Storm, Andrew C.

Abstract Background and aims Endoscopic resections are associated with bleeding and perforation and may be managed with through-the-scope (TTS) clips, over-the-scope clips and endoscopic suturing. The aim of this preclinical study was to compare technical success of closure using a novel TTS tissue helix tack and suture device (X-Tack) to TTS clips in a porcine model. Materials and methods Four subjects underwent 40 mucosal resections, diameter range 25–50 mm, in the stomach (n = 24) and colon (n = 16). Closures were randomized to X-Tack (n = 24) or clip (n = 16). Animals underwent weekly endoscopic follow-up for 4 weeks. Results Technical closure with X-Tack was successful in 24 of 24 (100 %) cases and with clips in 13 of 16 cases (81.3 %) (P = 0.0001). One colonic perforation occurred and was successfully managed using X-Tack. The rate of healing was not statistically different between the groups, and all sites healed at 4 weeks including the perforation and were confirmed by histology. Conclusions Compared to TTS clip, X-Tack is superior for effecting large mucosal defect closure, including durable sealing of full-thickness perforation. There was no difference in rate of healing between devices.

ABSTRACT Patients with surgically altered gastrointestinal anatomy are susceptible to gallstone disease and anastomotic strictures. In such cases, enteroscopy-assisted endoscopic retrograde cholangiopancreatography (ERCP) is traditionally used to access the biliary system through the Roux limb, with suboptimal success rates. With the advent of endoscopic ultrasound (EUS) and therapeutic tools including lumen-apposing metal stents, access to the biliary system in surgically altered anatomy has been made simpler. We report a case of EUS-guided transenteric ERCP done in a patient with surgically altered anatomy and a rescue technique for difficult gastrojejunal anastomosis creation.

Objective The diagnosis of autoimmune pancreatitis (AIP) is challenging. Sonographic and cross-sectional imaging findings of AIP closely mimic pancreatic ductal adenocarcinoma (PDAC) and techniques for tissue sampling of AIP are suboptimal. These limitations often result in delayed or failed diagnosis, which negatively impact patient management and outcomes. This study aimed to create an endoscopic ultrasound (EUS)-based convolutional neural network (CNN) model trained to differentiate AIP from PDAC, chronic pancreatitis (CP) and normal pancreas (NP), with sufficient performance to analyse EUS video in real time. Design A database of still image and video data obtained from EUS examinations of cases of AIP, PDAC, CP and NP was used to develop a CNN. Occlusion heatmap analysis was used to identify sonographic features the CNN valued when differentiating AIP from PDAC. Results From 583 patients (146 AIP, 292 PDAC, 72 CP and 73 NP), a total of 1 174 461 unique EUS images were extracted. For video data, the CNN processed 955 EUS frames per second and was: 99% sensitive, 98% specific for distinguishing AIP from NP; 94% sensitive, 71% specific for distinguishing AIP from CP; 90% sensitive, 93% specific for distinguishing AIP from PDAC; and 90% sensitive, 85% specific for distinguishing AIP from all studied conditions (ie, PDAC, CP and NP). Conclusion The developed EUS-CNN model accurately differentiated AIP from PDAC and benign pancreatic conditions, thereby offering the capability of earlier and more accurate diagnosis. Use of this model offers the potential for more timely and appropriate patient care and improved outcome.

INTRODUCTION: Endoscopic bariatric and metabolic therapies can potentially reproduce similar gastric and small intestinal anatomic and physiologic manipulations as Roux-en-Y gastric bypass. This proof of concept animal study was aimed to assess the feasibility, safety, efficacy, and impact on gastrointestinal physiology of combined intragastric balloons (IGB) and duodenal-jejunal bypass liner (DJBL) for the treatment of obesity. METHODS: Five Ossabaw pigs were fed a high-calorie diet to develop obesity and were randomly assigned to receive IGB or DJBL in sequence. The weight gain rate was calculated. Fasting and postprandial blood samples were drawn before any intervention (serving as the baseline group) and 1 month after second device insertion (serving as the combination group) to measure gut neurohormonal changes and metabolic parameters. RESULTS: Four pigs successfully received a sequential device insertion. One pig developed duodenal sleeve prolapse that was spontaneously resolved. One pig was early terminated because of developing a central line infection. The rate of weight gain in the combination group (0.63 ± 1.3 kg/wk) was significantly lower than the baseline group (1.96 ± 2.17 kg/wk) and numerically lower than after insertion of the IGB (1.00 ± 1.40 kg/wk) or the DJBL (0.75 ± 2.27 kg/wk) alone. A trend of higher postprandial glucagon-like peptide-1 was observed in the combination group compared with the baseline group. DISCUSSION: A combination of IGB and DJBL is feasible and well tolerated. A strategy of sequential use of these devices might offer a synergistic approach that can enhance weight loss and metabolic outcomes.

