Endoscopic closure of tracheoesophageal fistulas with the over-the-scope clip system.

Management of Tracheoesophageal Fistulas (TEFs) is associated with high morbidity and mortality and remains an interdisciplinary challenge. We describe the first two cases of successful endoscopic closure of TEFs due to tracheostomy tube and thoracic hydatid cysts surgery, using the Over-The-Scope Clip (OTSC) system. The OTSC system is composed of an application cap, which is mounted onto the distal tip of the endoscope and a connected releasing mechanism, installed on the handle of the scope. The rotation of the handle allows the release of the clip by a two tube sliding mechanism. Atraumatic version of OTSCs with medium sized caps, twin graspers and anchor were used in these cases. Both fistulae were successfully sealed with one clip. No complication was observed that could be ascribed to the clip itself or to the technique. One patient died because of pneumonia and septicemia after 1 week, but the symptoms of other patient were immediately improved. A thoracic radiography taken after 1 month showed that the clip is in place. Although prospective comparative clinical studies are needed to work out the drawbacks of the new OTSC device, it might be considered as a valid alternative to operation in TEFs.

Endoscopic management of gastric band erosions: a 7-year series of 14 patients.

BACKGROUND: Intragastric band migration is an unusual but major complication of gastric banding. We review our experience with endoscopic removal of eroded gastric bands. METHODS: We retrospectively evaluated the cases of 110 morbidly obese patients who underwent adjustable gastric banding between 2005 and 2012 to identify those who experienced band erosion. To remove the migrated band, we used an endoscopic approach with a Gastric Band Cutter. RESULTS: Band or tube erosion occurred in 14 patients (12.7%). The median time interval from the initial gastric band placement to the diagnosis of band erosion was 32 (range 18-52) months. Upper abdominal pain, port site infection, loss of restriction and weight regain were the most common symptoms. We used the Gastric Band Cutter to remove the band endoscopically. It was able to cut the band successfully in all but 1 patient, in whom twisting of the cutting wire required conversion from endoscopy to laparotomy. In 2 patients, the band, after being cut, was locked in the gastric wall and required laparotomic removal. In 1 patient, we performed surgery for intragastric penetration of the connecting tube broken close to the band. CONCLUSION: The Gastric Band Cutter was successful in dividing the band in all but 1 patient, although we could not always complete the procedure endoscopically. Endoscopic removal seems to be effective and safe for band erosion.

CONTEXTE: La migration intragastrique de l'anneau est une complication rare, mais majeure du cerclage gastrique. Nous faisons le point sur notre expérience du retrait endoscopique des anneaux gastriques érodés. MÉTHODES: Nous avons évalué de manière rétrospective le cas de 110 patients atteints d'obésité morbide qui ont subi un cerclage gastrique ajustable entre 2005 et 2012 afin de vérifier si les anneaux en place étaient érodés. Pour retirer les anneaux qui avaient migré, nous avons utilisé l'approche endoscopique et un dispositif pour sectionner l'anneau gastrique. RÉSULTATS: L'anneau ou le tube s'est érodé chez 14 patients (12,7 %). L'intervalle médian entre la pose initiale de l'anneau gastrique et le diagnostic d'érosion a été de 32 (entre 18 et 52) mois. La douleur abdominale haute, l'infection du port d'accès, la diminution de la restriction et la reprise de poids ont été les symptômes les plus fréquents. Nous avons utilisé un dispositif pour sectionner l'anneau gastrique afin de retirer l'anneau par voie endoscopique. Le dispositif a permis de sectionner l'anneau avec succès chez tous les patients sauf 1; dans ce dernier cas, une torsion du fil à sectionner a nécessité la conversion de l'endoscopie en une laparotomie. Chez 2 patients, une fois sectionné, l'anneau est resté emprisonné dans la paroi gastrique et a nécessité une extraction laparotomique. Chez 1 patient, nous avons effectué une intervention chirurgicale en raison de la pénétration intragastrique de la tubulure de raccord sectionnée à proximité de l'anneau. CONCLUSION: Le dispositif servant à sectionner l'anneau gastrique a bien fonctionné chez tous les patients sauf 1, même si les interventions n'ont pas toutes pu être entièrement réalisées par voie endoscopique. Le retrait endoscopique semble être une intervention efficace et sécuritaire dans les cas d'érosion de l'anneau.

Hepatitis C virus genotypes in Adana and Antakya regions of Turkey.

