Hot avulsion versus argon plasma coagulation for the management of the non-ensnarable polyp: A multicenter, randomized controlled trial.

Background and Aim: Snare resection of nonlifting colonic lesions often requires supplemental techniques. We compared the success rates of neoplasia eradication using hot avulsion and argon plasma coagulation in colonic polyps when complete snare polypectomy had failed. Methods: Polyps that were not completely resectable by snare polypectomy were randomized to argon plasma coagulation or hot avulsion for completion of resection. Argon plasma coagulation was delivered using a forward shooting catheter, using a nontouch technique (flow 1.2 L, 35 watts). Hot avulsion was performed by grasping the neoplastic tissue with hot biopsy forceps and applying traction away from the bowel wall while using EndoCut I or soft coagulation for avulsion. Surveillance colonoscopies were performed at 6, 12, and 18 months. Results: From November 2013 to July 2017, 59 patients were randomized to argon plasma coagulation (28) or hot avulsion (31). The median age was 69 (60-75), with 46% being female. The median residual tissue size was 10 mm (6-12). The residual adenoma rate at 6 months (hot avulsion 6% vs argon plasma coagulation 21% P = 0.09) and 18 months was not different between the groups (6.6% vs 3.6% P = 0.25). One patient in the argon plasma coagulation arm was diagnosed with metastatic cancer of likely colorectal origin despite benign histology in the original polypectomy specimen, supporting the importance of tissue acquisition. Conclusion: Both hot avulsion and argon plasma coagulation are effective and safe modalities to complete resection of non-ensnarable colonic polyps.

Erratum: Cold snare polypectomy of colorectal polyps ≤ 10 mm on clopidogrel: Australian and New Zealand randomized controlled trial.

[This corrects the article DOI: 10.1055/a-1813-1019.].

Is duodenal biopsy always necessary for the diagnosis of coeliac disease in adult patients with high anti-tissue transglutaminase (TTG) antibody titres?

Objective: Avoiding duodenal biopsy in adults for coeliac disease (CD) diagnosis is controversial. Some retrospective and prospective studies have shown that CD can be reliably diagnosed in adults with serology rather than duodenal biopsies. This study aimed to check the accuracy of a cut-off value of ≥10 upper limit of normal of anti-tissue transglutaminase antibody (anti-TTG IgA) titres for CD diagnosis in adult patients. Method: We retrospectively analysed adult patients (≥16 years) who underwent gastroscopy from 2013 to 2018 for positive coeliac serology. The relationship between titres and disease was determined by using linear models, whereas sensitivity and specificity were assessed by receiver operator curve. Results: We analysed 144 newly anti-TTG antibody-positive adult patients with a median age of 48.5 years (IQR 32-62); among them, 86 (60%) patients had CD (Marsh III: n=68 and Marsh II and I: n=18) with a higher prevalence in females (n=59 (69%)) and Europeans (n=60 (70%)). Fifty (58%) patients with CD had colonoscopy and five (6%) had imaging; only six patients were diagnosed with additional conditions. An anti-TTG IgA titre cut-off value of 150 U/L was 100% specific for CD in our dataset, with 70% (95% CI: 60% to 88%) sensitivity for this patient group. Conclusion: Coeliac serology using anti-TTG IgA with titres ≥10× normal value is an excellent predictor of CD, irrespective of age, gender and ethnicity. Duodenal biopsy may not be necessary in selected adult patients with CD, especially younger than 50 years of age without additional gastrointestinal red-flag signs and symptoms.

Quality of life after oesophageal stenting in patients with palliative oesophageal cancer.

AIM: Patients with incurable oesophageal cancer have poor outcomes, with disabling symptoms and a poor quality of life (QOL), which may be improved by oesophageal stenting. We aimed to measure change in symptoms related specifically to oesophageal cancer and overall QOL before and 30 days after stent insertion, to measure adverse effects and to define any patient factors that may be significant in predicting patients who may benefit most. METHODS: We prospectively enrolled patients in an observational study at Middlemore Hospital, New Zealand, and administered validated QOL- and symptomatology-based questionnaires before and 30 days after stent insertion. Additional patient-related demographics, procedural characteristics, adverse events and outcomes were collected. RESULTS: Between 31 March 2014 and 3 July 2020, 57 patients were initially recruited. Four patients withdrew from the study, and 13 patients died before 30 days. Forty patients (29 males; mean±SD age, 72±12 years) completed the study. A significant improvement was noted at one-month post stent insertion in the overall global QOL score (mean 35 to 46, p=0.01). The most significant score improvements were seen in dysphagia, trouble eating, trouble swallowing saliva and dry mouth (p<0.001). Physical, emotional, cognitive and social functioning did not change. Post-procedural adverse events occurred in 17 patients (43%). A poorer initial level of functioning was associated with reduced improvement in global QOL (p≤0.04). Patients followed-up died a mean of 2.8 months after insertion. CONCLUSION: In patients surviving longer than 30 days, there is significant improvement of overall QOL and dysphagia one-month post oesophageal stent insertion for malignant, palliative dysphagia. Multiple psychosocial facets were unchanged with this intervention. Stent-related adverse events were common.