Abstract Background Endoscopic intervention for pancreatic fluid collections (PFCs) with disconnected pancreatic duct syndrome (DPDS) has been associated with failures and increased need for additional endoscopic and non-endoscopic interventions. The primary aim of this study was to determine the outcomes of endoscopic ultrasound (EUS)-guided transmural drainage of PFCs in patients with DPDS. Methods In patients undergoing EUS-guided drainage of PFCs from January 2013 to January 2018, demographic profiles, procedural indications and details, adverse events, outcomes, and subsequent interventions were retrospectively collected. Overall treatment success was determined by PFC resolution on follow-up imaging or stent removal without recurrence. Results EUS-guided drainage of PFCs was performed in 141 patients. DPDS was present in 57 of them (40 %) and walled-off necrosis was the most frequent type of PFC (55 %). DPDS was not associated with lower clinical success, increased number of repeat interventions, or increased time to PFC resolution. Patients with DPDS were more likely to be treated with permanent transmural plastic double-pigtail stents (odds ratio [OR] 6.4; 95 % confidence interval [CI] 2.5 – 16.5; P < 0.001). However, when stents were removed, DPDS was associated with increased PFC recurrence after stent removal (OR 8.0; 95 %CI 1.2 – 381.8; P = 0.04). Conclusions DPDS frequently occurs in patients with PFCs but does not negatively impact successful resolution. DPDS is associated with increased PFC recurrence after stent removal.

Background and Aims Presence of malignant regional lymph nodes (MRLNs) precludes curative oncological resection or liver transplantation for cholangiocarcinoma (CCA). Limited data support the utility of endoscopic ultrasound (EUS)/fine needle aspiration (FNA) for detection of MRLNs in extrahepatic CCA, but there are no data for its role in intrahepatic CCA (iCCA). The aim of this study is to evaluate the staging impact of EUS for CCA, including analysis by subtype. Approach and Results We identified consecutive patients with CCA who underwent EUS staging at a single tertiary care center from October 2014 to April 2018. Among this cohort, we abstracted clinical demographic, radiographical, procedural, cytopathological, and surgical data. STATA 15 software was used for comparative analysis calculations (StataCorp LP, College Station, TX). The study cohort included 157 patients; 24 (15%), 124 (79%), and 9 (6%) with intrahepatic, perihilar, and distal CCA, respectively. EUS was able to identify regional lymph nodes (RLNs) in a higher percentage of patients compared to cross‐sectional imaging (86% vs. 47%; P < 0.001). FNA was performed in 133 (98.5%) patients with RLNs, with a median of three passes per node. EUS‐FNA identified MRLN in 27 of 31 (87.1%) patients ultimately found to have MRLNs. For iCCA, EUS detected a higher percentage of RLN compared to cross‐sectional imaging (83% vs. 50%; P = 0.048), with MRLNs identified in 4 (17%) patients. Among the entire cohort, identification of at least one MRLN by EUS was associated with lower median survival (353 vs. 1,050 days; P < 0.001) and increased risk of death (hazard ratio = 4.1; P < 0.001). Conclusions EUS‐FNA is effective for identifying MRLN in patients with CCA, and should be routinely incorporated into staging of all CCA subtypes given the impact of MRLN on prognosis and management decisions.

ABSTRACT Spontaneous hemobilia is a rare complication after liver transplantation and is largely secondary to the formation of an arteriobiliary fistula, which is generally treated by vascular interventional radiology embolization. We present a case of hemorrhagic shock secondary to arterial hemorrhage at an oversewn bile duct stump after liver transplantation, which failed vascular interventional radiology embolization, and was subsequently controlled using an endoscopic application of a gelatin sponge slurry (Gelfoam). We present this unique approach and review the history of this surgical and interventional hemostasis tool that has not been previously described for endoscopic use.

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.

INTRODUCTION: Over-the-scope clips (OTSC) are used for closure of fistulas, leaks, and acute perforations, and for GI bleeding. Adverse events include perforation, migration, and ulceration. Little is know about the natural history of OTSCs and no data addressing the longevity of clips is available. We present an interim analysis of our center’s experience with OTSC focusing on natural history. METHODS: OTSCs used from 1/1/2011 to 1/1/2019 were compiled and retrospective chart review undertaken. Primary endpoint was clip retention time (time when the clip was placed to time the clip was last seen or was physically removed). Secondary endpoints were rate of complications and factors that influence clip retention time and clinical success. Cox proportional hazards were used to evaluate variables impacting clip retention. Univariate regression was used to assess potential risk factors for adverse events. RESULTS: A total of 358 OTSC were placed in 299 patients (55.8% male, n = 184) with mean age 64 + 15.3 years. Procedures and indications presented in Table 1. Clip placement was clinically successful in 81% of cases (N = 265). Median time to clip loss as assessed by Kaplan-Meier curve was 267 days (95% CI 196-406) (Figure 1). Adverse events occurred in 34 clip placements (10.7%) and included bleeding (n = 8, 24.2%), perforation (n = 5, 15.2%), ulceration (n = 3, 9.1%), migration (n = 15, 45.5%), and infection (n = 1, 3.0%). Univariate analysis (Table 2) revealed that age, gender, type of clip used (there are 3 types of OTSC), and performing endoscopist did not impact clip retention rate. A size 14 clip had marginally higher rates of retention compared to others. Clips placed in the rectum or esophagus were lost earlier compared to those in the small/large intestine and stomach. Clips placed for fistulas and those associated with adverse event were associated with earlier clip loss. In evaluation of clinical success, clips placed for fistulas had a relative risk of clinical failure of 2.08 (95% CI 1.29-3.36) compared to all other indications. CONCLUSION: OTSCs are retained for a median of 8.9 months with clip location and indication for placement being key factors in time to clip loss. Clips used for fistula closure were more likely to be lost compared to those placed for other indications, less likely to be clinically successful, and more likely to cause a complication. These data help guide decision-making when considering OTSC use across clinical indications.