Peroral Endoscopic Myotomy: Short Versus Long Esophageal Myotomy for Achalasia Cardia: A Randomized Controlled Noninferiority Trial.

BACKGROUND AND AIMS: The appropriate length of esophageal myotomy in peroral endoscopic myotomy (POEM) for achalasia cardia remains unclear. This study aimed to compare the outcome of short (≤3 cm) and long (≥6 cm) esophageal myotomy in patients with type I and II achalasia cardia. METHODS: This single-blinded, randomized controlled noninferiority trial was conducted at a tertiary center between July 2021 and December 2021. Patients with achalasia types I and II were randomized into short (≤3 cm) and long (≥6 cm) esophageal myotomy groups. The primary outcome of the study was clinical success (Eckardt score ≤3) 1 year after the procedure. The secondary outcomes included a comparison of technical success, operating duration, occurrence of intraoperative adverse events, alterations in integrated relaxation pressure (IRP), change in barium column height after 5 minutes (1 mo), and gastroesophageal reflux disease (3 mo) between the groups. RESULTS: Fifty-four patients were randomized into the short (n=27) or long (n=27) esophageal myotomy groups. Technical success rates were 100% (27/27) and 96.3% (26/27) in short myotomy (SM) and long myotomy (LM) groups, respectively. The clinical success rates were 96.3% (26/27) and 96.2% (25/26) in the SM and LM groups, respectively (P=0.998). The mean (±SD) length of the esophageal myotomy was 2.75±0.36 cm in the SM and 6.69±1.35 cm in the LM groups (P<0.001). The mean (±SD) procedure time for the SM and LM groups was 61.22±8.44 and 82.42±14.70 minutes (P<0.001), respectively. The mean integrated relaxation pressure (IRP), Eckardt score, adverse events, reflux esophagitis, symptomatic gastroesophageal reflux disease, and esophageal acid exposure (>6%) did not differ significantly between the 2 groups following POEM treatment. CONCLUSIONS: Short myotomy is noninferior to long myotomy in terms of clinical success, gastroesophageal reflux disease, and intraoperative adverse events at the short-term follow-up (P>0.05). Short myotomy resulted in a reduced operative time (P<0.05).

Nasojejunal tube-assisted endoscopic ultrasound-guided gastrojejunostomy for the management of gastric outlet obstruction is safe and effective.

Background and aims: Endoscopic ultrasound-guided gastrojejunostomy (EUS-GJ) is a therapeutic option for patients with gastric outlet obstruction (GOO), which provides long-term luminal patency without the risk of tumor ingrowth and/or overgrowth and avoids surgical morbidity. The goal of this study was to assess technical success, clinical success, and adverse events associated with a nasojejunal tube-assisted EUS- GJ technique. Methods: This was a retrospective study conducted at a single tertiary care center. The nasojejunal tube (14F) was used to perform the EUS-GJ (device-assisted method). During the study period, consecutive GOO patients who underwent EUS-GJ between August 2018 and December 2021 were included. Technical success was defined as adequate positioning and deployment of the stent. The patient's ability to tolerate a normal oral diet without vomiting was defined as clinical success. Results: Thirty patients underwent EUS-GJ during this study period. Twenty-six patients had malignant GOO, while four had a benign obstruction. EUS-GJ was successfully performed in 29 patients, and technical success was 96.67% (29/30). Nasojejunal tube-assisted EUS-GJ technique was used in all patients. Clinical success was achieved in all patients who had technical success (29/29, 100%). The adverse events rate was 6.6%. During the procedure, the median procedure time was 25 min (interquartile range 15-42.5), and the average hospitalization was 4.4 days. Normal meals were tolerated by all patients. After 210 days of median follow-up (range 5-880 days), no recurrence of symptoms was observed. Conclusion: The nasojejunal tube-assisted EUS-GJ is a safe and effective technique to treat GOO symptoms.

Fresh-Frozen Plasma as a Low-Cost Replacement of Intravenous Immunoglobulin for the Treatment of Symptomatic Hypogammaglobulinemia.

Hypogammaglobulinemia commonly presents with chronic diarrhea. Unfortunately, these patients require intravenous immunoglobulin (IVIG) transfusions of 400-800 mg/kg every 3-4 weeks as a standard treatment for hypogammaglobulinemia. Repeated transfusion of IVIG is costly, and many patients may not be able to afford it. We report the case of a young male with chronic small intestinal diarrhea who was later diagnosed with hypogammaglobulinemia. We treated the patient with fresh-frozen plasma (FFP) and the patient responded favorably. FFP transfusion may be an affordable alternative to IVIG in the treatment of hypogammaglobulinemia.

Serological Immune Response Following ChAdOx1 nCoV-19 Vaccine (Covishield®) in Patients with Liver Cirrhosis.

