Endoscopic outcomes using a novel through-the-scope tack and suture system for gastrointestinal defect closure: a systematic review and meta-analysis.

BACKGROUND: Closure of gastrointestinal defects can reduce postprocedural adverse events. Over-the-scope clips and an over-the-scope suturing system are widely available, yet their use may be limited by defect size, location, operator skill level, and need to reinsert the endoscope with the device attached. The introduction of a through-the-scope helix tack suture system (TTSS) allows for closure of large irregular defects using a gastroscope or colonoscope, without the need for endoscope withdrawal. Since its approval 3 years ago, only a handful of studies have explored outcomes using this novel device. METHODS: Multiple databases were searched for studies looking at TTSS closure from inception until August 2023. The primary outcomes were the success of TTSS alone and TTSS with clips for complete defect closure. Secondary outcomes included complete closure based on procedure type (endoscopic mucosal resection [EMR], endoscopic submucosal dissection [ESD]) and adverse events. RESULTS: Eight studies met the inclusion criteria (449 patients, mean defect size 34.3 mm). Complete defect closure rates for TTSS alone and TTSS with adjunctive clips were 77.2% (95%CI 66.4-85.3; I2=79%) and 95.2% (95%CI 90.3-97.7; I2=42.5%), respectively. Complete defect closure rates for EMR and ESD were 99.2% (95%CI 94.3-99.9; I2 = 0%) and 92.1% (95%CI 85-96; I2=0%), respectively. The adverse event rate was 5.4% (95%CI 2.7-10.3; I2=55%). CONCLUSION: TTSS is a novel device for closure of postprocedural defects, with relatively high technical and clinical success rates. Comparative studies of closure devices are needed.

The Efficacy and Safety of Treatment Outcomes for Refractory Benign Esophageal Strictures Using a Novel Combination of Needle-Knife Stricturoplasty, Balloon Dilation, and Steroid Injection (with Video).

Background and Aims: Benign esophageal strictures often present with dysphagia and can significantly impair a patient's quality of life, especially when refractory to standard endoscopic techniques. When repeat dilations fail to achieve an adequate luminal diameter or resolve dysphagia, further therapy with needle-knife or steroid injections is needed. However, patients can still clinically fail. To manage such strictures, we employed a novel combination of all three techniques. Methods: Single-center case series of adult patients with benign strictures that were refractory to conventional endoscopic therapy and removable self-expanding metal stenting. Primary clinical success was defined as complete resolution in dysphagia. Secondary outcomes included periodic dilation index (frequency of dilations over the follow-up time), esophageal diameter changes, technical success, and complications. Results: Four patients (median age 49.7 years old, interquartile range [IQR] 30-59) underwent endoscopic therapy for complex, benign strictures using our triple therapy technique. Etiologies of the strictures included peptic strictures (n = 3) and an anastomotic stricture (n = 1). There was 100% technical success rate with no associated adverse events. There was a 50% clinical success rate, with 1 additional patient having partial improvement in dysphagia. The median diameter of the esophagus before and after triple therapy was 3.2 mm (IQR 3.5-5.5) and 12.8 mm (IQR 11.7-14.2), respectively. The periodic dilation index was 6.3 before and 1.5 after triple therapy. The median length of follow-up was 362.5 days. Conclusion: Triple combination therapy may be useful in benign strictures that are refractory to standard techniques. Larger studies are needed to validate these findings.

