Lumen-apposing metal stents in interventional endoscopy: a state-of-the-art review with focus on technical and clinical successes and complications Endoscopic transmural drainage is considered the initial treatment option for pancreatic fluid collections. Recently, lumen-apposing metal stents have been introduced for pancreatic fluid collections drainage under endoscopic ultrasound guidance, in addition to evolving data in bile duct and gallbladder drainage. We aimed to perform systematic review with reporting pooled data analysis on technical success, clinical success and complications rate of endoscopic ultrasound-guided lumen-apposing metal stents uses. A MEDLINE/PubMed and EMBASE search for all studies on lumen-apposing metal stents uses in pancreatic, biliary and other indications was conducted. Data regarding safety, complications and yield were extracted and included in the final pooled analysis. Overall, 19 articles dealing with pancreatic fluid collections drainage, 18 articles reporting on bile duct drainage and 19 articles relevant to gallbladder drainage were identified. Technical and clinical successes in all disease conditions were high and reached more than 95%. Complications rate in pancreatic fluid collections, bile duct and gallbladder drainages were 12%, 11.2% and 9.8%, respectively. Endoscopic ultrasound-guided lumen-apposing metal stents is technically feasible with very high success rate and acceptable complications rate.

Genetic polymorphisms present in IL10, IL23R, NOD2, and ATG16L1 associated with susceptibility to inflammatory bowel disease in Mexican population Objective: Ulcerative colitis and Crohn’s disease are the two clinical forms of inflammatory bowel disease (IBD). Diverse studies have shown the association of single nucleotide polymorphism (SNP) in molecules of the immune system and the occurrence of IBD. Here, several SNPs of the immune system with controversial results for their association with UC and CD were evaluated in a Mexican population. Methods: SNPs rs1800896, rs3024505 (IL-10); rs11209026 (IL23R); rs2066844, rs2066845 (NOD-2), and rs2241880 (ATG16L1) were assessed in 93 patients with IBD and 200 healthy controls by hybridization probes and quantitative PCR. Results: The AG genotype for rs1800896 was associated with an increased risk for both UC and CD (P = 0.005 and P = 0.026, respectively); whereas the AA genotype presents a negative association (P = 0.011 for UC, and 0.0038 for CD). For this SNP, G allele was associated with risk of UC (P = 0–043) but not for CD. For the rs3024505 in IL-10, T allele was associated with UC (P = 0.011). Moreover, this allele was associated with early onset of UC (P = 0.033) and with the use of steroid treatment (P = 0.019). No significant differences for NOD2 (rs2066844T and rs2066845C), IL23R (rs11209026), and ATG16L1 (rs22411880) were found between cases and controls and the homozygous TT genotype for rs2066844 and CC for rs2066845 were not observed. Conclusion: Our results show both genotypic and phenotypic associations of IL-10 SNPs with IBD but not with the other immune-related SNPs studied in this Mexican cohort.

Combining faecal calprotectin and sigmoidoscopy can predict mucosal healing in paediatric ulcerative colitis Objectives Mucosal healing is the endoscopic treatment target in inflammatory bowel disease. The treat-to-target strategy, emphasizing proactive assessment and optimizing treatment, is commonly applied in the clinical setting. Although colonoscopies are essential for this strategy to be successful, bowel preparation and sedative drugs are required for paediatric patients. We attempted to verify the usefulness of sigmoidoscopy, which is less invasive than colonoscopy, combined with faecal calprotectin, to assess mucosal healing. Methods A total of 58 paediatric patients diagnosed with ulcerative colitis and followed up at Severance Children’s Hospital from March 2015 to May 2018 were enrolled. Clinical data and laboratory findings (including faecal calprotectin and endoscopic data) were collected from medical records. The predictive power of mucosal healing of sigmoid colon and rectum (s-MH) combined with faecal calprotectin to predict mucosal healing throughout the colon was analysed. Results Among 58 patients (mean age 16.13 ± 2.88 years), 18 (31.0%) were in mucosal healing status. The median faecal calprotectin level was 486.5 μg/g. The faecal calprotectin cutoff value for predicting mucosal healing, identified using receiver-operating characteristic analyses, was 148 μg/g (area under the curve, 0.81). Sensitivity, specificity, positive predictive value, and negative predictive value of s-MH in predicting mucosal healing were 1.0, 0.82, 0.72, and 1.0, respectively. When we combined s-MH with faecal calprotectin less than the cutoff value, the sensitivity, specificity, positive predictive value, and negative predictive value were 0.56, 1.0, 1.0, and 0.83, respectively. Conclusion For patients with a low faecal calprotectin level, sigmoidoscopy might be sufficient to assess mucosal healing.

