Benefit, tolerance, and safety of hybrid argon plasma coagulation for treatment of Barrett's esophagus: US pilot study.

Background and study aims A novel technique for Barrett's esophagus (BE) ablation, termed hybrid APC, has recently been developed. The aims of this US pilot study were to evaluate the efficacy, tolerance and safety of hybrid APC for the treatment of BE. Patients and methods Patients with biopsy-proven BE referred to our tertiary care center over a 12-month period for mucosal ablation were eligible for this study. Efficacy of ablation was measured on follow-up endoscopy by demonstrating either a reduction of visible BE or biopsies proving complete resolution of intestinal metaplasia (CRIM). To evaluate tolerance and safety, patients were called on post-procedure days 1 and 7. Results Twenty-two patients with BE (4.5 % intramucosal carcinoma, 31.8 % high-grade dysplasia, 18.1 % low-grade dysplasia, 36.3 % non-dysplastic, 9.1 % indefinite for dysplasia) underwent 40 treatments with hybrid APC. All patients had endoscopic improvement of BE disease and 19 of 22 patients (86.4 %) achieved CRIM. With regard to tolerance, average pain scores (0 to 10 scale) on follow-up were 2.65 and 0.62 on days 1 and 7, respectively. With regards to safety, there were two treatment-related strictures (9.1 %) that required a single balloon dilation. Conclusions Hybrid APC appears to be promising in the treatment of BE. The ablation protocol used in this study demonstrated efficacy, tolerability, and a safety profile similar to radiofrequency ablation. Given the significant price difference between hybrid APC and other modalities for Barrett's ablation, this modality may be more cost-effective. These results warrant further study in a large prospective multicenter trial.

Impedance planimetry values for predicting clinical response following peroral endoscopic myotomy.

BACKGROUND: There is growing interest in developing impedance planimetry as a tool to enhance the clinical outcomes for endoscopic and surgical management of achalasia. The primary aim of this study was to determine whether impedance planimetry measurements can predict clinical response and reflux following peroral endoscopic myotomy (POEM). METHODS: A multicenter cohort study of patients with achalasia undergoing POEM was established from prospective databases and retrospective chart reviews. Patients who underwent impedance planimetry before and after POEM were included. Clinical response was defined as an Eckardt score of ≤ 3. Tenfold cross-validated area under curve (AUC) values were established for the different impedance planimetry measurements associated with clinical response and reflux development. RESULTS: Of the 290 patients included, 91.7 % (266/290) had a clinical response and 39.4 % (108/274) developed reflux following POEM. The most predictive impedance planimetry measurements for a clinical response were: percent change in cross-sectional area (%ΔCSA) and percent change in distensibility index (%ΔDI), with AUCs of 0.75 and 0.73, respectively. Optimal cutoff values for %ΔCSA and %ΔDI to determine a clinical response were a change of 360 % and 272 %, respectively. Impedance planimetry values were much poorer at predicting post-POEM reflux, with AUCs ranging from 0.40 to 0.62. CONCLUSION: Percent change in CSA and distensibility index were the most predictive measures of a clinical response, with a moderate predictive ability. Impedance planimetry values for predicting reflux following POEM showed weak predictive capacity.

Single-center experience demonstrating low adverse events and high efficacy with self-expandable metal esophageal and biliary stents for pseudocyst and walled off necrosis drainage.

Background and study aims Lumen-apposing metal stents (LAMS) have been designed as proprietary stents for the management of pseudocysts (PC)/walled off necrosis (WON). There has been concern about adverse events (AEs) with LAMS including bleeding, buried stent syndrome and migration. Prior to LAMS becoming available, fully-covered self-expandable metal esophageal and biliary stents (FCSEMSs) were used off-label for management of PC/WON with many centers demonstrating low rates of AEs. The primary aim of this study was to study the safety and efficacy of FCSEMS for the management of pseudocysts/WON. Patients and methods This was a retrospective review of all endoscopic ultrasound (EUS)-guided placement of FCSEMSs for drainage of PC/WON cases performed at our institution over 4-year period. The primary outcomes studied were technical success, AEs, PC/WON resolution, and salvage surgical/radiologic intervention. Results Technical success achieved in 65 of 65 (100 %) study patients. An AE occurred 0 of 25 patients (0 %) with PC, and in 10 of 40 patients (25 %) with WON: bleeding (3 %), migration (5 %) and stent dysfunction/infection (18 %). There was resolution in 25 of 25 patients (100 %) with a PC and 31 of 40 patients (78 %) with a WON. Salvage therapy by interventional radiology or surgery was performed in nine of 40 patients (22 %). Conclusions This single-center 4-year experience in the pre-LAMS era showed that FCSEMS was safe and effective in all patients with PC and over 75 % of patients with WON. Given the large cost differential between LAMS and FCSEMS and the efficacy and safety shown with FCSEMS, we believe that FCSEMS should still be considered a first-line option for patients with pancreatic fluid collections, particularly in patients with PCs.

Inflammatory Bowel Disease Training During Adult Gastroenterology Residency: A National Survey of Canadian Program Directors and Trainees.

