Safety and efficacy of Kaffes intraductal self-expanding metal stents in the management of post-liver transplant anastomotic strictures

BACKGROUND Endoscopic management is the first-line therapy for post-liver-transplant anas-tomotic strictures.Although the optimal duration of treatment with plastic stents has been reported to be 8-12 months,data on safety and duration for metal stents in this setting is scarce.Due to limited access to endoscopic retrograde cholan-giopancreatography(ERCP)during the coronavirus disease 2019 pandemic in our centre,there was a change in practice towards increased usage and length-of-stay of the Kaffes biliary intraductal self-expanding stent in patients with suitable anatomy.This was mainly due to the theoretical benefit of Kaffes stents allowing for longer indwelling periods compared to the traditional plastic stents.METHODS Adult liver transplant recipients aged 18 years and above who underwent ERCP were retrospectively identified during a 10-year period through a database query.Unplanned admissions post-Kaffes stent insertion were identified manually through electronic and scanned medical records.The main outcome was the incidence of complications when stents were left indwelling for 3 months vs 6 months.Stent efficacy was calculated via rates of stricture recurrence between patients that had stenting courses for≤120 d or>120 d.RESULTS During the study period,a total of 66 ERCPs with Kaffes insertion were performed in 54 patients throughout their stenting course.In 33 ERCPs,the stent was removed or exchanged on a 3-month interval.No pancreatitis,perfor-ations or deaths occurred.Minor post-ERCP complications were similar between the 3-month(abdominal pain and intraductal migration)and 6-month(abdominal pain,septic shower and embedded stent)groups-6.1%vs 9.1%respectively,P=0.40.All strictures resolved at the end of the stenting course,but the stenting course was variable from 3 to 22 months.The recurrence rate for stenting courses lasting for up to 120 d was 71.4%and 21.4%for stenting courses of 121 d or over(P=0.03).There were 28 patients that were treated with a single ERCP with Kaffes,21 with removal after 120 d and 7 within 120 d.There was a significant improvement in stricture recurrence when the Kaffes was removed after 120 d when a single ERCP was used for the entire stenting course(71.0%vs 10.0%,P=0.01).CONCLUSION Utilising a single Kaffes intraductal fully-covered metal stent for at least 4 months is safe and efficacious for the management of post-transplant anastomotic strictures.

One fifth of hospitalizations for peptic ulcer-related bleeding are potentially preventable

AIM: To calculate the proportion of potentially preventable hospitalizations due to peptic ulcer disease (PUD), erosive gastritis (EG) or duodenitis (ED).

Unpacking the challenge of gastric varices: A review on indication, timing and modality of therapy

Upper gastrointestinal bleeding from oesophageal or gastric varices is an important medical condition in patients with portal hypertension.Despite the emergence of a number of novel endoscopic and radiologic therapies for oesophagogastric varices,controversy exists regarding the indication,timing and modality of therapy.The aim of this review is to provide a concise and practical evidence-based overview of these issues.

Long-term clinical outcomes of lipiodol marking using standard gastroscopy for image-guided radiotherapy of upper gastrointestinal cancers