Introdução e objectivos: As estenoses esofágicas benignas apresentam-se frequentemente com disfagia e podem prejudicar significativamente a qualidade de vida, especialmente quando refractárias às técnicas de dilatação endoscópicas padrão. Quando as dilatações não conseguem isoladamente atingir um diâmetro luminal adequado ou resolver a disfagia, são necessárias terapêuticas adicionais (incisão com faca ou injecções de esteróides), embora a taxa de falha clínica não seja desprezível. Para abordagem destas estenoses refratárias utilizámos uma nova combinação das três técnicas. Métodos: Série de casos incluindo doentes adultos com estenoses benignas refractárias à dilatação convencional e à colocação de prótese metálica auto-expansível removível. O endpoint primário foi definido como resolução completa da disfagia. Os endpoints secundários incluíram o índice de dilatação periódica (frequência de dilatações ao longo do tempo de seguimento), alterações do diâmetro esofágico, sucesso técnico e complicações. Resultados: Quatro doentes (idade média 49.7 anos, intervalo interquartil [IQR] 30­59) foram submetidos a terapia endoscópica para estenoses benignas complexas utilizando a técnica de terapêutica tripla. As etiologias das estenoses incluíam estenoses pépticas (n = 3) e estenose anastomótica (n = 1). A taxa de sucesso técnico foi de 100%, sem eventos adversos associados. A taxa de sucesso clínico foi 50%, com um doente adicional apresentando melhoria parcial da disfagia. O diâmetro médio do esófago antes e depois da terapêutica tripla foi de 3,2 mm (IQR 3.5­5.5) e 12.8 mm (IQR 11.7­14.2), respetivamente. O índice de dilatação periódica foi de 6.3 antes e 1.5 após a terapêutica tripla. A duração média do seguimento foi de 362.5 dias. Conclusão: A terapêutica tripla de combinação pode ser útil em estenoses benignas refractários às técnicas convencionais embora sejam necessários estudos adicionais de validação da técnica.

Cold Snare Polypectomy in Small (<10 mm) Pedunculated Colorectal Polyps: A Systematic Review and Meta-analysis.

INTRODUCTION: Endoscopic removal techniques for colorectal polyps include cold snare polypectomy (CSP) and hot snare polypectomy (HSP). Although HSP is recommended for pedunculated polyps (PPs) larger than 10 mm, data regarding use of CSP for PPs <10 mm continues to emerge. We aimed to investigate outcomes of these techniques in small (<10 mm) pedunculated colorectal polyps. METHODS: Multiple databases were searched till June 2022 to identify studies involving the removal of small PPs with CSP and HSP. Random effects model was used to calculate outcomes and 95% CI. Primary outcome was the pooled rate of successful en-bloc resection. Secondary outcomes were immediate and delayed bleeding with CSP and HSP as well as prophylactic and post resection clip placement. RESULTS: Six studies including 1025 patients (1111 polyps with a mean size 4 to 8.5 mm) were analyzed. 116 and 995 polyps were removed with HSP and CSP, respectively. The overall pooled rate of successful en-bloc resection with CSP was 99.7% (CI 99.1-99.9; I2 0%). Pooled immediate and delayed bleeding after CSP was 49.8% (CI 46.8-52.91; I2 98%) and 0% (CI 0.00-0.00; I2 0%), respectively. Delayed bleeding was higher with HSP, relative risk 0.05 (CI 0.01-0.43; I2 0%), P =0.006, whereas immediate bleeding was higher with CSP, relative risk 7.89 (CI 4.36-14.29; I2 0%), P <0.00001. Pooled rates of prophylactic clip placement and post-procedure clip placement (to control immediate bleeding) were 55.3% and 47.2%, respectively. Finally, right colon polyp location significantly correlated with frequency of immediate bleeding. CONCLUSION: Our analysis shows that CSP is safe and effective for resection of small PPs.

Nonalcoholic Fatty Liver Disease (NAFLD) and Cardiovascular Risk: Is Imaging Helpful?

Nonalcoholic Fatty Liver Disease (NAFLD) is proving to be a globally prevalent condition. Moreover, NAFLD may be an independent risk factor associated with higher cardiovascular (CVD) morbidity and mortality. Further studies are needed to assess whether NAFLD needs to be included in the atherosclerotic risk score algorithms or whether patients with NAFLD need to be screened early on to assess their CVD risk especially since imaging such as positron emission tomography can be used to assess both NAFLD and CV disease at the same time. Therefore employing cardiovascular imaging modalities to investigate the incidence, extent, and nature of atherosclerotic lesions in NAFLD may be beneficial. Additionally, whether treating NAFLD halts the progression of CVD on imaging remains to be seen. Further research to delineate NAFLD and CVD associations, deciphering screening imaging modalities, and investigating targeted interventions could improve CVD morbidity and mortality in NAFLD.