Identification of upper gastrointestinal malignancy in patients with uncomplicated dyspepsia referred under the two-week-wait cancer pathway: a single-centre, 10-year experience Introduction In the United Kingdom, the National Institute for Health and Care Excellence 2015 guidance recommend that for suspected gastric or oesophageal cancer, general practitioners consider a non-urgent, direct-access endoscopy in patients over 55 years with only uncomplicated treatment-resistant dyspepsia. In practice, patients are referred under the urgent 2-week-wait cancer pathway. Methods We compared the frequency of gastric or oesophageal carcinoma in patients referred to our centre on the 2-week-wait pathway with uncomplicated dyspepsia to those who have a combination of additional alarm symptoms. The four most common indications for endoscopy referral on the 2-week-wait pathway and all combinations of those indications were examined: Dyspepsia (‘ulcer-like’, ‘non-ulcer-like’ or ‘reflux-like’ dyspepsia), anaemia, weight loss or dysphagia. Results Over 10 years, 9012 two-week-wait gastroscopies were performed, and a tumour was identified in 256 patients (2.84%). One thousand and three hundred six gastroscopies performed for uncomplicated dyspepsia and only 6 patients (0.46%) had a tumour. Therefore, uncomplicated dyspepsia alone had a poor positive predictive value of detecting gastric or oesophageal cancer. Our findings suggest dyspepsia had no significant cumulative effect on the number of patients with anaemia or weight loss found to have a lesion at endoscopy but indeed significantly decreased the likelihood of finding a tumour in those with dysphagia. Conclusion Dyspepsia as a parameter to investigate gastric or oesophageal cancer contributes significantly to the growth in number of 2-week-wait referrals at a time when endoscopy units battle to meet demand. Our data show patients with uncomplicated dyspepsia rarely have gastric or oesophageal cancer and should not undergo endoscopies under the urgent 2-week-wait pathway.

A randomized controlled trial of the effects of local tranexamic acid on mortality, rebleeding, and recurrent endoscopy need in patients with upper gastrointestinal hemorrhage Objective Tranexamic acid (TXA) is an antifibrinolytic agent used to control bleeding in different circumstances. We conducted a randomized controlled trial to assess the efficacy and safety of locally administered TXA in upper gastrointestinal hemorrhage. Methods This single-center, double-blind, randomized controlled trial was performed in a tertiary emergency department (ED) in patients presenting with upper gastrointestinal bleeding symptoms between 2016 and 2018. The patients received either 2000 mg of 5% TXA in 100 mL of isotonic saline solution or 100 mL isotonic saline (control group) via the nasogastric route. As a composite outcome, recurrent endoscopy need, rebleeding, surgery need, recurrent admission to the ED, and mortality parameters were evaluated at the end of a one-month period. Results During the study period, 78 patients were randomized into the TXA group, and 79 patients were randomized into the isotonic saline group. The majority of the bleedings (61%) were in Forrest class 3, and the most frequent cause was peptic ulcer disease. The composite outcome occurred in 25 of the TXA patients (32.1%) and 23 of the isotonic saline patients (29.1%); no statistically significant difference was found between the groups (P = 0.690). In addition, no statistically significant differences were observed between the TXA and control groups regarding mortality (10.3 vs 12.7%; P = 0.637), recurrent ED admission (17.9 vs 12.7%; P = 0.357), or thromboembolic complications (3.8 vs 1.3%; P = 0.367). Conclusion Locally administered TXA confers no additional benefit over standard care in patients with upper gastrointestinal hemorrhage.