Introduction: Data are limited on antibody response to the ChAdOx1 nCoV-19 vaccine (AZD1222; Covishield®) in cirrhosis. We studied the antibody response following two doses of the ChAdOx1 vaccine, given 4−12 weeks apart, in cirrhosis. Methods: Prospectively enrolled, 131 participants (71% males; age 50 (43−58); alcohol-related etiology 14, hepatitis B 33, hepatitis C 46, cryptogenic 21, autoimmune 9, others 8; Child−Turcott−Pugh class A/B/C 52/63/16). According to dose intervals, the participants were grouped as ≤6 weeks (group I), 7−12 weeks (group II), and 13−36 weeks (group III). Blood specimens collected at ≥4 weeks after the second dose were tested for anti-spike antibody titre (ASAb; positive ≥ 0.80 U/mL) and neutralizing antibody (NAb; positive ≥20% neutralization) using Elecsys Anti-SARS-CoV-2 S (Roche) and SARS-CoV-2 NAb ELISA Kit (Invitrogen), respectively. Data are expressed as number (proportion) and median (interquartile range) and compared using non-parametric tests. Results: Overall, 99.2% and 84% patients developed ASAb (titre 5440 (1719−9980 U/mL)) and NAb (92 (49.1−97.6%)), respectively. When comparing between the study groups, the ASAb titres were significantly higher in group II than in group I (2613 (310−7518) versus 6365 (2968−9463), p = 0.027) but were comparable between group II and III (6365 (2968−9463) versus 5267 (1739−11,653), p = 0.999). Similarly, NAb was higher in group II than in group I (95.5 (57.6−98.0) versus 45.9 (15.4−92.0); p < 0.001), but not between the groups II and III (95.5 (57.6−98.0) versus 92.4 (73.8−97.5); p = 0.386). Conclusion: Covishield® induces high titres of ASAb and NAb in cirrhosis. A higher titre is achieved if two doses are given at an interval of more than six weeks.

Retino-Renal Dissociation in Type 2 Diabetes Mellitus: An Observational Cross Sectional Study at a Tertiary Care Center of Sub-Himalayan Region.

INTRODUCTION: Diabetic retinopathy, the diabetes-specific long-term microvascular complication is an important predictor of diabetic nephropathy. Diabetes induced retinopathy mostly proceeds nephropathy in patients with Type1 diabetes; however, this sequence is not consistent in patients with Type 2 diabetes and has significant discordance. METHODS: It was a hospital-based prospective, observational study conducted at Indira Gandhi Medical College, Shimla Himachal Pradesh a tertiary care center in the sub-Himalayan region of India from July 2016 to June 2017. A total of 141 patients were recruited in this study period. RESULTS: 141 patients with type 2 diabetes, 83(58.9%) males,58(41.1%) females were recruited in the study. The mean duration of diabetes in this study was 5.78±6.21 years. Mean HbA1C in our study was 9.66±3.04%. 79(56.0%) patients in our study had HbA1C more than 9.0% while 39(27.7%) had HbA1C between 7.0- 9.0%. only 23 (16.3%) patients had HbA1C less than 7.0%. A total of 118 (83.7%) patients had poor glycaemic control. Out of a total of 141 patients, DKD (albuminuria and/or reduced eGFR) was present in 67 (47.52%) patients. 33 had diabetic retinopathy. CONCLUSION: The relationship between retinopathy and nephropathy in type 2 diabetic patients is not as clear as in type 1 diabetic patients. Patients with type 2 diabetes do not have diabetic nephropathy always and non-diabetic renal disease is also quite common. The absence of retinopathy, rapid progression diabetes, presence of RBC, and cast are some of the atypical findings, and patients presenting with them should be subjected to renal biopsy to rule out non-diabetic renal disease (NDRD).

Short course of low-dose pregabalin is effective for the treatment of restless leg syndrome in patients with cirrhosis: A pilot study.

BACKGROUND AND AIM: Restless leg syndrome (RLS) is common in patients with cirrhosis, but its treatment in such patients remains unclear. This pilot study assessed the clinical effectiveness of intravenous iron and a 6-week course of low-dose (75 mg/day) pregabalin for the treatment of RLS in patients with cirrhosis. METHODS: It was a prospective, interventional study that included adult patients with cirrhosis and RLS. The participants underwent serum ferritin measurement. Patients with low serum ferritin (< 75 µg/dL) were treated with intravenous iron. Those with normal ferritin levels and those with low levels whose RLS symptoms failed to respond to iron replacement were treated with oral pregabalin, initially 75 mg/day for 6 weeks, followed by 150 mg/day for 6 weeks if there was no response. Recurrence of symptoms was assessed at 6-12 weeks after stopping pregabalin. RESULTS: Of the 50 patients (male patients 52%; median age 48 [interquartile range: 21-65] years; median Child-Pugh-Turcotte score 8 [5-13] and median Model for End-Stage Liver disease score 17 [12-20]) studied, 29 (58%) had low ferritin; of them, 14 (48%) responded to intravenous iron alone. Eleven of 15 (38%) patients with low ferritin and nonresponse to iron, and 16 of 21 (76%) with normal ferritin levels had a response with low-dose pregabalin. Of the nine nonresponders who received 150 mg/day of pregabalin, four had to discontinue it because of adverse effects. CONCLUSION: A short course of low-dose (75 mg/day) pregabalin was effective (82%) in alleviating RLS in patients with cirrhosis. (CTRI/2019/02/017642).