Partially covered versus uncovered pyloro-duodenal stents for unresectable malignant gastric outlet obstruction: Randomized controlled study.

OBJECTIVES: The aim of the current study was to compare the efficacy of partially covered duodenal stent (PCDS) vs. uncovered duodenal stent (UCDS) in patients suffering from unresectable primary malignant gastric outlet obstruction (GOO). METHODS: This was a prospective international randomized controlled study conducted in 10 high-volume institutions. Consecutive patients suffering from malignant GOO were recruited. The primary outcome measurement was the reintervention rate. Secondary outcomes included technical and clinical success, 30-day adverse events, 30-day mortality, causes of stent dysfunction, and the duration of stent patency. RESULTS: Between March 2017 and October 2020, 115 patients (59 PCDS, 56 UCDS) were recruited. The 1-year reintervention was not significantly different (PCDS vs. UDCS = 12/59, 20.3% vs. 14/56, 25%, P = 0.84). There was a trend to fewer patients with tumor ingrowth in the PCDS group (6/59 [10.2%]) vs. 13/56 [23.2%], P = 0.07). There were no significant differences in the technical success (100% vs. 100%, P = 1), clinical success (91.5% vs. 98.2%, P = 0.21), procedural time (21.5 [interquartile range [IQR] 17-30] vs. 20.0 [IQR 15-34.75], P = 0.62), hospital stay (4 [IQR 3-12] vs. 5 [IQR 3-8] days, P = 0.81), 30-day adverse events (18.6% vs. 14.3%, P = 0.62), or 30-day mortality (6.8% vs. 5.2%, P = 1.00). CONCLUSION: The use of PCDS was associated with a lower risk of tumor ingrowth but did not improve on reintervention rates or stent patency. Both kinds of stents could be used in this group of patients.

Endoscopic ultrasonography-guided gastroenterostomy versus uncovered duodenal metal stenting for unresectable malignant gastric outlet obstruction (DRA-GOO): a multicentre randomised controlled trial.

BACKGROUND: Endoscopic ultrasonography-guided gastroenterostomy (EUS-GE) is a novel endoscopic method to palliate malignant gastric outlet obstruction. We aimed to assess whether the use of EUS-GE with a double balloon occluder for malignant gastric outlet obstruction could reduce the need for reintervention within 6 months compared with conventional duodenal stenting. METHODS: The was an international, multicentre, randomised, controlled trial conducted at seven sites in Hong Kong, Belgium, Brazil, India, Italy, and Spain. Consecutive patients (aged ≥18 years) with malignant gastric outlet obstruction due to unresectable primary gastroduodenal or pancreatobiliary malignancies, a gastric outlet obstruction score (GOOS) of 0 (indicating an inability in intake food or liquids orally), and an Eastern Cooperative Oncology Group performance status score of 3 or lower were included and randomly allocated (1:1) to receive either EUS-GE or duodenal stenting. The primary outcome was the 6-month reintervention rate, defined as the percentage of patients requiring additional endoscopic intervention due to stent dysfunction (ie, restenosis of the stent due to tumour ingrowth, tumour overgrowth, or food residue; stent migration; or stent fracture) within 6 months, analysed in the intention-to-treat population. Prespecified secondary outcomes were technical success (successful placement of a stent), clinical success (1-point improvement in gastric outlet obstruction score [GOOS] within 3 days), adverse events within 30 days, death within 30 days, duration of stent patency, GOOS at 1 month, and quality-of-life scores. This study is registered with ClinicalTrials.gov (NCT03823690) and is completed. FINDINGS: Between Dec 1, 2020, and Feb 28, 2022, 185 patients were screened and 97 (46 men and 51 women) were recruited and randomly allocated (48 to the EUS-GE group and 49 to the duodenal stent group). Mean age was 69·5 years (SD 12·6) in the EUS-GE group and 64·8 years (13·0) in the duodenal stent group. All randomly allocated patients completed follow-up and were analysed. Reintervention within 6 months was required in two (4%) patients in the EUS-GE group and 14 (29%) in the duodenal stent group [p=0·0020; risk ratio 0·15 [95% CI 0·04-0·61]). Stent patency was longer in the EUS-GE group (median not reached in either group; HR 0·13 [95% CI 0·08-0·22], log-rank p<0·0001). 1-month GOOS was significantly better in the EUS-GE group (mean 2·41 [SD 0·7]) than the duodenal stent group (1·91 [0·9], p=0·012). There were no statistically significant differences between the EUS-GE and duodenal stent groups in death within 30 days (ten [21%] vs six [12%] patients, respectively, p=0·286), technical success, clinical success, or quality-of-life scores at 1 month. Adverse events occurred 11 (23%) patients in the EUS-GE group and 12 (24%) in the duodenal stent group within 30 days (p=1·00); three cases of pneumonia (two in the EUS-GE group and one in the duodenal stent group) were considered to be procedure related. INTERPRETATION: In patients with malignant gastric outlet obstruction, EUS-GE can reduce the frequency of reintervention, improve stent patency, and result in better patient-reported eating habits compared with duodenal stenting, and the procedure should be used preferentially over duodenal stenting when expertise and required devices are available. FUNDING: Research Grants Council (Hong Kong Special Administrative Region, China) and Sociedad Española de Endoscopia Digestiva.