Complications of endoscopically placed duodenal stents for malignant duodenal outlet obstruction.

BACKGROUND: Endoscopically placed duodenal stents are commonly performed procedures for palliation of obstruction due to malignancy. A relatively small number of studies highlight the potential complications of this procedure, and to date no data have been published in New Zealand specifically addressing this issue. We aimed to retrospectively review complications from duodenal stents at our center and factors associated with the complications. METHOD: We retrospectively reviewed our endoscopy reporting system, Provation MD, for patients who underwent endoscopic duodenal stenting between 1 April 2010 and 31 March 2020. We searched the system for the keywords 'prosthesis or stent', 'duodenal mass or tumour' and 'duodenal stenosis or stricture'. Their clinical records were reviewed. Patients were included if they had a duodenal stent inserted to relieve a malignant duodenal obstruction. Patients were excluded if the obstruction was due to a benign pathology or if the obstruction was proximal to duodenum. Patient demographics, the type of stent used and any stent-related complications were recorded. Previous radiotherapy to chest or abdomen was also recorded. RESULTS: We identified 61 patients who underwent palliative endoscopic duodenal stenting. The overall complication rate was 15% (9/61), with five cases of stent migration, two cases of perforation and two cases of late tumour ingrowth requiring re-stenting. Three out of five stent-migration cases had non-obstructive lesions. Both the cases of perforation had previous radiotherapy. CONCLUSION: Duodenal stenting can be performed safely in most patients with malignant duodenal obstruction. The complication rate was found to be higher among the 60-69 age group, the New Zealand Maori/Pacific Islander ethnic group, patients with Niti-S stent and those with duodenal adenocarcinoma as the primary diagnosis, but these higher rates were not found to be statistically significant. Larger studies are required to assess factors associated with complication rates.

Study design of endoscopic polypectomy on clopidogrel (EPOC): A randomised controlled trial.

Concurrent cardiovascular disease and antiplatelet use (clopidogrel, prasugrel and ticagrelor) use poses a significant peri-endoscopic management challenge with a paucity of high-quality evidence available. Antiplatelet temporary interruption places patients at risk of serious cardiovascular thrombotic events. Continuing these agents potentially increases the risk of procedure related bleeding however this risk could be sufficiently mitigated by cold snare polypectomy and endoscopic clipping to manage intraprocedural bleeding, making routine colonoscopy on continued antiplatelet agents safe. The EPOC trial will examine whether continuation of antiplatelet therapy (clopidogrel, prasugrel or ticagrelor) as single or dual therapy with aspirin, is inferior or superior to temporary interruption of antiplatelet therapy, current standard of care, with regard to the use of endoscopic rescue clips or clinically significant post-polypectomy bleeding after cold snare polypectomy of polyps ≤10 mm. EPOC is a parallel group, proceduralist-blinded randomized controlled trial comparing recruiting patients on antiplatelet therapy undergoing elective colonoscopy. This trial is underway throughout Australia and New Zealand with a view to expanding to additional sites. 496 subjects in each arm are required for this study. EPOC is the first randomised controlled trial comparing temporary interruption with continuation of antiplatelet therapy in patients undergoing elective colonoscopy.

Chromoendoscopy versus standard colonoscopy for detection of nonpolypoid dysplasia in patients with inflammatory bowel disease.

AIM: Inflammatory bowel disease (IBD) is associated with an increased risk of colorectal cancer. Studies show that chromoendoscopy (CE) can increase the detection of dysplasia at surveillance colonoscopy, compared to standard white light endoscopy (WLE). We performed a retrospective cohort study to compare standard WLE to CE with targeted biopsies in detecting nonpolypoid dysplasia in IBD patients undergoing surveillance colonoscopy at a single tertiary centre. METHOD: Data was collected on 110 consecutive patients with IBD who underwent surveillance colonoscopy from 1 August 2015 to 31 July 2017 at Counties Manukau District Health Board, Auckland. Patients had either WLE or CE. Patient characteristics, endoscopic and histologic descriptions were reviewed. Rates of dysplasia detection by the different endoscopic techniques were compared using an exact Poisson test. RESULTS: 76/110 (69%) had WLE (mean age 56y; median disease duration 18y) and 34/110 (31%) had CE (median age 59y; median disease duration 19y). Nonpolypoid dysplasia was detected in 0/76 (0%) patients who had WLE. Seven nonpolypoid dysplastic lesions were detected in 4/34 (11.8%) patients who had CE. Dysplasia pick up rate was significantly higher in the CE group with a risk difference of 11.8%, 95% confidence interval (0.93, 22.59), p=0.008. Dysplasia detection rate per patient was also significantly higher in the CE group with a rate difference of 20.6 lesions per 100 patients, 95% confidence interval (5.3, 35.8), p=0.0003. As expected, there was no difference between the number of polypoid dysplastic lesions found between the two groups (p=0.12). CONCLUSION: In our cohort of IBD patients undergoing surveillance colonoscopy, CE with targeted biopsy is associated with a significantly increased nonpolypoid dysplasia detection rate when compared to WLE. These results are comparable to studies performed in the rest of the world.

