Efficacy of Vonoprazan vs. Intravenous Proton Pump Inhibitor in Prevention of Re-Bleeding of High-Risk Peptic Ulcers: A Randomized Controlled Pilot Study.

Background: Proton pump inhibitor (PPI) therapy is well-established for its effectiveness in reducing re-bleeding in high-risk peptic ulcer patients following endoscopic hemostasis. Vonoprazan (VPZ) has demonstrated the capacity to achieve gastric pH levels exceeding 4, comparable to PPIs. This study aims to evaluate the comparative efficacy of intravenous PPI infusion versus VPZ in preventing re-bleeding after endoscopic hemostasis in patients with high-risk peptic ulcers. Methods: A randomized, double-blind, controlled, and double-dummy design was employed. Patients with peptic ulcer bleeding (Forrest class IA/IB or IIA/IIB) who underwent endoscopic hemostasis were randomly assigned to either the PPI group or the VPZ group. Re-bleeding rates at 3, 7, and 30 days, the number of blood transfusions required, length of hospitalization, and ulcer healing rate at 56 days were assessed. Results: A total of 44 eligible patients were enrolled, including 20 patients (PPI group, n = 11; VPZ group, n = 9) with high-risk peptic ulcers. The mean age was 66 years, with 70% being male. Re-bleeding within 72 h occurred in 9.1% of the PPI group versus 0% in the VPZ group (p = 1.000). There was no significant difference in re-bleeding rates within 7 days and 30 days (18.2% vs. 11.1%, p = 1.000). Additionally, the ulcer healing rate did not significantly differ between the groups (87.5% vs. 77.8%). Conclusions: This pilot study demonstrates comparable efficacy between oral vonoprazan and continuous PPI infusion in preventing recurrent bleeding events among high-risk peptic ulcer patients following successful endoscopic hemostasis.

Lyophilized cell-free supernatants of Limosilactobacillus fermentum T0701 exhibited antibacterial activity against Helicobacter pylori.

Helicobacter pylori is a prominent gastrointestinal pathogen associated with various gastrointestinal illnesses. It presents substantial health risks due to its antibiotic resistance. Therefore, it is crucial to identify alternative treatments for H. pylori infections. Limosilactobacillus spp exhibit probiotic properties with beneficial effects in humans; however, the mechanisms by which it counteracts H. pylori infection are unknown. This study aimed to evaluate the potential of Limosilactobacillus fermentum T0701 lyophilized cell-free supernatants (LCFS) against H. pylori. The LCFS has varying antimicrobial activities, with inhibition zones of up to 10.67 mm. The minimum inhibitory concentration and minimum bacterial concentration of LCFS are 6.25-25.00 mg/mL and 6.25 mg/mL to > 50.00 mg/mL, respectively, indicating its capability to inhibit H. pylori. There is morphological damage observed in H. pylori treated with LCFS. Additionally, H. pylori adhesion to AGS cells (human gastric adenocarcinoma epithelial cells) reduces by 74.23%, highlighting the LCFS role in preventing bacterial colonization. Moreover, LCFS exhibits no cytotoxicity or morphological changes in AGS cells, and with no detected virulence or antimicrobial resistance genes, further supporting its safety profile. L. fermentum T0701 LCFS shows promise as a safe and effective non-toxic agent against H. pylori, with the potential to prevent gastric colonization.

A smartphone application to enhance bowel preparation for first-time colonoscopy: a randomized controlled study.

Background and aims: Colonoscopy is an essential cancer screening tool; however, bowel preparation is a multifaceted process that involves several steps. Proper preparation is crucial for a successful colonoscopy in terms of diagnostic accuracy and procedural safety. We evaluated the performance of a smartphone application with bowel preparation instructions on individuals undergoing their first colonoscopy. Methods: In this randomized, prospective, endoscopist-blinded study, participants were scheduled to undergo their first colonoscopy between January 2020 and January 2022. The study protocol was registered at Thai Clinical Trials Registry (TCTR20190928002). They were randomly assigned to the smartphone education application (APP) or the standard education (control) group. The Boston Bowel Preparation Scale (BBPS) score, polyp detection rate (PDR), and adenoma detection rate (ADR) were compared. Factors associated with excellent bowel preparation were also evaluated. Results: In total, 119 patients (APP group, n = 57; control group, n = 62) underwent their first colonoscopy. The mean BBPS score and proportion of excellent bowel preparation (BBPS≥8) were significantly higher in the APP group than in the control group. Smartphone application-guided bowel preparation achieved a higher proportion of adequate and excellent bowel preparation scores, was associated with other quality indicators, and achieved the target ADR, cecal intubation rate, and adequate withdrawal time. Conclusion: This application may be a user-friendly option to improve the first-time colonoscopy experience, resulting in effective screening of colorectal cancer. Clinical trial registration: The study protocol was registered at Thai Clinical Trials Registry (TCTR20190928002).