Changes in mesenteric fat thickness and its clinical impact in bariatric surgery.

Obesity, especially central obesity is associated with increased risk of metabolic syndrome, non-alcoholic fatty liver disease (NAFLD) and type 2 diabetes mellitus. The study aimed to investigate the associations of the changes of abdominal fat thicknesses with changes of anthropometric indexes and improvements of metabolic phenotypes in patients with obesity and T2DM before and after bariatric surgery. Between April 2016 and January 2017, 34 adult patients with concurrent obesity and T2DM scheduled for different bariatric surgeries were prospectively evaluated by ultrasound before and 1-year after bariatric surgery to determine abdominal fat thicknesses (mesenteric fat, preperitoneal fat and subcutaneous fat) and NAFLD. At 1 year, of the 25 patients that finished the study, significant decrease in mesenteric-fat-thickness was associated with significant reduction of obesity, that is, BMI (-24%, p < .001), remission of metabolic syndrome (32%, p = .008), NAFLD (60%, p < .001) and T2DM (44%, p < .001). Lower baseline mesenteric fat thickness was associated with remission of metabolic syndrome. Lower baseline mesenteric-fat-thickness may have the potential to predict metabolic syndrome remission after bariatric surgery.

The effect of Andrographis paniculata water extract on palliative management of metastatic esophageal squamous cell carcinoma-A phase II clinical trial.

Patients with metastatic esophageal squamous cell carcinoma (ESCC) have a grave prognosis with limited life expectancy. Here, a phase II clinical trial was conducted to investigate the effect of Andrographis paniculata (AP) on the palliative care of patients with metastatic ESCC. Patients with metastatic or locally advanced ESCC deemed unfit for surgery, and who have already completed palliative chemotherapy or chemoradiotherapy or are not fit for these treatments, were recruited. These patients were prescribed AP concentrated granules for 4 months. They also received clinical and quality of life assessments for clinical response, as well as positron emission tomography-computed tomography at 3 and 6 months after AP treatment for the assessment of tumor volume. Furthermore, the change in gut microbiota composition after AP treatment was studied. From the results, among the 30 recruited patients, 10 completed the entire course of AP treatment, while 20 received partial AP treatment. Patients who completed the AP treatment achieved significantly longer overall survival periods with the maintenance of the quality of life during the survival period when compared to those who could not complete AP treatment. The treatment effect of AP also contributed to the shift of the overall structure of gut microbiota for ESCC patients towards those of healthy individuals. The significance of this study is the establishment of AP as a safe and effective palliative treatment for patients with squamous cell carcinoma of the esophagus. To the best of our knowledge, this is the first clinical trial of AP water extract in esophageal cancer patients demonstrating its new medicinal use.

EUS-Guided Choledocho-duodenostomy Using Lumen Apposing Stent Versus ERCP With Covered Metallic Stents in Patients With Unresectable Malignant Distal Biliary Obstruction: A Multicenter Randomized Controlled Trial (DRA-MBO Trial).