Efficacy and safety of TC-325 (HemosprayTM) for non-variceal upper gastrointestinal bleeding at Middlemore Hospital: the early New Zealand experience.

AIMS: A case series to review early experiences with HemosprayTM for a variety of non-variceal upper gastrointestinal bleeding (UGIB) at Middlemore Hospital. METHODS: HemosprayTM was administered therapeutically as first line or rescue at the discretion of the endoscopist. All cases of UGIB requiring HemosprayTM at Middlemore Hospital were identified to the investigator who undertook analysis of electronic and hard copy notes. RESULTS: Between October 2013 and July 2016, 36 patients were treated endoscopically with HemosprayTM. Source of bleeding was predominantly gastric in 17, 15 were duodenal and four oesophageal. The majority of lesions were peptic ulcer or post-intervention (78%), with others being Mallory Weiss tear (MWT), gastric mass, Dieulafoy lesion, portal hypertensive gastropathy and post-biopsy. Thirty-one were actively bleeding with mostly oozing haemorrhage (75%). Twenty-three patients were on antithrombotic therapy (ATT), two each on warfarin and low molecular weight heparin (LMWH) and 19 on antiplatelet agents. HemosprayTM was administered therapeutically in all cases, as first line or rescue. Acute haemostasis was achieved in all patients; four (11%) episodes of re-bleeding occurred within seven days, with average follow-up of 16 months. There were no instances of equipment malfunction or adverse events specific to use of HemosprayTM. CONCLUSIONS: Our early experience with HemosprayTM is very promising and there is clear role for HemosprayTM as a rescue therapy when standard methods have failed to achieve haemostasis and possibly as first line in cases of diffuse bleeding not amenable to standard interventions. However, HemosprayTM is not recommended as a standalone therapy for spurting haemorrhage due to the increased frequency of re-bleeding.

Endoscopic Therapy for Treatment of Staple Line Leaks Post-Laparoscopic Sleeve Gastrectomy (LSG): Experience from a Large Bariatric Surgery Centre in New Zealand.

BACKGROUND: Laparoscopic sleeve gastrectomy (LSG) is one of the most commonly performed bariatric procedures for treatment of morbid obesity. Despite its popularity, it is not without risks, the most serious of which is the staple line leak. Staple line leaks are difficult to manage and require significant resources in the form of surgical, radiological and endoscopic interventions; long hospital and intensive care stay and significant morbidity. International experience is slowly emerging, but there are still no clear guidelines regarding optimal management of leaks. This study aims to describe the experience of endoscopic management of these leaks by the authors and the development of a customised stent for this condition. METHODS: Middlemore Hospital is the largest bariatric surgery centre in New Zealand. Since June 2007, a total of 21 patients have received endotherapy for post-LSG leak management. Treatment included the deployment of primary self-expanding metal stents (SEMS) across the leak site, combined with complementary endoscopic modalities. Persistent leaks were treated with follow-up stenting. This study aimed to evaluate the effectiveness of post-LSG staple line leak management at Middlemore Hospital. RESULTS: A total of 20/21 (95 %) patients now have resolved leaks following a mean of 75 days of treatment (median 47, range 9-187). The mean number of endoscopic procedures required was five. Inpatient stay and average duration till leak resolution has been notably reduced since the addition of customised stents. Clinically significant stent migration occurred in 19 % of primary stents. CONCLUSION: The use of SEMS in conjunction with complementary endotherapy has shown to be both safe and effective in treating sleeve leaks; however, migration is the limiting factor for optimal management. Recent improvements in stent design, such as the one proposed in this paper, show promise in addressing this problem. Earlier use of SEMS seems to reduce the time till closure as well as the total hospital stay, as is apparent from our data.

Efficacy of intralesional triamcinolone injections for benign refractory oesophageal strictures at Counties Manukau Health, New Zealand.