BACKGROUND: Clinical training in inflammatory bowel disease (IBD) is a mandated component of adult gastroenterology fellowship. This study aims to assess methods of instruction in IBD and identify priorities and gaps in IBD clinical training among residents and program directors (PDs). METHODS: Using both an online and in-person platform, we administered a 15-question PD survey and 19-question trainee survey that assessed the methods of IBD teaching and trainee perceptions of knowledge transfer of 22 IBD topics. The survey was previously developed and administered to US gastroenterology trainees and PDs. RESULTS: Surveys were completed by 9 of 14 (62.3%) PDs and 44 of 62 (71%) trainees. Both trainee years were equally represented (22 residents in each year of training). All respondents were based at university teaching hospitals with full-time IBD faculty on staff. Dedicated IBD rotations were not offered by more than half of training programs, and IBD exposure was most commonly encountered during inpatient rotations. Overall, only 14 (31.2%) trainees were fully satisfied with the level of IBD exposure during their training. Thirty-six (81.8%) trainees reported being comfortable with inpatient IBD management, whereas only 23 (52.3%) trainees reported being comfortable with outpatient IBD management. There was strong concordance between the proportion of PDs ranking an IBD topic as essential and trainee comfort in that area (Pearson's rho 0.59; P=0.004). Fewer than half of trainees reported comfort in 11 of 22 (50%) proposed IBD topics. Identified areas of deficiency included phenotypic and endoscopic classification of IBD, inpatient management of severe active IBD, perianal disease management, monitoring biologic therapy and extra-intestinal manifestations of IBD. CONCLUSIONS: Only one-third of Canadian gastroenterology trainees are fully satisfied with the level of IBD exposure under the current training model. Furthermore, several IBD topics appear to be inadequately covered during training. Our findings, which are similar to previously published US data, highlight the need for additional focus on IBD during gastroenterology residency.

Early experience with use of an endoscopic "hot" scissor-type knife for myotomy during per-oral endoscopic myotomy procedure.

BACKGROUND AND AIMS: Current devices used for per-oral endoscopic myotomy (POEM) function predominantly to either cut tissue or coagulate vessels. When bleeding vessels are encountered within the submucosa or muscle, dedicated coagulation grasping devices are often necessary. An endoscopic "hot" scissor-type knife is available that combines coagulation and cutting functions. Scissor-type knives may therefore be helpful during the POEM procedure. METHODS: We report 4 cases of achalasia that were treated by the POEM procedure using the Stag Beetle scissor-type knife for myotomy. Patients were identified from a prospectively maintained database of patients undergoing POEM at our center between September and October 2017. A single operator (K.J.C.) performed all of the procedures using both a hybrid knife and an SB knife. Demographic and clinical data were collected for all patients. RESULTS: All 4 POEM procedures were performed successfully without any adverse events. Only 3 spontaneous bleeding episodes occurred among the 4 procedures, and no perforation occurred. The patients were all doing very well at clinic follow-up at 4 weeks. CONCLUSIONS: The technique of using the SB knife during myotomy during the POEM procedure is feasible and appears safe. Muscle tissue and blood vessels can be coagulated and cut simultaneously, reducing bleeding and improving control. Further comparative studies are warranted to evaluate the efficacy, safety, and cost effectiveness against existing techniques.

An update on the latest chemical therapies for reflux esophagitis in children.

INTRODUCTION: Gastroesophageal reflux (GER), and its complicated form gastroesophageal reflux disease (GERD) is a common condition in infants and children. As GERD is often considered to cause extra-oesophageal symptoms in children and in the absence of standardized diagnostic and treatment algorithm, many children are inappropriately exposed to empirical anti-reflux treatments, with Acid-Suppressive Medications (ASM); mostly proton pump inhibitors (PPIs). AREAS COVERED: The authors summarize the pharmacological management of pediatric GERD and discuss the efficacy of PPIs as randomized controlled trials have failed to demonstrate their clinical efficacy in the pediatric population. They consider the controversies surrounding the use of PPIs in the pediatric population as increasing evidence suggests of, although controversially, an increased risk of adverse events such as infection of the respiratory or gastrointestinal tract. Esophagitis is a complication that has a significant impact on weight gain and growth, as well as on the quality of life, and in such case, the benefit of treatment largely outweighs the risk. EXPERT OPINION: Clinicians should reserve ASM use for infants and children with proven esophagitis and avoid their routine use in patients with merely symptoms of GER. Treatment need and options must be frequently re-evaluated to reduce the risks associated with ongoing therapy.

Endoscopic augmentation of gastroesophageal junction using a full-thickness endoscopic suturing device.