BACKGROUND & AIMS: Several studies have compared primary endoscopic ultrasound (EUS)-guided biliary drainage to endoscopic retrograde cholangiopancreatography (ERCP) with insertion of metal stents in unresectable malignant distal biliary obstruction (MDBO) and the results were conflicting. The aim of the current study was to compare the outcomes of the procedures in a large-scale study. METHODS: This was a multicenter international randomized controlled study. Consecutive patients admitted for obstructive jaundice due to unresectable MDBO were recruited. Patients were randomly allocated to receive EUS-guided choledocho-duodenostomy (ECDS) or ERCP for drainage. The primary outcome was the 1-year stent patency rate. Other outcomes included technical success, clinical success, adverse events, time to stent dysfunction, reintervention rates, and overall survival. RESULTS: Between January 2017 and February 2021, 155 patients were recruited (ECDS 79, ERCP 76). There were no significant differences in 1-year stent patency rates (ECDS 91.1% vs ERCP 88.1%, P = .52). The ECDS group had significantly higher technical success (ECDS 96.2% vs ERCP 76.3%, P < .001), whereas clinical success was similar (ECDS 93.7% vs ERCP 90.8%, P = .559). The median (interquartile range) procedural time was significantly shorter in the ECDS group (ECDS 10 [5.75-18] vs ERCP 25 [14-40] minutes, P < .001). The rate of 30-day adverse events (P = 1) and 30-day mortality (P = .53) were similar. CONCLUSION: Both procedures could be options for primary biliary drainage in unresectable MDBO. ECDS was associated with higher technical success and shorter procedural time then ERCP. Primary ECDS may be preferred when difficult ERCPs are anticipated. This study was registered to Clinicaltrials.gov NCT03000855.

Endoscopic full-thickness resection (EFTR) compared to submucosal tunnel endoscopic resection (STER) for treatment of gastric gastrointestinal stromal tumors.

Background and study aims Submucosal tunnel endoscopic resection (STER) is being increasingly performed for treatment of gastric gastrointestinal stromal tumor (GIST), while STER has been limited by close dissection within tunnel and risking breach of tumor capsule. Endoscopic full-thickness resection (EFTR) allows resection of GIST with margins to prevent recurrence. This study aimed to compare EFTR against STER for treatment of gastric GIST. Patients and methods We retrospectively reviewed clinical outcomes of patients with gastric GIST who received either STER or EFTR. Patients with gastric GISTs < than 4 cm were included. Clinical outcomes including baseline demographics, perioperative and oncological outcomes were compared between the two groups. Results From 2013 to 2019, 46 patients with gastric GISTs were treated with endoscopic resection, 26 received EFTR and 20 received STER. Most of the GISTs were in the proximal stomach. There was no difference in operative time (94.9 vs 84.9 mins; P  = 0.401), while endoscopic suturing was applied more for closure after EFTR ( P  < 0.0001). Patients after STER had earlier resumption of diet and shorter hospital stay while there was no difference in adverse event rate between two groups. The en-bloc resection rate for EFTR was significantly higher than for STER (100 % vs 80 %; P  = 0.029), while there was no difference in the local recurrence. Conclusions This study demonstrated that although patients who received EFTR had longer hospital stays and slower resumption of diet compared to those who underwent STER, EFTR achieved a significantly higher rate of en-bloc resection compared to STER for treatment of gastric GIST.

Droplet nuclei are generated during colonoscopy and are decreased by the use of carbon dioxide and water immersion technique.

OBJECTIVES: The COVID-19 pandemic has raised concerns on whether colonoscopies (CS) carry a transmission risk. The aim was to determine whether CS are aerosol-generating procedures. METHODS: This was a prospective observational trial including all patients undergoing CS at the Prince of Wales Hospital from 1 June to 31 July 2020. Three particle counters were placed 10 cm from each patient's anus and near the mouth of endoscopists and nurses. The particle counter recorded the number of particles of size 0.3, 0.5, 0.7, 1, 5, and 10 µm. Patient demographics, seniority of endoscopists, use of CO2 and water immersion technique, and air particle count (particles/cubic foot, dCF) were recorded. Multilevel modeling was used to test all the hypotheses with a post-hoc analysis. RESULTS: A total of 117 patients were recruited. During CS, the level of 5 µm and 10 µm were significantly higher than the baseline period (P = 0.002). Procedures performed by trainees had a higher level of aerosols when compared to specialists (0.3 µm, P < 0.001; 0.5 µm and 0.7 µm, P < 0.001). The use of CO2 and water immersion techniques had significantly lower aerosols generated when compared to air (CO2 : 0.3, 0.5, and 0.7 µm: P < 0.001; water immersion: 0.3 µm: P = 0.048; 0.7 µm: P = 0.03). There were no significant increases in any particle sizes during the procedure at the endoscopists' and nurses' mouth. However, 8/117 (6.83%) particle count tracings showed a simultaneous surge of all particle sizes at the patient's anus and endoscopists' and nurses' level during rectal extubation. CONCLUSION: Colonoscopy generates droplet nuclei especially during rectal extubation. The use of CO2 and water immersion techniques may mitigate these risks.