BACKGROUND Image-guided radiotherapy(IGRT)has significantly improved the precision in which radiotherapy is delivered in cancer treatment.Typically,IGRT uses bony landmarks and key anatomical structures to locate the tumor.Recent studies have demonstrated the feasibility of peri-tumor fiducials in enabling even more accurate delineation of target and normal tissue.The use of gold coils as fiducials in gastrointestinal tumors has been extensively studied.However,placement requires expertise and specialized endoscopic ultrasound equipment.This article reports the long-term outcomes of using a standard gastroscopy to inject liquid fiducials for the treatment of oesophageal and gastric tumors with IGRT.AIM To assess the long-term outcomes of liquid fiducial-guided IGRT in a cohort of oesophageal and gastric cancer patients.METHODS A retrospective cohort study of consecutive adults with Oesophagogastric cancers referred for liquid fiducial placement before definitive/neo-adjuvant or palliative IGRT between 2013 and 2021 at a tertiary hospital in Melbourne,Australia was conducted.Up to four liquid fiducials were inserted per patient,each injection consisting of 0.2-0.5mL of a 1:1 mixture of iodized oil(Lipiodol;Aspen Pharmacare)and n-butyl 2-cyanoacrylate(Histoacryl®;B.Braun).A 23-gauge injector(Cook Medical)was used for the injection.All procedures were performed by or under the supervision of a gastroenterologist.Liquid fiducial-based IGRT(LF-IGRT)consisted of computer-assisted direct matching of the fiducial region on cone-beam computerised tomography at the time of radiotherapy.Patients received standard-IGRT(S-IGRT)if fiducial visibility was insufficient,consisting of bone match as a surrogate for tumor position.Radiotherapy was delivered to 54Gy in 30 fractions for curative patients and up to 45Gy in 15 fractions for palliative treatments.RESULTS 52 patients were referred for liquid fiducial placement within the study period.A total of 51 patients underwent liquid fiducial implantation.Of these a total of 31 patients received radiotherapy.Among these,the median age was 77.4 years with a range between 57.5 and 88.8,and 64.5%were male.Twenty-seven out of the 31 patients were able to have LF-IGRT while four had S-IGRT.There were no complications after endoscopic implantation of liquid fiducials in our cohort.The cohort overall survival(OS)post-radiotherapy was 19 mo(range 0 to 87 mo).Whilst the progression-free survival(PFS)post-radiotherapy was 13 mo(range 0 to 74 mo).For those treated with curative intent,the median OS was 22.0 mo(range 0 to 87 mo)with a PFS median of 14.0 mo(range 0 to 74 mo).Grade 3 complication rate post-radiotherapy was 29%.CONCLUSION LF-IGRT is feasible in 87.1%of patients undergoing liquid fiducial placement through standard gastroscopy injection technique.Our cohort has an overall survival of 19 mo and PFS of 13 mo.Further studies are warranted to determine the long-term outcomes of liquid-fiducial based IGRT.

High-flow oxygen via oxygenating mouthguard in short upper gastrointestinal endoscopy:A randomised controlled trial

BACKGROUND Anaesthetic care during upper gastrointestinal(GI)endoscopy has the unique challenge of maintaining ventilation and oxygenation via a shared upper airway.Supplemental oxygen is recommended by international society guidelines,however,the optimal route or rate of oxygen delivery is not known.Various oxygen delivery devices have been investigated to improve oxygenation during upper GI endoscopy,however,these are limited by commercial availability,costs and in some cases,the expertise required for insertion.Anecdotally at our centre,higher flows of supplemental oxygen can safely be delivered via an oxygenating mouthguard routinely used during upper GI endoscopic procedures.AIM To assess the incidence of hypoxaemia(SpO2<90%)in patients undergoing upper GI endoscopy receiving supplemental oxygen using an oxygenating mouthguard at 20 L/min flow compared to standard nasal cannula(SNC)at 2 L/min flow.METHODS A single centre,prospective,randomised clinical trial at two sites of an Australian tertiary hospital between October 2020 and September 2021 was conducted.Patients undergoing elective upper gastrointestinal endoscopy under deep sedation were randomised to receive supplemental oxygen via high-flow via oxygenating mouthguard(HFMG)at 20 L/min flow or SNC at 2 L/min flow.The primary outcome was the incidence of hypoxaemia of any duration measured by pulse oximetry.Intraprocedural-related,procedural-related,and sedation-related adverse events and patient-reported outcomes were also recorded.RESULTS Three hundred patients were randomised.Eight patients were excluded after randomisation.292 patients were included in the intention-to-treat analysis.The incidence of hypoxaemia was significantly reduced in those allocated HFMG.Six patients(4.4%)allocated to HFMG experienced an episode of hypoxaemia,compared to thirty-four(22.1%)patients allocated to SNC(P value<0.001).No significant difference was observed in the rates of adverse events or patient-reported outcome measures.CONCLUSION The use of HFMG offers a novel approach to reducing the incidence of hypoxaemia during short upper gastrointestinal endoscopic procedures in low-risk patients undergoing deep sedation.