Endoscopic balloon catheter dilatation via retrograde or static technique is safe and effective for cricopharyngeal dysfunction

To evaluate the safety and efficacy of upper esophageal sphincter (UES) dilatation for cricopharyngeal (CP) dysfunction. To determine if: (1) indication for dilatation; or (2) technique of dilatation correlated with symptom improvement. METHODSAll balloon dilatations performed at our institution from over a 3-year period were retrospectively analyzed for demographics, indication and dilatation site. All dilatations involving the UES underwent further review to determine efficacy, complications, and factors that predict success. Dilatation technique was separated into static (stationary balloon distention) and retrograde (brusque pull-back of a fully distended balloon across the UES). RESULTSFour hundred and eighty-eight dilatations were reviewed. Thirty-one patients were identified who underwent UES dilatation. Median age was 63 years (range 27-81) and 55% of patients were male. Indications included dysphagia (28 patients), globus sensation with evidence of UES dysfunction (2 patients) and obstruction to echocardiography probe with cricopharyngeal (CP) bar (1 patient). There was evidence of concurrent oropharyngeal dysfunction in 16 patients (52%) and a small Zenker’s diverticula (≤ 2 cm) in 7 patients (23%). Dilator size ranged from 15 mm to 20 mm. Of the 31 patients, 11 had dilatation of other esophageal segments concurrently with UES dilatation and 20 had UES dilatation alone. Follow-up was available for 24 patients for a median of 2.5 mo (interquartile range 1-10 mo), of whom 19 reported symptomatic improvement (79%). For patients undergoing UES dilatation alone, follow-up was available for 15 patients, 12 of whom reported improvement (80%). Nineteen patients underwent retrograde dilatation (84% response) while 5 patients had static dilatation (60% response); however, there was no significant difference in symptom improvement between the techniques (P = 0.5). Successful symptom resolution was also not significantly affected by dilator size, oropharyngeal dysfunction, Zenker’s diverticulum, age or gender (P > 0.05). The only complication noted was uvular edema and a shallow ulcer after static dilatation in one patient, which resolved spontaneously and did not require hospital admission. CONCLUSIONUES dilatation with a through-the-scope balloon by either static or retrograde technique is safe and effective for the treatment of dysphagia due to CP dysfunction. To our knowledge, this is the first study evaluating retrograde balloon dilatation of the UES.

End-stage renal disease is associated with increased post endoscopic retrograde cholangiopancreatography adverse events in hospitalized patients

AIM To determine if end-stage renal disease (ESRD) is a risk factor for post endoscopic retrograde cholangio-pancreatography (ERCP) adverse events (AEs). METHODS We performed a retrospective cohort study using the Nationwide Inpatient Sample (NIS) 2011-2013. We identified adult patients who underwent ERCP using the International Classification of Diseases 9^(th) Revision (ICD-9-CM). Included patients were divided into three groups: ESRD, chronic kidney disease (CKD), and control. The primary outcome was post-ERCP AEs including pancreatitis, bleeding, and perforation determined based on specific ICD-9-CM codes. Secondary outcomes were length of hospital stay, in-hospital mortality, and admission cost. AEs and mortality were compared using multivariate logistic regression analysis.RESULTS There were 492175 discharges that underwent ERCP during the 3 years. The ESRD and CKD groups contained 7347 and 39403 hospitalizations respectively, whereas the control group had 445424 hospitalizations. Post-ERCP pancreatitis (PEP) was significantly higher in the ESRD group (8.3%) compared to the control group (4.6%) with adjusted odd ratio (aOR) = 1.7 (95% CI: 1.4-2.1, ~aP < 0.001). ESRD was associated with significantly higher ERCP-related bleeding (5.1%) compared to the control group 1.5% (aOR = 1.86, 95%CI: 1.4-2.4, ~aP < 0.001). ESRD had increased hospital mortality 7.1% vs 1.15% in the control OR = 6.6 (95%CI: 5.3-8.2, ~aP < 0.001), longer hospital stay with adjusted mean difference (aMD) = 5.9 d (95% CI: 5.0-6.7 d, ~aP < 0.001) and higher hospitalization charges aMD = $+82064 (95%CI: $68221-$95906, ~aP < 0.001). CONCLUSION ESRD is a risk factor for post-ERCP AEs and is associated with higher hospital mortality. Careful selection and close monitoring is warranted to improve outcomes.