Impact of endoscopic ultrasound-guided gallbladder drainage on reducing costs of reintervention and unplanned readmission: a budget impact analysis.

Background and study aims Endoscopic ultrasound-guided gallbladder drainage (EUS-GBD) is the preferred treatment for patients with acute calculous cholecystitis who are unfit for surgery. The aim of this study was to perform a cost-effective analysis (CEA) comparing EUS-GBD with percutaneous gallbladder drainage (PT-GBD). Patients and methods CEA was performed on patients recruited for our prior randomized controlled trial. A budget impact model was developed to compare the base-case and scenario of EUS-GBD applications. The costs including peri-procedure and intra-procedure, reinterventions, expenses associated with treatment of adverse events (AEs), costs of hospital stay, subsequent clinic follow-up, and unplanned readmission were included. Results PT-GBD had a lower total procedure cost per patient (USD$4,375.00) than EUS-GBD (USD$9,397.44). For EUS-GBD, the cost of cautery-enhanced lumen-apposing stent accounted for the major part of the expense (USD$4,910.26). EUS-GBD resulted in a lower expected cost (USD$108.26 vs USD$1,601.54) for a re-procedure. The expected cost per patient in unplanned readmissions in the EUS-GBD group (USD$450.00) was lower than that in the PT-GBD group (USD$1,717.56). Based on the budget impact analysis, the net budget impact per year of introducing EUS-GBD to replace PT-GBD was higher (USD$16,424.10 vs USD$11,433.08). The net budget impact was most sensitive to the cost of stent and linear echoendoscope used in EUS-GBD. Conclusions The net budget impact per year was higher for introducing EUS-GBD. The cost of the stent accounted for the major cost difference between the two procedures. EUS-GBD saved on the cost in management of AEs, reinterventions, and unplanned readmissions but these did not offset the cost of the stent.

Cigarette smoke promotes colorectal cancer through modulation of gut microbiota and related metabolites.

OBJECTIVE: Cigarette smoking is a major risk factor for colorectal cancer (CRC). We aimed to investigate whether cigarette smoke promotes CRC by altering the gut microbiota and related metabolites. DESIGN: Azoxymethane-treated C57BL/6 mice were exposed to cigarette smoke or clean air 2 hours per day for 28 weeks. Shotgun metagenomic sequencing and liquid chromatography mass spectrometry were parallelly performed on mice stools to investigate alterations in microbiota and metabolites. Germ-free mice were transplanted with stools from smoke-exposed and smoke-free control mice. RESULTS: Mice exposed to cigarette smoke had significantly increased tumour incidence and cellular proliferation compared with smoke-free control mice. Gut microbial dysbiosis was observed in smoke-exposed mice with significant differential abundance of bacterial species including the enrichment of Eggerthella lenta and depletion of Parabacteroides distasonis and Lactobacillus spp. Metabolomic analysis showed increased bile acid metabolites, especially taurodeoxycholic acid (TDCA) in the colon of smoke-exposed mice. We found that E. lenta had the most positive correlation with TDCA in smoke-exposed mice. Moreover, smoke-exposed mice manifested enhanced oncogenic MAPK/ERK (mitogen-activated protein kinase/extracellular signal­regulated protein kinase 1/2) signalling (a downstream target of TDCA) and impaired gut barrier function. Furthermore, germ-free mice transplanted with stools from smoke-exposed mice (GF-AOMS) had increased colonocyte proliferation. Similarly, GF-AOMS showed increased abundances of gut E. lenta and TDCA, activated MAPK/ERK pathway and impaired gut barrier in colonic epithelium. CONCLUSION: The gut microbiota dysbiosis induced by cigarette smoke plays a protumourigenic role in CRC. The smoke-induced gut microbiota dysbiosis altered gut metabolites and impaired gut barrier function, which could activate oncogenic MAPK/ERK signalling in colonic epithelium.