BACKGROUND/AIM: Hepatitis C virus (HCV) genotype 1 was found to be dominant in Turkey. In this study, HCV genotypes were examined in the Adana and Antakya regions of Turkey. MATERIALS AND METHODS: The study consisted of 639 HCV-RNA-positive patients with chronic HCV infection in Adana (214 males and 101 females) and Antakya (139 males and 185 females) in Turkey. Real time-polymerase chain reaction was used for genotype determination. RESULTS: In Antakya, it was determined that the percentages of genotypes of type la (0.31%), 1b (86.73%), 2 (9.26%), 3 (0.93%), and 4 (2.78%) were compatible with the nationwide results seen in Turkey. In Adana, the percentages of genotypes of type 1a (3.49%), 1b (55.24%), 2 (14.60%), 3 (26.03%), and 4 (0.63%) were found to be different. This difference was mainly due to the infection rates in males: genotype 1b was significantly lower (42.5% versus 82.2%, P < 0.001) in men in Adana, but genotype 2 (17.8% versus 7.9%, P = 0.021) and genotype 3 (34.6% versus 7.9%, P < 0.001) were significantly higher in men than in women in Adana. CONCLUSION: Rates of genotypes 2 and 3 were unexpectedly high in Adana compared to other parts of Turkey.

A case of entecavir resistance which is developed after complete viral suppression during entecavir treatment for nucleoside-naive chronic hepatitis B.

Entecavir (ETV) is a potent nucleoside analogue against hepatitis B virus (HBV), and the emergence of drug resistance is rare in nucleoside-naive patients because development of ETV resistance (ETVr) requires at least three amino acid substitutions in HBV reverse transcriptase. We observed a case of genotypic ETVr with viral and biochemical breakthrough during ETV treatment of nucleoside-naive patients with chronic hepatitis B (CHB). A 57-years-old HBeAg-positive man received ETV 0.5 mg/day for 145 weeks. HBV DNA was 7.7 log10 copies/ml at baseline, decreased to below 2 at week 48, declined to a nadir of 0 (negative) at week 72, and rebounded to 2.2 log10 copies/ ml at week 90 and remained this level until 109 weeks and increased to 6.8 log10 copies/ml at week 145. Alanine aminotransferase (ALT) level increased to 440 IU/L at week 145. The ETVr-related substitution (rtS202P) and lamivudine resistance-related substitutions (rtL180M+rtM204V) were detected by DNA sequencing analysis at week 145. The patient discontinued ETV therapy at week 145, and then received 245 mg of tenofovir disoproxil fumarate (TDF). Afterwards, HBV DNA level dropped to below 2.6 log10 copies/ml and ALT level was normalized after 19 weeks of TDF dosing. The three substitutions associated with ETV and lamivudine resistance developed after complete viral suppression in a nucleoside-naive CHB patient during ETV treatment. In spite of the extremely rare chance of viral mutation during ETV treatment, nucleoside-naive patients should be carefully monitored for resistance even if complete suppression is present.

Five percent weight lost in the first month of intragastric balloon treatment may be a predictor for long-term weight maintenance.

BACKGROUND: Most of the weight loss with the BioEnterics intragastric balloon (BIB) has occurred during the first 3-4 months. This study aimed to evaluate the effect of initial weight loss on long-term weight maintenance. METHODS: From 2008 to 2011, 50 patients who had mean body mass index (BMI) of 44.7 ± 12.4 kg/m(2) underwent BIB therapy for 6 months. All patients were given a diet of 1,100 kcal/day. Weight loss parameters [absolute weight loss, BMI loss, percentage of body weight loss (BWL%), and percentage of excess BMI loss] were recorded at the baseline, 1 month, 6 months (time of BIB removal), 12 months, and 18 months from the baseline. Successful weight loss was defined as ≥ 10 % weight loss after 6, 12, and 18 months. RESULTS: Twenty-seven patients (54 %) achieved a percentage of BWL ≥ 10 at the time of removal. Eighteen (36 %) and 12 (24 %) patients were able to maintain weight loss of 10 % at 12 and 18 months. Percentage of BWL after 1 month was positively correlated with BWL% after 6, 12, and 18 months (r = 0.77, 0.65, and 0.62, p < 0.001, respectively). Twenty-four patients who lost 5 % of the BWL after 1 month of treatment succeeded in maintaining a lasting percentage of BWL ≥ 10 after the BIB removal: more precisely, this cutoff point was achieved in 96 % at the time of removal and in 71 %, 50 % at 12 months, and 18 months of follow-up. CONCLUSIONS: Five percent BWL after 1 month of treatment may be a predictor for long-term weight maintenance.

Long-term effectiveness of BioEnterics intragastric balloon in obese patients.