An Atypical Presentation of a Polyarticular Gout Flare: Case Report.

A 54-year-old man with a history of hypertension, atrial fibrillation, chronic kidney disease, nonischemic cardiomyopathy, osteoarthritis, and gout presented to the emergency department (ED) with dysuria, painful scrotal swelling, severe bilateral flank pain, back pain, atraumatic right arm (elbow and distally) pain and swelling, and bilateral knee pain. His physical exam was notable for fever, tachycardia, bilateral costovertebral angle (CVA) tenderness, exquisite pain, erythema, and swelling of bilateral knees and the right arm (elbow and distally). He met Systemic Inflammatory Response Syndrome (SIRS) criteria, was placed on Ceftriaxone for presumed septic pyelonephritis, and was admitted to the medicine team. With initially unremarkable imaging studies, the differential diagnosis was broadened, and subsequent infectious workups yielded grossly normal results. At the end of hospital day one, the patient remained febrile and without symptomatic improvement. Rheumatology was consulted and empirically treated; the patient with a dose of Anakinra due to concerns about a polyarticular flare of crystalline arthropathy. Subsequent arthrocentesis confirmed a final diagnosis of a polyarticular gout flare. This case highlights the diagnostic challenges a polyarticular gout flare poses and the importance of early involvement of specialists for prompt recognition, treatment, and avoidance of unnecessary interventions.

Recurrent cholecystitis with complete internal migration of a pigtail stent treated with EUS-guided gallbladder drainage.

Video 1Complete internal migration of a cholecystoduodenal pigtail stent leading to recurrent cholecystitis, which was then rescued with new EUS-guided gallbladder drainage.

Icteric Leptospirosis Leading to Multiorgan Failure and Concomitant Pancreatitis.

Leptospirosis is a zoonotic disease caused by the spirochete Leptospira interrogans with a majority of cases occurring in the tropics. Diagnosing leptospirosis is challenging due to the variable and non-specific clinical presentation. While severe leptospirosis may present with renal failure, liver failure, and pulmonary hemorrhage, there are few described cases of renal failure and liver failure accompanied by pancreatitis and dysrhythmias, particularly in temperate climates. We present a case of severe leptospirosis presenting with bilateral calf pain, acute oliguric renal failure, acute liver failure, dysrhythmias, and pancreatitis. Clinicians must consider this diagnosis in temperate climates and consider testing and empirically treating for leptospirosis in patients with similar symptom constellations, vague symptoms, and lab abnormalities of unknown etiology.

Immunotherapy for Hepatocellular Carcinoma in the Setting of Liver Transplantation: A Review.

The emerging field of immuno-oncology has brought exciting developments in the treatment of hepatocellular carcinoma (HCC). It has also raised urgent questions about the role of immunotherapy in the setting of liver transplantation, both before and after transplant. A growing body of evidence points to the safety and efficacy of immunotherapeutic agents as potential adjuncts for successful down-staging of advanced HCCs to allow successful transplant in carefully selected patients. For patients with recurrent HCC post-transplant, immunotherapy has a limited, yet growing role. In this review, we describe optimal regimens in the setting of liver transplantation.

Building a community of experts in medication-assisted treatment (MAT) using the Project ECHO© model.

BACKGROUND: Project Extension for Community Healthcare Outcomes (ECHO) utilizes telemedicine to connect a multidisciplinary team of experts with a -network of primary care physicians to enable rapid dissemination of evidence-based -guidelines and practices at scale. In this study, the Project ECHO model disseminated the Arizona Pain and Addiction Curriculum to providers in rural Arizona with the goal to educate providers on medication-assisted treatment (MAT). METHODS: Participants engaged in biweekly, virtual teleECHO sessions, and post-session surveys were used to collect data on provider satisfaction, self-efficacy, knowledge, barriers to change, and changes in practice behavior. RESULTS: Between February 2020 and November 2020, the MAT-ECHO program hosted 20 teleECHO sessions (N = 20) with 255 unique participating providers and delivered 877 learning hours. Analysis of a 6-month post-ECHO survey (N = 13) demonstrated that teleECHO sessions had broad geographic outreach. Participants had an average of 12 years of experience, 38 percent held NP/PA professional degrees, and 54 percent practiced in opioid treatment program settings. Assessment of job satisfaction and well-being revealed overall improved satisfaction among the small cohort of nonwaivered respondents (N = 8), except for meeting patient's needs. MAT-waivered respondents reported no post-session changes. CONCLUSIONS: Data from this study demonstrated that teleECHO sessions were well attended, consisted of a diverse cohort with various degrees, and had broad geographic outreach; hence, the utilization of the teleECHO model has the potential to reach rural providers and subsequently increase the availability and -efficacy of MAT in rural America.