EUS-guided fiducial marker insertion for radiotherapy in advanced esophageal carcinoma: submucosal insertion may lead to less migration when compared to intratumoral insertion.

BACKGROUND: The use of radiotherapy is frequently required in the treatment of locally advanced esophageal squamous cell carcinoma. However, the margins of the tumor are often difficult to ascertain on computed tomography. Thus, EUS-guided fiducial marker insertion can aid the localization of the margins of the tumor. However, the optimal technique of the procedure is still uncertain. METHODS: This was a retrospective study of all patients that received EUS-guided fiducial marker insertion between March 2015 and December 2018. All patients suffering from esophageal squamous cell carcinoma scheduled for radiotherapy underwent the procedure within one week of the scheduled appointment. Gold fiducial markers were inserted under EUS guidance either intratumorally or within the submucosa just proximal and distal to the tumor. Outcome parameters included tumor characteristics, early and late migration rates, and tumor response rates. RESULTS: During the study period, 40 patients were recruited. 10 fiducial markers were placed intratumorally and 30 markers were placed submucosally. When comparing fiducials that were placed in the submucosa versus intratumorally, significantly more fiducials had early (40% vs 0%, RR = 0.6, 95% CI 0.36, 1.00) and late migration (60% vs 0%, RR = 0.33, 95% CI 0.13, 0.84) in the intratumoral group. The submucosal group had significantly more patients intended for curative intent (96.7% vs 70%, RR = 0.34, 95%CI 0.003, 0.361) and more patients with partial and complete response. There was no difference between the gross tumor volume, the clinical target volume, and the total radiation dose. CONCLUSION: In esophageal carcinomas planned for radiotherapy, fiducial markers placed in the submucosa may lead to less migration.

LIMK1 promotes peritoneal metastasis of gastric cancer and is a therapeutic target.

Peritoneal metastasis is a common form of metastasis among advanced gastric cancer patients. In this study, we reported the identification of LIM domain kinase 1 (LIMK1) as a promoter of gastric cancer peritoneal metastasis, and its potential to be a therapeutic target of dabrafenib (DAB). Using transcriptomic sequencing of paired gastric cancer peritoneal metastasis, primary tumors, and normal gastric tissues, we first unveiled that LIMK1 is selectively up-regulated in metastatic tumors. Increased LIMK1 in gastric cancer peritoneal metastasis was validated by immunohistochemistry analysis of an independent patient cohort. In vitro functional studies demonstrated that LIMK1 knockout or knockdown significantly inhibited cell migration and invasion of gastric cancer cells. LIMK1 knockout also abrogated peritoneal and liver metastases of gastric cancer cells in nude mice in vivo. Dabrafenib, a small molecule targeting LIMK1, was found to decrease cell migration and invasion of gastric cancer cells in vitro and abolish peritoneal and liver metastasis formation in vivo. Mechanistically, either LIMK1 knockout or Dabrafenib inhibited LIMK1 expression and phosphorylation of its downstream target cofilin. Taken together, our results demonstrated that LIMK1 functions as a metastasis promoter in gastric cancer by inhibiting LIMK1-p-cofilin and that Dabrafenib has the potential to serve as a novel treatment for gastric cancer peritoneal metastasis.

A prospective 5-year study on the use of transient elastography to monitor the improvement of non-alcoholic fatty liver disease following bariatric surgery.

