASDTs, such as large duodenal tumors where EMR achieves low en-bloc resection rates and the local recurrence may be higher. However, this technique may have a higher risk of perforations.

ESD versus EMR in non-ampullary superficial duodenal tumors: a systematic review and meta-analysis

Background and study aims u2002Endoscopic submucosal dissection (ESD) has been developed as an option for treatment of esophageal, gastric and colorectal lesions. However, there is no consensus on the role of ESD in duodenal tumors. Methods u2002This systematic review and meta-analysis compared ESD and endoscopic mucosal resection (EMR) in sporadic non-ampullary superficial duodenal tumors (NASDTs), including local experience. We conducted a search in PubMed, Scopus and the Cochrane library up to August 2017 to identify studies that compared both techniques reporting at least one main outcome (en-bloc/complete resection, local recurrence). Pooled outcomes were calculated under fixed and random-effect models. Subgroup analyses were conducted. Results u2002A total of 753 patients presenting with 784 NASDTs (242 ESD, 542 EMR) in 14 studies were included. Tumor size (MD: 5.88, [CI95u200a%: 2.15, 9.62], P u200a=u200a0.002, I 2 u200a=u200a79u200a%) and procedure time (MD: 65.65, [CI95u200a%: 40.39, 90.92], P u200a<u200a0.00001, I 2 u200a=u200a88u200a%) were greater in the ESD group.u200aEn-bloc resection rate was significantly higher in Asian studies (OR: 2.16 [CI95u200a%: 1.15, 4.08], P u200a=u200a0.02, I 2 : 46u200a%). ESD provided a higher complete resection rate (OR: 1.63 [I95u200a%: 1.06, 2.50], P u200a=u200a0.03, I 2 : 59u200a%), but there was no risk difference in the risk of local recurrence (RD: –u200a0.03 [CI95u200a%: –u200a0.07, 0.01], P u200a=u200a0.15, I 2 : 0u200a%) or delayed bleeding. ESD was associated with an increased number of intraoperative perforations [RD: 0.12 (CI95u200a%: 0.04, 0.20), P u200a=u200a0.002, I 2 : 56u200a%] and emergency surgery for delayed perforations. The inclusion of eligible studies was limited to retrospective series with inequalities in comparative groups. Conclusions u2002Duodenal ESD for NASDTs may achieve higher en-bloc and complete resections at the expense of a greater perforation rate compared to EMR. The impact on local recurrence remains uncertain.

Risk factors for conversion to snare resection during colorectal endoscopic submucosal dissection in an expert Western center

BACKGROUNDnThere are limited data regarding the risk factors and consequences of conversion to endoscopic mucosal resection (rescue EMR) during colorectal endoscopic submucosal dissection (ESD) in Western centers.nnnMETHODSnThis was a retrospective analysis of a prospectively collected database, from which 225 consecutive ESDs performed between 2013 and 2017 were selected. Of the included patients, 39 (18.6u200a%) required rescue EMR. Pre- and per-procedure characteristics were evaluated to determine the features associated with the need for rescue EMR. Outcomes and complications were also assessed.nnnRESULTSn210 patients were included, with median tumor size of 40u200amm (range 20u200a-u200a110) and most tumors being in a non-rectal location (66.2u200a%). When compared with full ESD, rescue EMR was significantly associated with lower rates of en bloc resection (43.6u200a% vs. 100u200a%) and complete resection (R0 status; 28.2u200a% vs. 88.9u200a%), and with a higher rate of recurrence (5.1u200a% vs. 0u200a%) and more need for surgery (15.4u200a% vs. 3.5u200a%). In multivariable analysis, non-lifting (adjusted odds ratio [ORa] 3.06, 95u200a% confidence interval [CI] 1.23u200a-u200a7.66; Pu200a=u200a0.02), nongranular-type laterally spreading tumor (LST-NG; ORa 2.56, 95u200a%CI 1.10u200a-u200a5.99; Pu200a=u200a0.03), and difficult retroflexion (OR 3.22, 95u200a%CI 1.01u200a-u200a10.28; Pu200a=u200a0.049) were independent risk factors associated with conversion to rescue EMR, while tumor size and location were not.nnnCONCLUSIONSnDuring ESD, the presence of poor lifting, LST-NG morphology, and a difficult retroflexed approach were factors associated with the need to convert to rescue EMR. Conversion to rescue EMR remains a valuable strategy.