Percutaneous transluminal angioplasty balloons for endoscopic ultrasound-guided pancreatic duct interventions

BACKGROUND Endoscopic ultrasound(EUS)-guided main pancreatic duct(PD)access may be used when conventional endoscopic retrograde cholangiopancreatography(ERCP)techniques fail.The use of a percutaneous transluminal angioplasty balloon(PTAB),originally developed for vascular interventions,can be used to facilitate transmural(e.g.,transgastric)PD access and to dilate high-grade pancreatic strictures.AIM To describe the technique,efficacy,and safety of PTABs for EUS-guided PD interventions.METHODS Patients who underwent EUS with use of a PTAB from March 2011 to August 2021 were retrospectively identified from a tertiary care medical center supply database.PTABs included 3-4 French angioplasty catheters with 3-4 mm balloons designed to use over a 0.018-inch guidewire.The primary outcome was technical success.Secondary outcomes included incidence of adverse events(AEs)and need for early reintervention.RESULTS A total of 23 patients were identified(48%female,mean age 55.8 years).Chronic pancreatitis was the underlying etiology in 13(56.5%)patients,surgically altered anatomy(SAA)with stricture in 7(30.4%),and SAA with post-operative leak in 3(13.0%).Technical success was achieved in 20(87%)cases.Overall AE rate was 26%(n=6).All AEs were mild and included 1 pancreatic duct leak,2 cases of post-procedure pancreatitis,and 3 admissions for post-procedural pain.No patients required early re-intervention.CONCLUSION EUS-guided use of PTABs for PD access and/or stricture management is feasible with an acceptable safety profile and can be considered in patients when conventional ERCP cannulation fails.

Endoscopic ultrasound-guided injectable therapy for pancreatic cancer:A systematic review

BACKGROUND Given the low survival rate in pancreatic cancer,new therapeutic techniques have been explored,especially for unresectable or borderline resectable disease.Endoscopic ultrasound(EUS)provides real-time imaging and minimally invasive access for local and targeted injection of anti-tumor agents directly into the pancreatic tumor.Limited studies have been reported using this technique for the treatment of pancreatic ductal adenocarcinoma(PDAC).AIM To evaluate the progress made with EUS-guided injectable therapies in the treatment of PDAC.METHODS All original articles published in English until July 15,2021,were retrieved via a library-assisted literature search from Ovid Evidence-Based Medicine Reviews and Scopus databases.Reference lists were reviewed to identify additional relevant articles.Prospective clinical studies evaluating the use of EUS-guided injectable therapies in PDAC were included.Studies primarily directed at non-EUS injectable therapies and other malignancies were excluded.Retrieved manuscripts were reviewed descriptively with on critical appraisal of published studies based on their methods and outcome measures such as safety,feasibility,and effectiveness in terms of tumor response and survival.Heterogeneity in data outcomes and therapeutic techniques limited the ability to perform comparative statistical analysis.RESULTS A total of thirteen articles(503 patients)were found eligible for inclusion.The EUS-injectable therapies used were heterogeneous among the studies consisting of immunotherapy(n=5)in 59 patients,chemotherapy(n=1)in 36 patients,and viral and other biological therapies(n=7)in 408 patients.Eleven of the studies reviewed were single armed while two were double armed with one randomized trial and one non-randomized comparative study.Overall,the included studies demonstrated EUS-guided injectable therapies to be safe and feasible with different agents as monotherapy or in conjunction with other modalities.Promising results were also observed regarding their efficacy and survival parameters in patients with PDAC.CONCLUSION EUS-guided injectable therapies,including immunotherapy,chemotherapy,and viral or other biological therapies have shown minimal adverse events and potential efficacy in the treatment of PDAC.Comparative studies,including controlled trials,are required to confirm these results in order to offer novel EUS-based treatment options for patients with PDAC.

Endoscopic pancreatic duct stenting for pain palliation in selected pancreatic cancer patients:a systematic review and meta-analysis

Background Abdominal pain is a debilitating symptom affecting-80%of pancreatic cancer(PC)patients.Pancreatic duct(PD)decompression has been reported to alleviate this pain,although this practice has not been widely adopted.We aimed to evaluate the role,efficacy,and safety of endoscopic PD decompression for palliation of PC post-prandial obstructive-type pain.Methods A systematic review until 7 October 2020 was performed.Two independent reviewers selected studies,extracted data,and assessed the methodological quality.Results We identified 12 publications with a total of 192 patients with PC presenting with abdominal pain,in whom PD decompression was attempted,and was successful in 167 patients(mean age 62.5 years,58.7%males).The use of plastic stents was reported in 159 patients(95.2%).All included studies reported partial or complete improvement in pain levels after PD stenting,with an improvement rate of 93%(95%confidence interval,79%-100%).The mean duration of pain improvement was 94616 days.Endoscopic retrograde cholangiopancreatography(ERCP)-related adverse events(AEs)were postsphincterotomy bleeding(1.8%),post-ERCP pancreatitis(0.6%),and hemosuccus pancreaticus(0.6%).AEs were not reported in two patients who underwent endoscopic ultrasound-guided PD decompression.In the 167 patients with technical success,the stent-migration and stent-occlusion rates were 3.6%and 3.0%,respectively.No AE-related mortality was reported.The methodological quality assessment showed the majority of the studies having low or unclear quality.Conclusion In this exploratory analysis,endoscopic PD drainage may be an effective and safe option in selected patients for the management of obstructive-type PC pain.However,a randomized–controlled trial is needed to delineate the role of this invasive practice.