Liver stiffness measurement (LSM) by transient elastography (TE) is a non-invasive assessment for diagnosing and staging liver fibrosis in non-alcoholic fatty liver disease (NAFLD). Evidence on its role as a longitudinal monitoring tool is lacking. This study aims to evaluate the role of TE in monitoring NAFLD improvement following bariatric surgery. This study prospectively recruited 101 morbidly obese patients undergoing laparoscopic bariatric surgery for intraoperative liver biopsy. Thirty-seven patients of the cohort received perioperative TE. Postoperative anthropometric, biochemical and LSM data were collected annually for 5 years. In 101 patients receiving liver biopsy (mean age 40.0 ± 10.3 years, mean body-mass-index (BMI) 40.0 ± 5.7 kg/m2), NASH and liver fibrosis were diagnosed in 42 (41.6%) and 48 (47.5%) patients respectively. There were 29 (28.7%) stage 1, 11 (10.9%) stage 2, 7 (6.9%) stage 3, and 1 (1.0%) stage 4 fibrosis. In 37 patients receiving TE (mean age 38.9 ± 10.8 years, mean BMI 41.1 ± 5.6 kg/m2), the percentages of total weight loss were 21.1 ± 7.6% at 1 year, 19.7 ± 8.3% at 3 years, and 17.1 ± 7.0% at 5 years after surgery. The mean LSM reduced significantly from 9.8 ± 4.6 kPa at baseline to 6.9 ± 3.4 kPa at 1 year, 7.3 ± 3.0 kPa at 3 years, and 6.8 ± 2.6 kPa at 5 years (P = 0.002). Using pre-defined LSM cut-offs, the rates of significant fibrosis, advanced fibrosis and cirrhosis being ruled out at 5 years improved from baseline values of 43.7 to 87.5% (P < 0.001), 56.8 to 91.7% (P < 0.001), and 64.9 to 91.7% (P < 0.001), respectively. TE was a useful monitoring tool in demonstrating the improvement of liver fibrosis following bariatric surgery.

The effect of bariatric surgery on the improvement of lower urinary tract symptoms in morbidly obese male patients.

BACKGROUND: Lower urinary tract symptoms (LUTS) are strongly linked with obesity. Whether bariatric surgery can effectively alleviate LUTS in morbidly obese men is unknown. The objective of the present study was to evaluate the effectiveness of bariatric surgery in reducing the prevalence and severity of male LUTS in obese patients. METHODS: This was a prospective observational study on consecutive morbidly obese men undergoing bariatric surgery. The International Prostate Symptom Score (IPSS) was used to assess for LUTS before and at 1-3 years after surgery. The 3-year changes in IPSS, the changes in LUTS severity, and the factors associated with LUTS improvement were evaluated. RESULTS: This study recruited 143 morbidly obese men (mean age 43.0 ± 10.4 years) undergoing sleeve gastrectomy (n = 89) and Roux-en-Y gastric bypass (n = 54). The rates of follow-up after surgery were 94.4% (n = 119/126) at 1 year, 90.6% (n = 96/106) at 2 years, and 81.2% (n = 69/85) at 3 years. After surgery, there was significant body mass index reduction from 39.1 ± 5.2 kg/m2 preoperatively to 30.1 ± 4.8 kg/m2 at 1 year and 31.5 ± 4.9 kg/m2 at 3 years (P < 0.001). There was significant reduction in IPSS total symptom score, quality of life score, frequency score, and nocturia score (P < 0.05). The prevalence of moderate to severe LUTS reduced from 35.0% (29.4% moderate; 5.6% severe) preoperatively to 21.8% (19.3% moderate; 2.5% severe) at 1 year and 30.4% (24.6% moderate; 5.8% severe) at 3 years (P < 0.001). LUTS improvement was significantly associated with body fat percentage reduction (P = 0.012) and was not associated with weight loss or improvement of metabolic parameters. CONCLUSIONS: Bariatric surgery was an effective and durable intervention for alleviating the prevalence and severity of LUTS in morbidly obese men for up to 3 years.

EUS-guided gallbladder drainage versus laparoscopic cholecystectomy for acute cholecystitis: a propensity score analysis with 1-year follow-up data.

BACKGROUND AND AIMS: EUS-guided gallbladder drainage (EUS-GBD) is a safe alternative to percutaneous cholecystostomy (PT-GBD) for acute cholecystitis. How the procedure compares with laparoscopic cholecystectomy (LC) is uncertain. The aim of the current study is to compare the outcomes of EUS-GBD with LC for acute cholecystitis. METHODS: This was propensity score analysis of all patients admitted for acute cholecystitis between 2012 and 2018. Consecutive patients who received EUS-GBD or LC were included. Patients were matched for age, sex, and age-adjusted Charlson score. Outcome measurements included 30-day adverse events, mortality, recurrent cholecystitis, recurrent biliary events, reinterventions, and readmissions. RESULTS: During the study period, 60 patients were selected (30 EUS-GBD vs 30 LC) after propensity score matching. Technical success rates (100% vs 100%), clinical success rates (93.3% vs 100%, P = 1), lengths of hospital stay (6.8 [8.1] vs 5.5 [2.7], P = 1), 30-day adverse events (4 [13.3%] vs 4 [13.3%], P = 1), and mortality rates (2 [6.7%] vs 0 [0%], P = .492) were similar. The rates of recurrent biliary events (3 [10%] vs 3 [10%], P = .784), reinterventions (4 [13.3%] vs 3 [10%], P = 1), and unplanned readmissions (3 [10%] vs 3 [10%], P = .784) in 1 year were also similar. CONCLUSIONS: The outcomes of EUS-GBD for acute cholecystitis were comparable with LC with acceptable rates of recurrent acute cholecystitis. These results support the role of EUS-GBD as an alternative to LC in patients who may or may not be surgically fit to undergo definitive cholecystectomy.

