Side-Viewing Duodenoscope versus Forward-Viewing Gastroscope for Endoscopic Retrograde Cholangiopancreatography in Billroth II Gastrectomy Patients.

Introduction: Endoscopic retrograde cholangiopancreatography (ERCP) in patients with Billroth II gastrectomy is still a challenging procedure. The optimal approach, namely the type of endoscope and sphincter management, has yet to be defined. Aim: To compare the efficacy and safety of forward-viewing gastroscope and the side-viewing duodenoscope in ERCP of patients with Billroth II gastrectomy. Methods: We conducted a retrospective, single-center cohort study of consecutive patients with Billroth II gastrectomy submitted to ERCP in an expert center for ERCP between 2005 and 2021. The outcomes assessed were: papilla identification, deep biliary cannulation, and adverse events (AEs). Multivariate analysis was performed to evaluate potential associations and predictors of the main outcomes. Results: We included 83 patients with a median age of 73 (IQR 65-81) years. ERCP was performed using side-viewing duodenoscope in 52 and forward-viewing gastroscope in 31 patients. Patients' characteristics were similar in the two groups. The global rate of papilla identification was 66% (n = 55). The rate of deep cannulation was 58% considering all patients and 87% in the subgroup of patients in which the papilla major was identified. Cannulation was performed with standard methods in 65% of cases and with needle-knife fistulotomy in 35%. AEs occurred in 4 patients. There was no difference between duodenoscope and gastroscope in papilla identification (64% [95% CI: 51-77] vs. 71% [55-87]). Although not statistically significant, duodenoscope had a lower deep cannulation rate when considering all patients (52% [15-39] vs. 68% [7-35]) and a higher AEs rate (8% [1-15] vs. 0% [0-1]). In a multivariate analysis, the use of gastroscope significantly increased the deep cannulation rate (OR = 152.62 [2.5-9,283.6]). Conclusion: This study demonstrates that forward-viewing gastroscope is at least as effective and safe as side-viewing duodenoscope for ERCP in patients with Billroth II gastrectomy. Moreover, our study showed that gastroscope is an independent predictor of successful cannulation.

Introdução: Colangiopancreatografia retrógrada endoscópica (CPRE) em doentes submetidos previamente a gastrectomia com reconstrução Billroth II é ainda um exame desafiante. A melhor abordagem, nomeadamente o tipo de endoscópio e a técnica de canulação biliar, ainda não está definida. Objectivo: Comparar a eficácia e segurança do gastroscópio de visão frontal e do duodenoscópio de visão lateral na CPRE de doentes com gastrectomia com reconstrução Billroth II. Métodos: Conduzimos um estudo de coorte retrospectivo e unicêntrico que incluiu consecutivamente doentes com gastrectomia com reconstrução Billroth II submetidos a CPRE num centro de referência para CPRE entre 2005 e 2021. Os outcomes avaliados foram: identificação da papila, canulação biliar profunda e efeitos adversos (EAs). Regressão logística foi realizada para avaliar possíveis associações e preditores dos outcomes. Resultados: Incluímos 83 doentes com uma idade mediana de 73 (IIQ 65­81) anos. A CPRE foi realizada usando duodenoscópio em 52 doentes e usando o gastroscópio de visão frontal em 31 doentes. As características dos doentes foram semelhantes entre os dois grupos. A taxa global de identificação da papila foi de 66% (n = 55). A taxa de canulação profunda foi de 58% considerando todos os doentes e de 87% considerando apenas o subgrupo de doentes nos quais a papila major foi identificada. A canulação foi realizada usando métodos convencionais em 65% e usando fistulotomia com faca em 35% dos doentes. EAs ocorreram em 4 doentes. Não houve diferenças entre duodenoscópio e gastroscópio relativamente à identificação da papila [64% (95% CI: 51­77) vs 71% (55­87)]. Apesar de estatisticamente não significativo, o uso de duodenoscópio teve uma menor taxa de canulação profunda quando considerados todos os doentes [52% (15­39) vs 68% (7­35)] e uma maior taxa de EAs [8% (1­15) vs 0% (0­1)]. Na regressão logística, o uso de gastroscópio significativamente aumentou a taxa de canulação profunda [OR = 152.62 (2.5­9,283.6)]. Conclusão: Este estudo demonstra que o uso de gastroscópio de visão frontal é pelo menos igualmente eficaz e seguro ao duodenoscópio na CPRE de doentes com gastrectomia com reconstrução Billroth II. Para além disso, o nosso estudo demonstrou que o uso de gastroscópio é um predictor independente para canulação.