Higher anti-tumor necrosis factor levels are associated with perianal fistula healing and fistula closure in Crohn’s disease Objective Limited data are available regarding the relationship between anti-tumor necrosis factor (TNF) drug/antibody levels and perianal fistula outcomes in Crohn’s disease. The aims of this study were to assess the relationship between maintenance anti-TNF levels and perianal fistula outcomes. Methods This was a retrospective cross-sectional study of patients receiving maintenance adalimumab or infliximab therapy (minimum 24 weeks) for the treatment of Crohn’s disease with associated perianal fistulas, who had anti-TNF drug/antibody levels (trough for infliximab) measured within 4 weeks of clinical assessment. The primary outcome was the association of anti-TNF levels with perianal fistula healing defined as the absence of drainage. The secondary outcome was the association of anti-TNF levels with complete perianal fistula closure. Results A total of 64 patients (adalimumab, n = 35; infliximab, n = 29) were included. Patients with fistula healing had higher levels of anti-TNF vs. those without fistula healing (adalimumab: 12.6 vs. 2.7 μg/mL, P < 0.01; infliximab: 8.1 vs. 3.2 μg/mL, P < 0.01). Patients with fistula closure also had significantly higher anti-TNF levels vs. those without fistula closure (adalimumab: 14.8 vs. 5.7 μg/mL, P < 0.01; infliximab: 8.2 vs. 3.2 μg/mL, P < 0.01). For adalimumab, receiver operator characteristic analysis identified an optimum level of >6.8 μg/mL and >9.8 μg/mL for fistula healing and closure, respectively. For infliximab, receiver operator characteristic analysis identified an optimum trough level of >7.1 μg/mL for both fistula healing and closure. Conclusion Higher maintenance anti-TNF levels are associated with perianal fistula healing and closure in Crohn’s disease.

A prospective study comparing patient-reported outcomes in Crohn’s disease Background Patient reported outcomes are important in Crohn’s disease. In this prospective cohort, we investigated the performance of the Bristol Stool Form Scale (BSFS) and a visual analog scale (VAS) for abdominal pain as outcome measures in Crohn’s disease. Methods Patients with active Crohn’s disease starting glucocorticoids or anti-tumor necrosis factor were included. Before treatment and 10 weeks later we collected: clinical activity [Harvey Bradshaw Index (HBI) and Crohn’s-Disease-Activity-Index (CDAI)], serum C-reactive protein (CRP) and fecal calprotectin, and BSFS (1–7) and a 100-mm VAS based on a 7-day diary. Clinical response was defined as a reduction by at least 3 and at least 100 of HBI and CDAI, respectively. Fecal calprotectin-response and CRP-response were defined as reduction of at least 50%. Results Thirty-eight patients completed follow-up. At baseline, BSFS-parameters correlated more strongly with clinical activity (range: rs: 0.31–0.74) than with CRP (rs: −0.01 to 0.16) and fecal calprotectin (rs: 0.14–0.26). VAS scores correlated very weakly to moderately with clinical activity (rs: 0.18–0.45), and weakly to moderately with CRP (rs: 0.24–0.34) and fecal calprotectin (rs: 0.35–0.43). Changes in VAS scores correlated moderately to strongly (rs: 0.55–0.71) with changes in clinical activity, and weakly with changes in CRP and fecal calprotectin (rs: 0.21–0.35). Changes in BSFS parameters correlated weakly to moderately (rs: 0.23–0.53) with changes in clinical activity, and very weakly to weakly (rs: 0.01–0.35) with changes in CRP and fecal calprotectin. Responsiveness of VAS and BSFS was moderate to high (Guyatt’s statistic 0.41–2.17) and highly dependent on the definition of response. Conclusions The BSFS and a VAS appear to be responsive with moderate-to-strong construct validity to monitor patients with Crohn’s disease.