Bariatric Surgery in Vegetarians: Asia-Pacific Metabolic and Bariatric Surgery Society (APMBSS) survey of Asian surgeon experience.

PURPOSE: Bariatric and metabolic surgery is increasing in Asia to address the growing obesity epidemic. Literature is scarce regarding this surgery in vegetarian patients. We aim to survey surgeons regarding their practices and experiences with the vegetarian population. MATERIALS AND METHODS: The regional bariatric and metabolic surgery society distributed a multi-national electronic questionnaire to surgeon members. The questionnaire was in the English and Chinese languages. RESULTS: Fifty-six bariatric and metabolic surgeons responded to the questionnaire (response rate 40.6%). Twenty-two respondents (48.9%) have vegetarian patients in their case volume. Patients mostly consume a vegetarian diet for religious (66.7%) and health (66.7%) reasons. More than 60% of surgeons are unsure of micronutrient deficiency status amongst these patients. Over half of the respondents (58.8%) reported that their vegetarian patients do not take multivitamins or vitamin supplements. Significant proportions of respondents (44.4-61.1%) were unsure of the iron, vitamin B12, vitamin D, zinc, and folic acid deficiency status of these patients. Only 38.9% of respondents routinely prescribe multivitamin supplementation. CONCLUSIONS: Vegetarian bariatric patients in East and South-East Asia are an under-recognized patient cohort at risk of micronutrient deficiencies. There is a knowledge gap among regional surgeons in long-term nutritional assessment and management.

An international survey on recognition and characterization of atrophic gastritis and intestinal metaplasia.

Background and study aims Atrophic gastritis (AG) and intestinal metaplasia (IM) are premalignant conditions of gastric cancer and endoscopic recognition and characterization may help in stratifying the gastric cancer risk for screening and surveillance. However, there is currently lack of consensus in defining the severity of AG and IM. We aimed to conduct an international survey to understand the current practice of endoscopists worldwide. Methods An online survey was designed to collect data regarding participants' practice in endoscopic assessment of AG & IM. A test using images was conducted to evaluate the difference in accuracy of characterization of AG & IM. Results From July to October 2017, 249 endoscopists responded to the survey. Around 70 % of participants received some form of training on recognition of AG & IM. There was significant variety in the training received across different continents. One hundred seventy-six participants (70 %) would document the presence of both AG and IM, but the classification systems used were inconsistent between endoscopists. Overall accuracy in diagnosis of AG & IM in the image test was 84.5 % and 80.7 % respectively. The diagnostic accuracy was significantly higher among Japanese and Korean endoscopists compared to the rest of the world. Conclusion Training regarding endoscopic recognition of AG & IM differs significantly in different parts of the world. The difference in diagnostic accuracy for these premalignant gastric conditions may also explain the discrepancy in the early cancer detection rates among different countries. A simple unified classification system may be beneficial for better stratification of cancer risks.

Tissue fusion technology versus suture and staple in porcine bowel anastomosis: an in vivo study.