BACKGROUND AND AIMS: Refractory benign strictures of the oesophagus can present a significant clinical challenge and may require repeated attempts at dilatation. Intralesional triamcinolone injections have been used in a limited number of studies to aid in the dilatation of benign, refractory oesophageal strictures. It is hypothesised that intralesional steroid injection inhibits the scar formation, thereby reducing the need for dilatations. The purpose of this study was to assess if steroid injection reduces the need for serial endoscopic dilatations and aids in maintaining oesophageal patency. METHOD: We report a case series of 25 patients with refractory oesophageal strictures. The mean age was 75 years and range between 41-95 years. The etiology of strictures consisted of peptic (68%), anastomotic (4%), radiation induced (16%) and eosinophilic oesophagitis (12%). Majority (75%) were distal in location. Triamcinolone (40-80 mg) was injected via 25-gauge sclerotherapy catheter in a four quadrantic manner in aliquots of 0.5 ml each into the proximal end of the stricture and also into the stricture itself after dilatation. Dilatation was carried out with over the guidewire Savary-Gilliard or through the scope (CRE) Balloon dilators depending upon the preference of the endoscopist. Dilatations were continued every 4-6 weeks until asymptomatic and/or endoscopic resolution of stricture. Periodic Dilatation Index (PDI) was calculated by the number of dilatations required over the duration of time in months. RESULTS: The number of dilatations reduced from mean of 3.12 to 1.41 in the peptic strictures but there was no decrease in the other groups. However, the triamcinolone injection resulted in reducing the periodic dilatation index in all groups except the eosinophilic oesophagitis. The rate ratio of PDI before and after intralesional triamcinolone injection use being 0.45 with 95% confidence interval [0.30 -0.68] (p=0.0005). Furthermore triamcinolone injections showed a trend to increase the maximal achieved diameter of the strictures. CONCLUSION: This study demonstrates the efficacy of triamcinolone intralesional steroids in reducing the requirement for repeated dilatations in refractory peptic strictures of oesophagus. Strictures related to eosinophilic oesophagitis failed to demonstrate similar efficacy.

Evolving endoscopic management options for symptomatic stenosis post-laparoscopic sleeve gastrectomy for morbid obesity: experience at a large bariatric surgery unit in New Zealand.

BACKGROUND: Symptomatic stenosis is an increasingly recognised complication following laparoscopic sleeve gastrectomy (LSG) to treat obesity with a reported prevalence between 0.1 and 3.9 %. This study aimed to determine the prevalence and management options for symptomatic stenosis (SS) after LSG. METHODS: A total of 857 patients underwent LSG at Counties Health Auckland New Zealand between May 2008 and June 2013. All cases referred for management of symptomatic stenosis after LSG were recorded. RESULTS: Symptomatic stenosis developed in 26 (3.03 %) out of 857 receiving LSG confirmed by barium swallow. Three of these 26 patients developed a fixed stenosis in the proximal stomach. These were all successfully treated by one dilatation of controlled radial expansion (CRE) balloon of <20 mm. Of the 23 patients that showed a fixed stenosis at the incisura angularis, 16 were initially treated with dilatation by a CRE balloon. Seven of these patients were successfully dilated although one needed two dilatations. Of the nine failures, six were successfully treated using a 30-mm achalasia balloon dilator and the other three required temporary placement of a self-expandable metal stent (SEMS). Based on this experience, seven other patients who presented with strictures at the incisura >3 cm long were initially treated with the achalasia balloon. Five were successfully dilated, but two required temporary placement of a SEMS. None of the 26 patients required a surgical procedure to correct their stenosis. CONCLUSIONS: The use of a 30-mm achalasia balloon and a SEMS is an effective and safe treatment for patients with SS post-LSG who do not respond to dilatation. Achalasia balloon could be the first-line treatment in selected cases.

Endoscopic injection therapy for non-variceal upper gastrointestinal bleeding at Auckland Hospital.

AIM: The aim of this study was to audit the efficacy of endoscopic injection therapy for non-variceal upper gastrointestinal (GI) bleeding at Auckland Hospital. METHODS: The medical records of 183 patients who had undergone endoscopic injection of adrenaline for non-variceal upper GI bleeding at Auckland Hospital between November 1996 and May 1999 were reviewed. RESULTS: Primary haemostasis was achieved in 177 (96.7%) patients and six (3.3%) patients had early surgery due to failure of injection therapy. The overall rate of rebleeding was 18.6%. The rate of rebleeding according to the stigmata seen at the time of endoscopy was 36.8% for patients showing spurting vessel; 24% for active ooze; 18.2% for visible vessel; and 3.2% for adherent clot. Active spurting vessels seen on endoscopy were associated with higher risk of repeat injection (p <0.01) and death (p <0.001). Sixteen (9%) patients had repeat injection. Haemostasis was achieved in all, and no deaths or surgical interventions were observed in this subgroup. CONCLUSIONS: Endoscopic injection therapy is an effective, simple and cheap first-line therapy for non-variceal upper GI bleeding. The repeat injection also appears to be an effective treatment for patients rebleeding after the initial injection therapy.