Simultaneous local excision of synchronous rectal polyps by transanal endoscopic microsurgery Background: The approach to surgical resection of multiple rectal lesions when endoscopic polypectomy is unsuccessful has historically been radical rectal resection with total mesorectal excision. This approach is fraught with high morbidity and mortality. We explored the possibility of performing one transanal endoscopic microsurgery procedure to resect multiple synchronous rectal lesions. Materials and methods: A retrospective analysis of all adult patients undergoing transanal endoscopic microsurgery at a single institution between 2004 and 2015. Clinical, demographic, and pathologic data were analyzed for all patients with synchronous rectal lesions that were excised via one transanal endoscopic microsurgery procedure. Results: Of the 158 patients who underwent transanal endoscopic microsurgery during the study period, 14 (8.8%) had two or more synchronous rectal lesions resected. The mean tumor size was 2.5 cm (range 0.5–3.5). The mean distance from the anal verge for the upper/proximal lesions: 10 ± 2.5 cm, and for the lower/distal lesions: 7 ± 2 cm. Mean operative time was 112 minutes (range 75–170). Median hospitalization time was 3 days (range 2–4). Two patients had urinary retention. No other complications were noted. All the transanal endoscopic microsurgery specimens were with clear margins. Conclusion: Transanal endoscopic microsurgery is a safe and feasible procedure for patients with multiple rectal lesions. We demonstrate no increase in surgical time, completeness of specimen resection, no increase in complications or hospital length or stay when compared to patients undergoing transanal endoscopic microsurgery for a single lesion.

Surgical versus endoscopic resection of large sessile duodenal and papillary lesions Background Data on the endoscopic resection of duodenal and papillary lesions less than 15 mm in size have been well supported by systematic studies. However, for large sessile lesions of the duodenum or papilla (LSL-D/P), surgery is often performed despite significant morbidity and mortality. This study aimed to compare the outcomes and costs between endoscopic and surgical resection of such lesions. Methods Patients who underwent endoscopic or surgical resection of LSL-D/P at Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University from 2013 to 2017 were retrospectively analyzed. Endoscopic and surgical outcomes and costs were compared. Results A total of 68 lesions were evaluated (47.1% of patients were male; mean lesion size 25 mm); 46 were treated by endoscopic resection, and 22 were managed by surgical resection. At the initial procedure, complete resection was achieved in 93.4%. Major complications (perforation, delayed bleeding, pancreatitis, infections and admission to the ICU) occurred in 15.3% of the endoscopic group and 22.6% of the surgical group. For recurrence at the first surveillance endoscopic examination, there was a 12.1% recurrence rate in the endoscopic group and a 5.3% recurrence rate in the surgical group (P = 0.654). Compared with surgical resection, regardless of lesion location, endoscopic resection had a shorter procedural time and hospital stay, a lower morbidity rate and was less costly. Conclusion In centers specialized in complex endoscopic resection, patients with LSL-D/P would likely benefit from advanced endoscopic management, which offers a lower morbidity profile and reduced costs.

Arterial stiffness is associated independently with liver stiffness in biopsy-proven nonalcoholic fatty liver disease: a transient elastography study Background Nonalcoholic fatty liver disease (NAFLD) has been associated with an increased arterial stiffness. However, the question as to whether an association exists between the extent of vascular and liver stiffness in patients with biopsy-proven NAFLD remains open. In this study, we sought to investigate whether pulse wave velocity (PWV) and augmentation index (AIx) – two common indices of arterial stiffness – are associated with (a) liver stiffness measurement (LSM) on transient elastography (TE) and (b) histological liver fibrosis. Patients and methods We examined 125 patients with biopsy-proven NAFLD and 55 age-matched and sex-matched controls. Arterial stiffness of the brachial artery was measured using a Mobil-O-Graph arteriography system. LSM was assessed using TE, whereas the presence of advanced fibrosis (F ≥ 3) was determined on histology. Results Patients with NAFLD had higher PWV [median: 7.2 (6.3−8.2) and 6.2 (5.5−6.7) m/s, respectively, P < 0.001] and AIx (mean: 21.3 ± 13.5 and 17.2 ± 11.9%, respectively, P=0.01) compared with the controls. LSM showed positive correlations with both PWV (ρ = 0.300; P<0.01) and AIx (ρ = 0.223, P = 0.02). Both indices of arterial stiffness were higher in patients with advanced fibrosis than in those with nonadvanced fibrosis (F ≤ 2). Conclusion The severity of arterial and liver stiffness increases in parallel in patients with biopsy-proven NAFLD. Systematic risk assessment for reducing arterial stiffness is recommended in the presence of TE-determined advanced fibrosis.