Retrospective multicenter study on endoscopic treatment of upper GI postsurgical leaks.

BACKGROUND AND AIMS: Therapeutic endoscopy plays a critical role in the management of upper GI (UGI) postsurgical leaks. Data are scarce regarding clinical success and safety. Our aim was to evaluate the effectiveness of endoscopic therapy for UGI postsurgical leaks and associated adverse events (AEs) and to identify factors associated with successful endoscopic therapy and AE occurrence. METHODS: This was a retrospective, multicenter, international study of all patients who underwent endoscopic therapy for UGI postsurgical leaks between 2014 and 2019. RESULTS: Two hundred six patients were included. Index surgery most often performed was sleeve gastrectomy (39.3%), followed by gastrectomy (23.8%) and esophagectomy (22.8%). The median time between index surgery and commencement of endoscopic therapy was 16 days. Endoscopic closure was achieved in 80.1% of patients after a median follow-up of 52 days (interquartile range, 33-81.3). Seven hundred seventy-five therapeutic endoscopies were performed. Multimodal therapy was needed in 40.8% of patients. The cumulative success of leak resolution reached a plateau between the third and fourth techniques (approximately 70%-80%); this was achieved after 125 days of endoscopic therapy. Smaller leak initial diameters, hospitalization in a general ward, hemodynamic stability, absence of respiratory failure, previous gastrectomy, fewer numbers of therapeutic endoscopies performed, shorter length of stay, and shorter times to leak closure were associated with better outcomes. Overall, 102 endoscopic therapy-related AEs occurred in 81 patients (39.3%), with most managed conservatively or endoscopically. Leak-related mortality rate was 12.4%. CONCLUSIONS: Multimodal therapeutic endoscopy, despite being time-consuming and requiring multiple procedures, allows leak closure in a significant proportion of patients with a low rate of severe AEs.

Management of Gastrointestinal Toxicity from Immune Checkpoint Inhibitor.

Immune checkpoint inhibitors have shown anti-tumour activity in cancers such as melanoma, renal cell carcinoma, non-small-cell lung cancer, urothelial carcinoma, colorectal cancer, and Hodgkin's lymphoma. Though immune checkpoint inhibitors have revolutionized the treatment and prognosis of some advanced malignancies, they are also associated with a significant risk of immune-related adverse events. These adverse events can occur in any organ system, but gastrointestinal side effects are among the most commonly reported, with manifestations ranging from mild diarrhoea to severe colitis, sharing some features with inflammatory bowel disease. Anticipating a greater use of these drugs in the future, gastroenterologists should expect to be increasingly faced with gastrointestinal immune-related adverse events. Knowledge of these toxicities, as well as effective management algorithms, is essential to enable early diagnosis and treatment, decreasing morbidity and mortality. We reviewed the currently available literature on gastrointestinal toxicity induced by immune checkpoint inhibitors, namely the clinical features, diagnosis, and management.

Os inibidores dos checkpoint imunológicos demonstraram atividade antitumoral em neoplasias como o melanoma, o carcinoma de células renais, o carcinoma pulmonar de não pequenas células, o carcinoma urotelial, o carcinoma colorretal e o linfoma de Hodgkin. Estes fármacos, embora tenham revolucionado o tratamento e o prognóstico de algumas neoplasias avançadas, também se associam a um risco considerável de efeitos adversos associadosao sistema imunitário. Qualquer órgão pode ser afetado, mas os efeitos adversos gastrointestinais estão entre os mais comumente relatados. As manifestações gastrointestinais variam desde diarreia ligeira a colite grave, a qual pode evidenciar características idênticas às da doença inflamatória intestinal. Antecipando uma maior utilização destes fármacos no futuro, os gastroenterologistas devem esperar confrontar-se cada vez mais com este tipo de efeitos adversos. O conhecimento dessas toxicidades, bem como dos algoritmos de abordagem destes doentes é fundamental para um diagnóstico e tratamento precoces, diminuindo desta forma a morbilidade e a mortalidade. Os autores pretenderam rever a literatura mais atual sobre a toxicidade gastrointestinal induzida pelos inibidores dos checkpoint imunológicos, nomeadamente apresentação clínica, abordagem diagnóstica e terapêutica.