BACKGROUND/AIMS: The BioEnterics intragastric balloon has been considered an effective and less invasive method for weight loss. This study aimed to evaluate the effect of this method on long-term weight loss. MATERIAL AND METHODS: From June 2009 to June 2011, 32 patients (14 male, 18 female) underwent BioEnterics intragastric balloon therapy for 6 months. The mean age of the subjects was 39,7±11,1 years and mean body mass index was 44,4±12 kg/m 2 . All patients were given a diet of 1100 kcal/day. Weight loss parameters [absolute weight loss, body mass index loss, percentage of body weight loss, and percentage of excess body massindex loss (excess body mass index loss%)] were recorded at baseline, after 1 month, after 6 months (time of BioEnterics intragastricballoon removal), and after 12 months from baseline. Successful weight loss was defined as ≥10% weight loss after 6 (end of treatment success) and 12 months (long-term success). Statistical analysis was done using SPSS computer program. RESULTS: The mean weight loss and body mass index loss were 12,4 kg (standart deviation, 13,5) and 4.3 kg/m 2 (standart deviation, 4,7), respectively (p<0.001). The mean percentage of body weight loss was 9.5% (standart deviation, 9,8). The percentage of excess body mass index loss reached 25,2% (standart deviation, 25,9). Fifteen patients (46,9%) achieved a percentage of body weight loss >10% at the end of treatment. Eleven of these patients (73%) were able to maintain weight loss of 10% at the completion of the study, resulting ina longterm success rate of 34.4%. Percentage of body weight loss and percentage of excess body mass index loss were inversely relatedto age (p< 0,05). CONCLUSION: BioEnterics intragastric balloon has been effective in long-term loss of body weight.

Endoscopic closure of an endoscope-related duodenal perforation using the over-the-scope clip.

Perforations of the duodenum are a significant source of morbidity in clinical practice. Surgical repair is usually mandated, but it is associated with significant morbidity and mortality. Until recently, there has been no technique available which reproducibly and safely allowed endoscopic closures of penetrating defects within the digestive tract. With the new over-the-scope clipping system", which regarding design and function is similar to a bear-trap, the endoscopic closure of perforations has become possible. Here, we report our first experience with the over-the-scope clipping system for the closure of duodenal perforation developed during endoscopic retrograde cholangiopancreatography. A 79-year-old woman with jaundice resulting from obstruction of the common bile duct caused by choledocholithiasis underwent endoscopic retrograde cholangiopancreatography. At the time of the procedure, an endoscope-related perforation measuring about 15 mm was visualized proximal to the papilla. Endoscopic repair was performed by using the over-the-scope clipping according to a standardized operating procedure. Amsterdam type plastic stent was placed into the common bile duct. An abdominal computed tomography with gastrographin showed a pneumoretroperitoneum in the peripancreatic-perirenal area and complete closure of the perforation. The patient remained symptom free, no signs of sepsis developed, and the obstructive jaundice was relieved by endoscopic biliary drainage. The patient was allowed to have a full diet one week later and was discharged from the hospital 2 weeks later. It seems that, the over-the-scope clipping is effective for endoluminal closure of endoscope-related duodenal perforations.

Alanine aminotransferase normalization at week 8 predicts viral response during hepatitis C treatment.

AIM: To investigate alanine aminotransferase (ALT) and sustained virological response (SVR) in chronic hepatitis C (CHC) during peginterferon-ribavirin treatment. METHODS: One hundred and fifty-one genotype 1 CHC patients underwent treatment for 48 wk with peginterferon and ribavirin, and were retrospectively divided into two groups as having a rapid virological response (RVR) (Group 1, n = 52) and not having an RVR (Group 2, n = 99). We also subdivided each group into two according to the initial ALT level being high (Group 1h and Group 2h) or normal (Group 1n and Group 2n). HCV RNA and ALT levels were measured at baseline; at 4, 12, 24 and 48 wk during the treatment period; and at 24 wk follow-up. ALT levels were also obtained at 8 wk. According to the results of ALT, patients were enrolled in either the follow-up abnormal or follow-up normalized ALT groups at each interval. Patients with high and normal ALT levels were compared for each interval in terms of SVR. RESULTS: The SVR rates were 83% vs 40% (P = 0.000), 82% vs 84% (P = 0.830), and 37% vs 44% (P = 0.466) when comparing Group 1 with 2, 1h with 1n, and 2h with 2n, respectively. In Group 2h, the SVR rates were 34% vs 40% (P = 0.701), 11% vs 52% (P = 0.004), 12% vs 50% (P = 0.007), 7% vs 50% (P = 0.003), 6% vs 53% (P = 0.001), and 0% vs 64% (P = 0.000) when comparing patients with high and normalized ALT levels at week 4, 8, 12, 24, 48 and 72, respectively. The multiple logistic regression analysis revealed that RVR (OR = 7.05; 95%CI: 3.1-16.05, P = 0.000), complete early virological response (cEVR) (OR = 17.55; 95%CI: 6.32-48.76, P = 0.000), normalization of ALT at 8 wk (OR = 3.04; 95%CI: 1.31-7.06, P = 0.008), and at 12 wk (OR = 4.21; 95%CI: 1.65-10.76, P = 0.002) were identified as independent significant predictive factors for SVR. CONCLUSION: Normalization of ALT at 8 wk may predict viral response during peginterferon-ribavirin treatment in genotype-1 CHC patients especially without RVR.

