Short benign ileocolonic anastomotic strictures-management with bi-flanged metal stents:Six case reports and review of literature

BACKGROUND The endoscopic management of benign short post-anastomotic ileocolonic stricture(PAICS) that is refractory to primary and secondary treatment modalities remains challenging.The lumen-apposing metal stent(LAMS) is a novel device recently developed for therapeutic gastrointestinal endoscopy.LAMSs have demonstrated significantly better results with regard to stent migration than fully covered self-expandable metal stents(FCSEMSs).CASE SUMMARY This article presents six cases of symptomatic PAICS successfully treated with a LAMS and a review of the relevant literature.We report a life-saving technique not previously documented and the use of technology to improve patient outcomes.The six patients(median age,75 years) suffered from vomiting,constipation and recurrent abdominal pain,with symptoms starting 23-25 wk post-surgery.The median stricture length was 1.83 cm.All six patients underwent successful and uneventful bi-flanged metal stent(BFMS)-LAMS placement for benign PAICS.All patients remained asymptomatic during the three months of stent indwelling and up to a median of 7 mo after stent removal.According to the literature,the application of LAMS for PAICS is associated with a < 10% risk of migration and a < 5% risk of bleeding.Conversely,FCSEMS has a high migration rate(15%-50%).CONCLUSION The evolving role of interventional endoscopy and the availability of LAMSs provide patients with minimally invasive treatment options,allowing them to avoid more invasive surgical interventions.The BFMS(NAGI stent) is longer and larger than the prototype AXIOS-LAMS,which should be considered in the management of short ileocolonic post-anastomotic strictures longer than 10 mm and shorter than 30 mm.

Turnkey algorithmic approach for the evaluation of gastroesophageal reflux disease after bariatric surgery

Bariatric surgeries are often complicated by de-novo gastroesophageal reflux disease(GERD)or worsening of pre-existing GERD.The growing rates of obesity and bariatric surgeries worldwide are paralleled by an increase in the number of patients requiring post-surgical GERD evaluation.However,there is currently no standardized approach for the assessment of GERD in these patients.In this review,we delineate the relationship between GERD and the most common bariatric surgeries:sleeve gastrectomy(SG)and Roux-en-Y gastric bypass(RYGB),with a focus on pathophysiology,objective assessment,and underlying anatomical and motility disturbances.We suggest a stepwise algorithm to help diagnose GERD after SG and RYGB,determine the underlying cause,and guide the management and treatment.

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.

Superiority of urgent vs early endoscopic hemostasis in patients with upper gastrointestinal bleeding with high-risk stigmata

Background Guidelines recommend that all patients with upper gastrointestinal bleeding(UGIB)undergo endoscopy within 24 h.It is unclear whether a subgroup may benefit from an urgent intervention.We aimed to evaluate the influence of endoscopic hemostasis and urgent endoscopy on mortality in UGIB patients with high-risk stigmata(HRS).Methods Consecutive patients with suspected UGIB were enrolled in three Japanese hospitals with a policy to perform endoscopy within 24 h.The primary outcome was 30-day mortality.Endoscopic hemostasis and endoscopy timing(urgent,6h;early,>6h)were evaluated in a regression model adjusting for age,systolic pressure,heart rate,hemoglobin,creatinine,and variceal bleeding in multivariate analysis.A propensity score of 1:1 matched sensitivity analysis was also performed.Results HRS were present in 886 of 1966 patients,and 35 of 886(3.95%)patients perished.Median urgent-endoscopy time(n=769)was 3.0h(interquartile range[IQR],2.0–4.0 h)and early endoscopy(n紏117)was 12.0h(IQR,8.5–19.0 h).Successful endoscopic hemostasis and urgent endoscopy were significantly associated with reduced mortality in multivariable analysis(odds ratio[OR],0.22;95%confidence interval[CI],0.09–0.52;P=0.0006,and OR,0.37;95%CI,0.16–0.87;P=0.023,respectively).In a propensity-score-matched analysis of 115 pairs,adjusted comparisons showed significantly lower mortality of urgent vs early endoscopy(2.61%vs 7.83%,P<0.001).Conclusions A subgroup of UGIB patients,namely those harboring HRS,may benefit from endoscopic hemostasis and urgent endoscopy rather than early endoscopy in reducing mortality.Implementing triage scores that predict the presence of such lesions is important.

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.