Predictive Factors Correlated with Successful Early Endoscopic Removal of Pancreaticolithiasis in Chronic Pancreatitis after Extracorporeal Shock Wave Lithotripsy.

BACKGROUND: The treatment of chronic pancreatitis (CP) and symptomatic pancreatic duct (PD) calculi often involves techniques like endoscopic retrograde cholangiopancreatography (ERCP), extracorporeal shock wave lithotripsy (ESWL), or a combination of both. However, identifying predictive factors for the successful removal of these calculi remains variable. This study aimed to determine the factors predicting successful ESWL and endoscopic removal in CP and PD calculi patients. METHODS: We examined data from CP patients who underwent complete PD calculi removal via ESWL combined with ERCP between July 2012 and 2022, and assessed baseline characteristics, imaging findings, and treatment details. Patients were categorized into early- and late-endoscopic complete removal groups (EER and LER groups, respectively). RESULTS: Of the 27 patients analyzed, 74.1% were male with an average age of 44 ± 9.6 years. EER was achieved in 74% of the patients. Patients in the EER group exhibited smaller PD calculi diameter (8.5 vs. 19 mm, p = 0.012) and lower calculus density (964.6 vs. 1313.3 HU, p = 0.041) compared to the LER group. Notably, PD stricture and the rate of PD stent insertion were not different between the groups. A calculus density threshold of 1300 HU on non-contrast CT demonstrated 71% sensitivity and 80% specificity in predicting EER. CONCLUSIONS: Smaller and low-density PD calculi may serve as predictors for successful EER, potentially aiding in the management of CP patients with PD calculi.

Clinical Outcomes of the Endoscopic Step-Up Approach with or without Radiology-Guided Percutaneous Drainage for Symptomatic Walled-Off Pancreatic Necrosis.

Background and objectives: Symptomatic walled-off pancreatic necrosis is a serious local complication of acute necrotising pancreatitis. The endoscopic step-up approach is the standard treatment for symptomatic walled-off pancreatic necrosis; however, adjunctive radiologic percutaneous drainage for this condition is controversial. This study compared the clinical and radiologic resolution of walled-off pancreatic necrosis achieved with the endoscopic step-up approach with or without radiology-guided percutaneous drainage. Material and Methods: This retrospective, single-centre cohort study enrolled patients with symptomatic walled-off pancreatic necrosis who underwent endoscopic transmural drainage (ETD) followed by directed endoscopic necrosectomy (DEN) with or without radiology-guided drainage. A total of 34 patients (endoscopic approach, n = 22; combined modality approach, n = 12) underwent the endoscopic step-up approach (ETD followed by DEN). Baseline characteristics, clinical success, and resolution of necrosis were compared between groups. Results: All patients achieved symptom resolution from walled-off pancreatic necrosis. The mean patient age was 58.4 years, and 21 (61.8%) were men. Following treatment with the endoscopic approach and combined modality approach, clinical success was achieved in 90.9% of patients within 11.5 days, and 66.7% of patients within 16.5 days, respectively. Both length of hospital stay (55 days vs. 71 days; p = 0.071) and time to complete radiologic resolution were shorter (93 days vs. 124 days; p = 0.23) in the endoscopic approach group. Conclusion: Both the endoscopic step-up approach and the CMD approach resulted in a favourably high clinical resolution rates in patients with symptomatic WON. However, clinical success rates seemed to be higher, and the length of hospital stay tended to be shorter in the endoscopic approach than in the CMD approach, as well as the significantly shorter necrosectomy time in each procedure was observed. Of note, these findings might be from some inherited differences in baseline characteristics of the patients between the two groups, and a randomized controlled trial with a larger sample size to verify these results is warranted.

Postoperative outcomes of resectable periampullary cancer accompanied by obstructive jaundice with and without preoperative endoscopic biliary drainage.

