McDonald, Nicholas

Background Cold snare endoscopic mucosal resection (CS-EMR) can reduce the risks associated with electrocautery during colon polyp resection. Data on efficacy are variable. This systematic review and meta-analysis aimed to estimate the pooled efficacy and safety rates of CS-EMR. Methods We conducted a comprehensive literature search of multiple databases, from inception to March 2023, for studies addressing outcomes of CS-EMR for colon polyps. The weighted pooled estimates with 95 %CIs were calculated using the random effects model. I2 statistics were used to evaluate heterogeneity. Results 4137 articles were reviewed, and 16 studies, including 2592 polyps in 1922 patients (51.4 % female), were included. Overall, 54.4 % of polyps were adenomas, 45 % were sessile serrated lesions (SSLs), and 0.6 % were invasive carcinomas. Polyp recurrence after CS-EMR was 6.7 % (95 %CI 2.4 %–17.4 %, I2 = 94 %). The recurrence rate was 12.3 % (95 %CI 3.4 %–35.7 %, I2 = 94 %) for polyps ≥ 20 mm, 17.1 % (95 %CI 4.6 %–46.7 %, I2 = 93 %) for adenomas, and 5.7 % (95 %CI 3.2 %–9.9 %, I2 = 50 %) for SSLs. The pooled intraprocedural bleeding rate was 2.6 % (95 %CI 1.5 %–4.5 %, I2 = 51 %), the delayed bleeding rate was 1.5 % (95 %CI 0.8 %–2.7 %, I2 = 18 %), and no perforations or post-polypectomy syndromes were reported, with estimated rates of 0.6 % (95 %CI 0.3 %–1.3 %, I2 = 0 %) and 0.6 % (95 %CI 0.3 %–1.4 %, I2 = 0 %), respectively. Conclusion CS-EMR demonstrated an excellent safety profile for colon polyps, with variable recurrence rates based on polyp size and histology. Large prospective studies are needed to validate these findings.

Abstract Background There are limited data on how vedolizumab (VDZ) impacts extraintestinal manifestations (EIMs) in inflammatory bowel disease (IBD). The aim of this study was to determine the clinical outcomes of EIMs after initiation of VDZ for patients with IBD. Methods A multicenter retrospective study of patients with IBD who received at least 1 dose of VDZ between January 1, 2014 and August 1, 2019 was conducted. The primary outcome was the rate of worsening EIMs after VDZ. Secondary outcomes were factors associated with worsening EIMs and peripheral arthritis (PA) specifically after VDZ. Results A total of 201 patients with IBD (72.6% with Crohn disease; median age 38.4 years (interquartile range, 29-52.4 years); 62.2% female) with EIMs before VDZ treatment were included. The most common type of EIM before VDZ was peripheral arthritis (PA) (68.2%). Worsening of EIMs after VDZ occurred in 34.8% of patients. There were no statistically significant differences between the worsened EIM (n = 70) and the stable EIM (n = 131) groups in term of age, IBD subtype, or previous and current medical therapy. We found that PA was significantly more common in the worsening EIM group (84.3% vs 59.6%; P < 0.01). Worsening of EIMs was associated with a higher rate of discontinuation of VDZ during study follow-up when compared with the stable EIM group (61.4% vs 44%; P = 0.02). Treatment using VDZ was discontinued specifically because of EIMs in 9.5% of patients. Conclusions Almost one-third of patients had worsening EIMs after VDZ, which resulted in VDZ discontinuation in approximately 10% of patients. Previous biologic use or concurrent immunosuppressant or corticosteroid therapy did not predict EIM course after VDZ.

INTRODUCTION: Peripancreatic fluid collections may occur following pancreatic resection and are traditionally managed by percutaneous surgical drains. Endoscopic management of these peripancreatic fluid collections is increasingly utilized and there is growing experience in this realm. CASE DESCRIPTION/METHODS: A 54-year-old woman with a history of resectable adenocarcinoma of the pancreatic tail (T1a) who received FOLFIRINOX neoadjuvant therapy and was transitioned to Gemcitabine/Abraxane, presented for surgical management. She initially underwent laparoscopic, hand-assisted distal pancreatectomy and splenectomy. She tolerated surgery with no immediate complications. On postoperative day #4, she developed moderate abdominal pain. Computed tomography (CT) demonstrated an irregularly-shaped, hypodense fluid collection measuring 7.5 × 6.5 × 8.3 cm about the pancreatic tail, concerning for pancreatic duct leak. The decision was made to perform endoscopic drainage under endoscopic ultrasound guidance. On postoperative day 6, EUS demonstrated a 7 × 4 cm septated collection in the postoperative bed in the region of the distal pancreas (Figure A). The acute collection had not yet become walled off based on CT and EUS. The common wall between the stomach and cyst was interrogated utilizing color Doppler and an ideal puncture sight was determined. An electrocautery enhanced lumen apposing metal stent (LAMS) was advanced into the cyst and a 10 × 10 mm LAMS was placed with flanges in close approximation to the fluid collection and stomach wall through cystgastrostomy (Figure B). An additional 7 Fr by 4 cm soft double pigtail stent was then placed coaxial to the LAMS to maintain patency. At follow-up, two weeks later, her abdominal symptoms had resolved. Her interval scan demonstrated a significantly decreased pancreatic tail collection and transgastric LAMS. At postoperative day 10, cross sectional imaging demonstrated complete resolution of her fluid collection, and endoscopy was performed with uneventful LAMS removal (Figure C). DISCUSSION: This case demonstrates a patient with an acute postoperative peripancreatic fluid collection after distal pancreatectomy which was successfully treated six days postoperatively with transgastric cystgastrostomy using a LAMS. While traditional management in the acute postoperative setting has been percutaneous drain placement, further study is needed to evaluate the safety and efficacy of minimally invasive, endoscopic methods of postoperative drainage.