Comparison of the efficacy of tenofovir and entecavir for the treatment of nucleos(t)ide-naive patients with chronic hepatitis B.

BACKGROUND/AIMS: Chronic hepatitis B virus infection is an important cause of morbidity and mortality. Tenofovir disoproxil fumarate and entecavir were licensed for the treatment of hepatitis B virus infection. We evaluated the first 12 months of chronic hepatitis B treatments with tenofovir and entecavir and compared their efficiencies. METHODS: The study enrolled 94 chronic hepatitis B patients with compensated liver disease. The entecavir group consisted of 29 patients who received entecavir 0.5 mg/day and the tenofovir group consisted of 65 patients who received tenofovir 245 mg/day. There was no statistically significant demographic or HBeAg status difference between the groups. Patients returned to the clinic every four weeks for laboratory assessments of serum chemical and hematologic values, liver function and for documentation of any adverse events. Hepatitis B serologic markers and HBV-DNA levels were assessed every 12 weeks. The primary efficacy endpoint was a plasma HBV-DNA level of less than 400 copies/ml over 48 weeks. RESULTS: At the end of 48 weeks, treatment with either tenofovir or entecavir resulted in clinically important suppression of HBV-DNA, as 71.3%. There was no statistical difference in inducing undetectable levels of HBV-DNA between the entecavir (69%) and tenofovir (72.3%) groups. Furthermore, no side effect as an increase in creatinine was seen. HBeAg seroconversion was seen in only one patient in the entecavir group, but in no patients of the tenofovir group. CONCLUSIONS: In the first year of treatment for chronic hepatitis B, virologic response and tolerability did not differ significantly between tenofovir and entecavir. Both drugs are safe and efficacious for patients infected with HBV.

Relationship of CA 19-9 with choledocholithiasis and cholangitis.

BACKGROUND/AIMS: It is well known that increased concentrations of CA 19-9 can be found in benign disease of the liver, pancreas and biliary tract, especially in cases with gallstone disease with cholangitis. The aim of this study was to investigate the relation of CA 19-9 with the number and size of the stones, cholangitis and biliary obstruction in patients with choledocholithiasis. METHODS: Seventy patients with radiologically proven choledocholithiasis were studied. Endoscopic retrograde cholangiopancreatography, sphincterotomy and stone extraction were applied to all patients. In each case, the parameters recorded included the levels of CA 19-9 and other laboratory tests before and after endoscopic retrograde cholangiopancreatography and the results of imaging techniques and immunoserologic tests. The correlations of these parameters were determined by SPSS 17 package program for statistical analysis. RESULTS: Elevation of CA 19-9 was found in 32 patients (46%), while 8 patients (11%) had extraordinarily high levels (>1000 U/ml). CA 19-9 levels were correlated with serum alkaline phosphatase (r=0.5, p<0.01), gamma glutamyl transpeptidase (r=0.5, p<0.01) and bilirubin (r=0.4, p<0.01) levels but not with aspartate aminotransferase or alanine aminotransferase levels. There was also no association between serum CA 19-9 levels and the number and size of stones. Six patients had cholangitis. CA 19-9 levels were found higher in patients with cholangitis than others (100% vs. 41%, p<0.01) as well as alkaline phosphatase, gamma glutamyl transpeptidase and bilirubin levels. After stone extraction, CA 19-9 levels started to decrease and reached normal values 1-28 days later. CONCLUSION: In conclusion, CA 19-9 levels are associated with biliary obstruction and cholangitis but not with the number and size of stones in patients with choledocholithiasis.

Gastroscopic removal of a migrated adjustable gastric band: a case report.

Laparoscopic gastric banding is a popular method for treating morbid obesity. Band migration is a well-known late complication and the treatment is usually reoperation. In this case report, we show that a band penetrating the gastric wall can be treated by gastroscopic operation with the Gastric Band Cutter device without complication. It seems that this technique is simpler than reoperation and is beneficial even when the intraluminal migration is partial.