Background: Preoperative biliary drainage (PBD) is useful in resectable periampullary cancer with obstructive jaundice. Whether it is better than direct surgery (DS) in terms of postoperative complications and mortality is controversial. Methods: All cases of successful pancreaticoduodenectomy (PD) in patients with periampullary cancer with obstructive jaundice performed between January 2016 and January 2021 were retrospectively reviewed. Endoscopic PBD was performed; data pertaining to serum bilirubin level, procedural technique, and duration before surgery were obtained. The incidence of postoperative complications and survival rate were compared between the PBD and DS group. Results: A total of 104 patients (PBD, n = 58; DS, n = 46) underwent curative PD. The mean age was 63.8 ± 10 years and 53 (51%) were male. Age, body mass index (BMI), sex, Eastern Cooperative Oncology Group status, presence of comorbid disease, initial laboratory results, and pathological diagnoses were not significantly different between the two groups. The incidence of postoperative complications was 58.6% in the PBD group while 73.9% in the DS group (relative risk [RR] 1.26, 95% confidence interval [CI] 0.92, 1.73, p=0.155) and the difference was not significant except in bile leakage (RR 8.83, 95% CI 1.26, 61.79, p = 0.021) and intraoperative bleeding (RR 3.97, 95% CI 0.88, 17.85, p = 0.049) which were higher in the DS group. The one-year survival rate was slightly less in the DS group but the difference was not statistically significant. The independent predictors for death within 1-year were intraoperative bleeding and preoperative total bilirubin > 14.6 mg/dL. Conclusions: PBD in resectable malignant distal biliary obstruction showed no benefit in terms of 1-year survival over DS approach. But it demonstrated the benefit of lower risks of intraoperative bleeding, and bile leakage. Additionally, the level of pre-operative bilirubin level of over 14.6 mg/dL and having intraoperative bleeding were associated with a lower 1-year survival in such patients. Overall, PBD may be not necessary for all resectable periampullary cancer patients, but there might be a role in those with severely jaundice (>14.6 mg/dL), as it helps lower risk of intraoperative bleeding, and might lead to a better survival outcome.

Diagnostic performance of endoscopic ultrasound-guided tissue acquisition by EUS-FNA versus EUS-FNB for solid pancreatic mass without ROSE: a retrospective study.

BACKGROUND: Endoscopic ultrasound-guided tissue acquisition (EUS-TA) is an established diagnostic procedure for solid pancreatic mass. However, the diagnostic yield between fine-needle aspiration (FNA) and fine-needle biopsy (FNB) remains unclear. We aimed to evaluate and compare the diagnostic yields between FNA and FNB using conventional FNA and Franseen needles of the same size 22-gauge needle, in patients with solid pancreatic mass who underwent EUS-TA without rapid onsite cytopathology evaluation (ROSE). METHODS: All cases of EUS-TA by FNA or FNB for solid pancreatic mass between January 2017 and October 2020 in a single-centre university hospital were retrospectively reviewed. All procedures were performed without an onsite cytologist. Before the endoscopist finished the procedure, macroscopic onsite evaluation (MOSE) was confirmed. The diagnostic yield and the average number of needle passes between FNB and FNA were then compared. RESULTS: A total of 151 patients (FNA, n = 77; FNB, n = 74) with solid pancreatic mass detected by cross-sectional imaging underwent EUS-TA. The mean age was 62.3 ± 12.8 years, with 88 (58.3%) males. Age, sex, mass location, tumour size and disease stage from imaging were not significantly different between the two groups. The diagnostic performance was higher in EUS-FNB (94.6%) than in EUS-FNA (89.6%). The mean number of needle passes was clearly fewer in FNB than in FNA (2.8 vs. 3.8, p < 0.001). The total procedure time was shorter in FNB (34.7 min) than in FNA (41 min). The adverse event rate between FNB and FNA was not significantly different. CONCLUSIONS: The diagnostic yield of solid pancreatic mass was higher in FNB using the Franseen needle than in FNA using the conventional FNA needle in a centre where ROSE is unavailable, without serious adverse event. In addition, FNB had fewer needle passes and shorter total procedure time.

Multiple Esophageal Leiomyoma Presenting with Clinical Dysphagia from Mechanical Obstruction and Motility Disorder.

Esophageal leiomyoma is uncommon. However, this tumor is the most common subepithelial tumor affecting the esophagus, comprising approximately two-thirds of benign esophageal tumors. Leiomyomas of the esophagus rarely cause symptoms when they are single and <5 cm. The mainstay of treatment is esophagectomy for symptomatic patients. A 68-year-old male patient presented with progressive dysphagia for 4 months. The degree of dysphagia and chest discomfort was more severe on solid rather than liquid diet. The CT scan of the chest showed multiple well-defined, submucosal nodules, up to 1.9 cm in diameter located at the middle esophagus. The barium swallow study illustrated multiple, well-defined, smooth, semilunar filling defects along the mid to distal esophagus. Meanwhile, esophagogastroduodenoscopy revealed 8 smooth subepithelial masses. Moreover, the radial EUS showed multiple hypoechoic masses arising from the 4th layer, with some of the tumors connected to others as a horseshoe-like shape causing narrowed lumen. Last, high-resolution esophageal manometry revealed ineffective esophageal motility. We report a rare case of numerous esophageal leiomyomas which caused dysphagia as a result of both mechanical obstruction and hypomotility disorder. The histopathology confirmed the diagnosis of esophageal leiomyoma. Symptoms improved significantly after lifestyle modifications and adherence to dietary advice on the part of the patient.