Endo-anesthesia:a primer

Gastrointestinal(GI)endoscopy has witnessed a Cambrian explosion of techniques,indications,and expanding target populations.GI endoscopy encompasses traditional domains that include preventive measures,palliation,as alternative therapies in patients with prohibitive risks of more invasive procedures,and indicated primary treatments.But,it has expanded to include therapeutic and diagnostic interventional endosonography,luminal endoscopic resection,third space endotherapy,endohepatology,and endobariatrics.The lines between surgery and endoscopy are blurred on many occasions within this paradigm.Moreover,patients with high degrees of co-morbidity and complex physiology require more nuanced peri-endoscopic management.The rising demand for endoscopy services has resulted in the development of endoscopy referral centers that offer these invasive procedures as directly booked referrals for regional and rural patients.This further necessitates specialized programs to ensure appropriate evaluation,risk stratification,and optimization for safe sedation and general anesthesia if needed.This landscape is conducive to the organic evolution of endo-anesthesia to meet the needs of these focused and evolving practices.In this primer,we delineate important aspects of endo-anesthesia care and provide relevant clinical and logistical considerations pertaining to the breadth of procedures.

Development of a narrow-band imaging classification to reduce the need for routine biopsies of gastric polyps

Background Most incidental gastric polyps identified during upper endoscopy are considered low-risk.However,current guidelines recommend sampling all gastric polyps for histopathologic analysis.We aimed to devise a simple narrow-band imaging(NBI)classification to reduce the need for routine biopsies of low-risk gastric polyps.Methods Pairs of NBI and white-light images were collected from 73 gastric polyps for which concurrent histopathologic diagnosis was available.A diagnostic accuracy cohort study was performed.Two blinded endoscopists independently analysed NBI features of each polyp for color,vessel pattern,surface pattern,and any combinations thereof to develop a classification scheme to differentiate low-risk polyps(fundic-gland or hyperplastic)from high-risk polyps(adenomatous or adenocarcinoma)and fundic-gland polyps(FGPs)from non-FGPs.Results An isolated lacy vessel pattern and a homogenous absence of surface pattern successfully differentiated low-risk from high-risk gastric polyps.Combining both descriptors into a single algorithm resulted in a negative predictive value(NPV)of 100%[95%confidence interval(CI):100%–100%],positive predictive value(PPV)of 13.7%(95%CI:2.6–24.8),sensitivity of 100%(95%CI:100%–100%),and specificity of 53.7%(95%CI:45.3%–62.0%)for high-risk polyps.This would reduce the number of polyps requiring biopsy by 50%,while still capturing all high-risk polyps.Regarding FGPs,using a rule not to biopsy polyps with isolated lacy vessels resulted in a 94.9%NPV(95%CI:89.2%–100%),63.2%PPV(95%CI:47.2%–79.2%),94.8%sensitivity(95%CI:89.5%–100%),and 63.6%specificity(95%CI:51.3%–76.0%)for non-FGPs.Conclusion In this derivation cohort study,NBI is helpful for differentiating between high-risk and low-risk gastric polyps,thereby reducing the need for routine sampling of low-risk polyps.These results need to be validated in a separate test population.

Celiac artery mesenteric fat measurement with endosonography(CAMEUS)reliably correlates with obesity and related comorbidities

Background:Visceral fat represents a metabolically active entity linked to adverse metabolic sequelae of obesity.We aimed to determine if celiac artery mesenteric fat thickness can be reliably measured during endoscopic ultrasound(EUS),and if these measurements correlate with metabolic disease burden.Methods:This was a retrospective analysis of patients who underwent celiac artery mesenteric fat measurement with endosonography(CAMEUS)measurement at a tertiary referral center,and a validation prospective trial of patients with obesity and nonalcoholic steatohepatitis who received paired EUS exams with CAMEUS measurement before and after six months of treatment with an intragastric balloon.Results:CAMEUS was measured in 154 patients[56.5%females,mean age 56.5±18.0years,body mass index(BMI)29.8±8.0 kg/m^(2)]and was estimated at 14.7±6.5mm.CAMEUS better correlated with the presence of non-alcoholic fatty liver disease(NAFLD)(R^(2)=0.248,P<0.001)than BMI(R^(2)=0.153,P<0.001),and significantly correlated with metabolic parameters and diseases.After six months of intragastric balloon placement,the prospective cohort experienced 11.7%total body weight loss,1.3 points improvement in hemoglobin A1c(P=0.001),and a 29.4%average decrease in CAMEUS(−6.4±5.2mm,P<0.001).CAMEUS correlated with improvements in weight(R^(2)=0.368),aspartate aminotransferase to platelet ratio index(R^(2)=0.138),and NAFLD activity score(R^(2)=0.156)(all P<0.05).Conclusions:CAMEUS is a novel measure that is significantly correlated with critical metabolic indices and can be easily captured during routine EUS to risk-stratify susceptible patients.This station could allow for EUS access to sampling and therapeutics of this metabolic region.