Intra-gastric balloon with lifestyle modification: a promising therapeutic option for overweight and obese patients with metabolic dysfunction-associated steatotic liver disease.

BACKGROUND: Data on effects of intra-gastric balloon (IGB) on metabolic dysfunction-associated steatotic liver disease (MASLD) are scarce, in part with contradictory results, and mainly obtained in tertiary care patients with diabetes and other comorbidities. We here explore effects of IGB in patients with MASLD referred to a first-line obesity clinic. METHODS: In this prospective cohort study, patients with at least significant fibrosis (≥ F2) and/or severe steatosis (S3) according to screening transient elastography (FibroScan®) were offered a second FibroScan® after 6 months lifestyle modification with or without IGB (based on patient preference). RESULTS: 50 of 100 consecutively screened patients (generally non-diabetic) qualified for repeated evaluation and 29 (58%) of those had a second FibroScan®. At baseline, at least significant fibrosis was present in 28% and severe steatosis in 91%. IGB was placed in 19 patients (59%), whereas 10 patients (41%) preferred only lifestyle modification (no differences in baseline characteristics between both groups). After 6 months, liver stiffness decreased markedly in the IGB group (median: from 6.0 to 4.9 kPa, p = 0.005), but not in the lifestyle modification only group (median: from 5.5 to 6.9 kPa, p = 0.477). Steatosis improved in both groups, (controlled attenuation parameter values; IGB, mean ± SD: from 328 ± 34 to 272 ± 62 dB/m, p = 0.006: lifestyle modification only, mean ± SD: from 344 ± 33 to 305 ± 43 dB/m: p = 0.006). CONCLUSION: Both steatosis and fibrosis improve markedly in overweight/obese patients with MASLD after 6 months IGB combined with lifestyle modification. Our results warrant further research into long-term effect of IGB in these patients.

Single and sequential biodegradable stent placement for refractory benign esophageal strictures: a prospective follow-up study.

BACKGROUND AND STUDY AIM: Although biodegradable stents do not require removal, a single biodegradable stent may only temporarily relieve dysphagia in patients with refractory benign esophageal stricture (RBES). The aim of this study was to evaluate the safety and long term efficacy of single and sequential biodegradable stent placement in patients with RBES. PATIENTS AND METHODS: All patients who underwent biodegradable stent placement for RBES between August 2008 and March 2011 were prospectively followed to evaluate recurrent dysphagia and complication rates. RESULTS: In total, 59 stents were placed in 28 patients. Patients had previously been treated with multiple dilations (n = 20) or multiple dilations and non-biodegradable esophageal stenting (n = 8). A total of 13 patients underwent sequential biodegradable stent placement (median 3, range 2 - 8) during the study period. After initial stent placement, the median dysphagia-free period was 90 days (range 14 - 618 days). Clinical success (absence of dysphagia ≥ 6 months after stent placement) was achieved in seven patients (25 %) and major complications occurred in eight patients (29 %). After placement of a second biodegradable stent, the median dysphagia-free period was 55 days (range 25 - 700 days) and clinical success was achieved in 15 % of patients. After placement of a third stent, the median dysphagia-free period was 106 days (range 90 - 150 days), but none of the patients was clinically dysphagia-free. CONCLUSION: Placement of a single biodegradable stent is only temporarily effective in the vast majority of patients with RBES treated in a tertiary referral center. Sequential stenting may however be an option to avoid serial dilations.

Endoclips for fixation of nasoenteral feeding tubes: a review.

BACKGROUND: Maintaining the position of an endoscopically placed nasoenteral feeding tube beyond the pylorus is often problematic because of retrograde migration. Fixation of a feeding tube to the small intestinal wall with an endoclip may prevent this. This article reviews available literature on the feasibility, efficacy and safety of endoclips for fixation of nasoenteral feeding tubes. METHODS: A systematic search of the English literature was performed using MEDLINE, EMBASE and Cochrane databases to identify articles assessing the use of endoclips for fixation of feeding tubes, as well as articles assessing duration of attachment of endoclips. RESULTS: Five cohort series were identified that evaluated the applicability of endoclips for fixation of feeding tubes to the small intestinal wall. In all patients, except one, a nasoenteral feeding tube could be successfully fixated to the small intestinal wall. During follow-up, no spontaneous migrations of feeding tubes were observed. No complications related to placement or removal of endoclips were observed. Three comparative studies evaluated duration of attachment of different types of endoclips to the gastrointestinal wall. Duration of attachment ranged from less than 1 week to more than 18 weeks, depending on the type of endoclip. CONCLUSIONS: Based on available literature the use of endoclips for fixation of nasoenteral feeding tubes is feasible, effective and safe. Data from randomized controlled trials are needed.

Stent-in-stent technique for removal of embedded esophageal self-expanding metal stents.

OBJECTIVES: Partially covered self-expanding metal stents (SEMSs) are regularly used for malignant and occasionally for benign esophageal disorders. Safe removal of these stents can be challenging due to embedding of the uncovered stent ends. Our aim is to report the results of removal of embedded, partially covered SEMSs by induction of pressure necrosis using the stent-in-stent technique. METHODS: Consecutive patients referred to three endoscopy units in 2007-2009, treated by the stent-in-stent technique, were reviewed. The partially covered SEMSs were inserted for malignant (n=3) or benign (n=16) conditions and were left in situ for a median of 42 days (14-189). When SEMSs were found to be embedded, a fully covered self-expanding plastic stent (SEPS) or fully covered SEMS was placed inside the partially uncovered SEMS. Subsequent removal of both stents was planned after a period of 10-14 days. RESULTS: In total, 23 stent-in-stent procedures were performed in 19 patients (10 males). Placement of a fully covered stent (SEPS: n=9 and SEMS: n=14) was technically successful in all patients. In 21 of 23 (91%) procedures, both stents were successfully removed in one procedure after a median of 12 days (5-18). In two patients, a repeat stent-in-stent procedure was needed for persistent embedding of the partially uncovered SEMSs. One (5%) procedure was complicated by severe bleeding, which could be treated endoscopically. In seven (36%) patients, the initial disorder had resolved after stent removal and no further endoscopic interventions were needed. Two (10%) patients were treated with chemoradiation or surgery for esophageal cancer after stent removal. In 10 (53%) patients, a repeat endoscopic intervention was required during follow-up because of progressive dysphagia or a persisting leak or fistula. CONCLUSIONS: The stent-in-stent technique is safe and effective for the removal of partially covered SEMSs that are embedded in the esophageal wall.

Esophageal perforation due to removal of partially covered self-expanding metal stents placed for a benign perforation or leak.

Benign esophageal perforations and anastomotic leaks can be effectively managed by stent placement. However, when partially covered self-expanding metal stents (SEMS) are used, safe removal may be complicated. In this case series, we evaluated the complicated removal of SEMS placed for a benign esophageal perforation or leak in four patients. In all patients a partially covered SEMS was placed. After a median stent time of 29 days (range 21 - 30), the SEMS were found to have become embedded in the esophageal wall. Endoscopic removal resulted in perforation in all patients. All patients recovered uneventfully, although one patient underwent esophagectomy. If uncovered SEMS ends become embedded, removal of the stent may cause major damage to the esophageal wall. It is therefore recommended to remove embedded partially covered SEMS only after first placing a fully covered SEMS or self-expanding plastic stent inside this stent to necrotize the ingrown tissue at the uncovered stent ends.