The aim of this study was to make a comparison between the tissue fusion technique and conventional methods for sealing bowel anastomosis. Eighteen female domestic pigs (Suidae, Sus) were used in our study. Tissue-fused anastomoses (LigaSure groups) were made in 13 animals (5 anastomoses per animal), which were subdivided into 4 groups according to different manufacturing settings: "LigaSure-L-1" and "LigaSure-L-2", with low energy output level with 1 or 2 device-activated tissue sealing times, and "LigaSure-M" and "LigaSure-H", with medium or high energy output level. As controls, automatically stapled (GIA group) and hand-sewn (suture group) anastomoses were utilized in 3 and 2 animals, respectively. There was no statistical difference in the overall leakage rate between the GIA group (6.7%) and the LigaSure groups (15%) (P=1.000). There was less proliferating epithelium covering the anastomosis gap in the LigaSure groups compared with the other two groups. The gap between the two extremities of muscular layers of the anastomosis in the LigaSure groups was filled with collagen fibers. More proliferating cell nuclear antigen (PCNA)-positive cells were found in the anastomoses of the LigaSure groups compared with the other two groups (P=0.010). Our results showed that the tissue fusion technology was a feasible and safe method for anastomoses.

Endosonography-guided gallbladder drainage versus percutaneous cholecystostomy in very high-risk surgical patients with acute cholecystitis: an international randomised multicentre controlled superiority trial (DRAC 1).

OBJECTIVE: The optimal management of acute cholecystitis in patients at very high risk for cholecystectomy is uncertain. The aim of the current study was to compare endoscopic ultrasound (EUS)-guided gallbladder drainage (EUS-GBD) to percutaneous cholecystostomy (PT-GBD) as a definitive treatment in these patients under a randomised controlled trial. DESIGN: Consecutive patients suffering from acute calculous cholecystitis but were at very high-risk for cholecystectomy were recruited. The primary outcome was the 1-year adverse events rate. Secondary outcomes include technical and clinical success, 30-day adverse events, pain scores, unplanned readmissions, re-interventions and mortalities. RESULTS: Between August 2014 to February 2018, 80 patients were recruited. EUS-GBD significantly reduced 1 year adverse events (10 (25.6%) vs 31 (77.5%), p<0.001), 30-day adverse events (5 (12.8%) vs 19 (47.5%), p=0.010), re-interventions after 30 days (1/39 (2.6%) vs 12/40 (30%), p=0.001), number of unplanned readmissions (6/39 (15.4%) vs 20/40 (50%), p=0.002) and recurrent cholecystitis (1/39 (2.6%) vs 8/40 (20%), p=0.029). Postprocedural pain scores and analgesic requirements were also less (p=0.034). The technical success (97.4% vs 100%, p=0.494), clinical success (92.3% vs 92.5%, p=1) and 30-day mortality (7.7% vs 10%, p=1) were statistically similar. The predictor to recurrent acute cholecystitis was the performance of PT-GBD (OR (95% CI)=5.63 (1.20-53.90), p=0.027). CONCLUSION: EUS-GBD improved outcomes as compared to PT-GBD in those patients that not candidates for cholecystectomy. EUS-GBD should be the procedure of choice provided that the expertise is available after a multi-disciplinary meeting. Further studies are required to determine the long-term efficacy. TRIAL REGISTRATION NUMBER: NCT02212717.

Bariatric surgery for Prader-Willi syndrome was ineffective in producing sustainable weight loss: Long term results for up to 10 years.

BACKGROUND: Obesity control in Prader-Willi syndrome (PWS) is notoriously difficult. The role of bariatric surgery in PWS remains controversial as long-term data are lacking. OBJECTIVES: To evaluate the 10-year outcomes of bariatric surgery in PWS. METHODS: This was a prospective observational study on PWS patients who received bariatric surgery and multidisciplinary follow-up programmes for obesity control. Outcomes on weight reduction and comorbidity resolution were evaluated. RESULTS: Between 2008 and 2013, five PWS patients (two males, mean age 19.2 ± 3.0 years) with body mass index of 47.3 ± 6.9 kg m-2 received sleeve gastrectomy (n = 2), one anastomosis gastric bypass (n = 2), and Roux-en-Y gastric bypass (n = 1) after failing all non-operative weight loss programmes. The median follow-up was 8.4 ± 2.2 years. The best mean percentage of total weight loss (%TWL) was achieved at 2 years (24.7%). %TWL dropped to 23.3% at 3 years, 11.9% at 5 years, 4.1% at 8 years, and 0% at 10 years. Each patient had at least three comorbidities preoperatively, but none of them had resolution of any one of the comorbidities at the last follow-up. CONCLUSIONS: Bariatric surgery could not produce sustainable long-term weight loss or comorbidity resolution in PWS. This study suggests that bariatric surgery cannot be recommended to PWS patients as a standard treatment.