The economic impact of using single-operator cholangioscopy for the treatment of difficult bile duct stones and diagnosis of indeterminate bile duct strictures

BACKGROUND AND STUDY AIMnConventional endoscopic retrograde cholangiopancreatography (ERCP) combines endoscopy and radiography to diagnose and treat pathological conditions of the bile duct. The aim of the present analysis was to evaluate the clinical and economic impact of the use of single-operator intraductal cholangioscopy (IDC), which allows for direct visualization of the bile duct, as an alternative to ERCP for the treatment of difficult bile duct stones and the diagnosis of bile duct strictures.nnnPATIENTS AND METHODSnThe clinical and economic consequences of single-operator IDC use were evaluated using two decision-tree models, one for management of difficult-to-remove stones and one for stricture diagnosis. A hospital perspective was adopted. Data to populate the models were derived from two Belgian hospitals that specialize in endoscopic procedures of the bile duct. Overall, the examined population consisted of 62 patients with difficult stones and 49 patients with indeterminate strictures.nnnRESULTSnIn the model for difficult stone management, the use of IDC determined a decrease in the number of procedures (-u200a27u200a% relative reduction) and costs (-u200a€73u2005000;u200a-u200a11u200a% relative reduction) when compared with ERCP. In the model for stricture diagnosis, the use of IDC determined a decrease in the number of procedures (-u200a31u200a% relative reduction) and costs (-u200a€13u2005000;u200a-u200a5u200a% relative variation) when compared with ERCP.nnnCONCLUSIONSnThe single-operator IDC system performed better than ERCP for the treatment of difficult bile duct stones and the diagnosis of bile duct strictures, and reduced the overall expenditure in hospitals in Belgium.

Management of long post-radiation esophageal strictures by means of endoscopic submucosal dissection.

We read with interest the article by Perbtani et al [1], presenting the endoscopic management of 6 patients with complete post-radiation esophageal obliteration. Four patients presented short strictures (<3cm), and were managed with combined antegrade-retrograde approach, with the help of a 19-gauge endoscopic ultrasound (EUS) needle, under fluoroscopic guidance and translumination. In 2 cases with longer strictures (4cm and 5cm, respectively), the authors successfully used a submucosal tunneling technique with repeat injections of saline/indigo carmine and dissection with a T-Type Hybrid Knife (ERBE). The presentation of this case series is followed by a review of the literature concerning all published techniques for the management of complete post-radiation esophageal strictures. In most reports the strictures were short (<3cm). Devices/ techniques used for recanalization included the following: needle knife, guidewire, balloon dilation, forceps, EUS needle, sclerotherapy needle and the T-Type Knife. What we would like to comment on is the advantage of endoscopic submucosal dissection in the management of long strictures. Such a technique offers direct visualization of the recanalization procedure, in contrast to the aforementioned techniques, which are blind, with high risk of perforation and injury to surrounding critical structures. We have previously published a report on a case of total esophageal recanalization [2], which was not included in the review by Perbtani et al, in a patient with a postradiation stricture extending from the hypopharynx to the Z line (>25cm in length). In brief, a standard endoscope was advanced through the preexisting gastrostomy track; the submucosal space separating the muscular layers of the esophagus was enlarged by injection of a mixture of a gelatin plasma substitute methylene blue and epinephrine; and progression and recanalization toward the upper esophagus was obtained with a 1.5-mm Dual Knife (Olympus) using spray coagulation (ERBE, VIO300) under permanent visual control. Antegrade transillumination was necessary only for the proximal 2cm of the hypopharynx due to altered anatomy. At 2 years of follow up the patient is able to eat mixed meals and undergoes periodic dilations of the upper esophagus and hypopharynx. Endoscopists should be aware of this technique, which based on our experience is safer than blind dissection and it is not limited by the length of the stricture.