Background and study aims This preliminary study was conducted to determine the feasibility and safety of endoscopic augmentation of the gastroesophageal junction (GEJ) using the Apollo OverStitch endoscopic suturing system in patients with gastroesophageal reflux disease (GERD) symptoms. Patients and methods Endoscopic augmentation of GEJ was performed on 10 consecutive patients and the data were analyzed retrospectively. Using a double-channel gastroscope affixed to the endoscopic suturing platform, interrupted sutures were placed on the gastric side of the GEJ in 2 layers in order to create a narrowed and elongated GEJ. Results Technical success was achieved in all patients, including those with a history of previous antireflux procedures (n = 7) and those with a hiatal hernia (n = 6). The median follow-up duration was 5 mo (range: 2 - 12). The median pre-procedure GERD-Health Related Quality of Life Questionnaire improved from 20 (range: 11 - 45) to a post-procedure score of 6 (range: 3 - 25) ( P  = 0.001). The median duration of GERD symptom improvement after the procedure was 1 mo (range: 0.5 - 4). Adverse events were limited to 1 patient who developed nausea and vomiting, which was self-limited. Conclusions The use of a novel endoscopic suturing technique for the treatment of GERD is feasible and safe. The procedure resulted in short-term GERD symptom improvement. Further prospective studies using refined techniques are currently underway to improve durability and to prove efficacy.

Frequency and Variables Associated with Fasting Orders in Inpatients with Ulcerative Colitis: The Audit of Diet Orders-Ulcerative Colitis (ADORE-UC) Study.

INTRODUCTION: Current clinical practice guidelines suggest that patients with ulcerative colitis (UC) hospitalized because of a disease flare should be offered a normal diet, unless such a diet is not tolerated. Studies of hospitalized patients have demonstrated iatrogenic malnutrition from unjustified or inappropriate nil per os (NPO) or clear liquid diet (CLD) orders. In this study, we aim to characterize the burden of this problem in hospitalized patients with UC. METHODS: We conducted a retrospective cohort study of all patients with UC admitted to the gastroenterology service or the general internal medicine service at a tertiary, academic hospital between January 2009 and December 2014, with a length of stay between 2 and 30 days. The frequency and duration of bowel rest and CLD orders was recorded, and the number of meals missed because of these orders was assessed. NPO or CLD diet orders were considered justified if the patient had intractable nausea or vomiting, pancreatitis, bowel obstruction, toxic megacolon or were awaiting endoscopy, or if alternative enteral nutrition was provided. Clinical and demographic factors associated with unjustified underfeeding were identified. RESULTS: A total of 187 admissions among 158 patients with UC were identified during the study period and included in the final analysis. Most admissions were to the gastroenterology service (148/187, 79.1%). The mean age at admission was 35.0 years (SD = 15), and 83/158 (52.5%) were female. The median length of stay was 8 days (interquartile range = 4-12). Registered dietician consultation was obtained in only 32 admissions (17.1%), and admission weight was recorded in only 68 (36.4%) admissions. A total of 252 NPO or CLD dietary orders were encountered in 142 admissions (75.9%). Of those, 112 orders were unjustified (44%). On average, patients with unjustified NPO or CLD orders spent 3 days on an NPO or CLD diet, which corresponded to a mean of 10 missed meals. Characteristics associated with unnecessary fasting included female gender, less frequent endoscopic disease staging, less frequent escalation of therapy to prednisone and/or biologics, and admission to a non-gastroenterology service. CONCLUSIONS: There is a high burden of unjustified underfeeding among hospitalized patients with UC, particularly in patients admitted without evidence of objective disease flare. This may lead to nutritional compromise in an at-risk population, and further studies are needed to assess the nutritional impact of unjustified bowel rest on patients with UC. Our findings also suggest that targeted quality improvement interventions are needed to decrease the frequency of inappropriate bowel rest among hospitalized patients with UC.

Ischemic Proctitis Presenting as Rectal Pain and Bloody Diarrhea with No Apparent Cause.

Acute ischemic proctitis is a rare condition usually resulting from severe vascular disease or an acute vascular occlusion. The diagnosis is made on endoscopy, and mortality rates approach 20-40%. Many patients will require a proctectomy as the definitive treatment, especially for gangrenous proctitis. We describe an unusual presentation of acute ischemic proctitis in a patient without preexisting vascular disease or other precipitants. Furthermore, our patient recovered entirely with conservative management and intravenous antibiotics alone. We review the existing literature on ischemic proctitis and highlight the need for future research to better diagnose and manage this rare condition.

Severe Acute Hepatitis B in HBV-Vaccinated Partner of a Patient with Multiple Myeloma Treated with Cyclophosphamide, Bortezomib, and Dexamethasone and Autologous Stem Cell Transplant.

Hepatitis B reactivation can occur with various forms of immunosuppression. Cyclophosphamide, Bortezomib, and Dexamethasone (CYBOR-D) chemotherapy is commonly used for the treatment of multiple myeloma and has not been noted in guidelines to be causative in HBV reactivation. Indeed, current guidelines do not recommend providing antiviral prophylaxis to patients with prior HBV infection. We present a case of HBV reactivation as a result of CYBOR-D and autologous stem cell transplant which is complicated by the patient's partner who developed acute hepatitis B. Our case highlights the need to review the role of antiviral prophylaxis for patients undergoing treatment of multiple myeloma and also the role of ensuring immunity for close contacts of these patients who may also be at risk.