Cutaneous Manifestations of Nutritional Deficiencies in the Context of Food Deserts of United States.

Food deserts exist due to a multitude of factors ranging from socioeconomic status, racial disparities, geography, cost, and healthful food access. Given the vast biological function of vitamins and minerals, the clinical presentation for nutritional deficiencies ranges from benign to life-threatening. Often, the first indicators of underlying nutritional deficiencies are cutaneous manifestations. The first patient case is a 36-year-old female at 25 weeks gestation with a pruritic and painful rash that began in the genital region and spread centrifugally to her legs. The second patient case is a 42-year-old male with a pruritic rash that began at his abdomen and progressed to his thighs. The third patient case is a 48-year-old female with scattered lower extremity ecchymoses in different healing stages and scattered perifollicular erythema with corkscrew hairs. All three patients were found to have nutritional deficiencies and lived in identified food deserts. Deficiencies of zinc, vitamin A, thiamine, pyridoxine, and vitamin C and their subsequent cutaneous manifestations have scarce documentation within food deserts. These cases provide further insight into nutritional deficiencies and offer an opportunity for providers to identify patients at risk. To promote wellness, patients suffering from food insecurity must be identified efficiently and connected with essential resources.

The diagnostic performance of probe-based confocal laser endomicroscopy in the detection of gastric cancer: a systematic review and meta-analysis.

Background: Gastric cancer (GC) represents a significant global health burden with high morbidity and mortality, especially when diagnosed at advanced stages. Therefore, early detection of GC is critical. Probe-based confocal laser endomicroscopy (pCLE) is a new evolving technology that uses real-time, high-resolution imaging to inspect the mucosa at the cellular and microvascular level, using a confocal probe. Widespread studies using pCLE are limited at the current time. We aimed to investigate the diagnostic efficacy of this modality for the detection of GC. Methods: Multiple databases were searched from inception until November 2021. The diagnostic performance of pCLE was assessed by calculating its sensitivity, specificity and accuracy for the detection of GC, using pooled proportions and 95% confidence intervals (CI) with a random-effects model. Heterogeneity was assessed using I2. Results: Seven studies were included, with a total of 567 patients (mean age 61.7 years, 364 males). Pooled performance metrics of pCLE included a sensitivity of 87.9% (95%CI 81.4-92.4; P<0.001; I2=0%), specificity 96.5% (95%CI 91.5-98.6; P<0.001; I2=51.84%), and an accuracy of 94.7% (95%CI 89.5-97.4; P<0.001; I2=65.44%). Conclusions: pCLE is a highly effective diagnostic modality for detecting GC. Larger, randomized controlled studies are needed to determine its role in daily practice compared to conventional endoscopic practices.

The diagnostic utility of endocytoscopy for the detection of gastric cancer: a systematic review and meta-analysis.

BACKGROUND/AIMS: Endocytoscopy (ECS) is an evolving technology that utilizes ultra-high power magnification for real time cellular imaging without the need for physical biopsy. Its application for gastric cancer (GC) detection is not well evaluated at the current time, but there is potential that ECS can make a real time histopathological diagnosis to differentiate neoplastic from benign lesions. We aimed to investigate the diagnostic utility of ECS for GC detection. METHODS: Literature searches through multiple databases were performed for studies using ECS for GC detection until November 2021. Measured outcomes included the pooled sensitivity, specificity and accuracy. Quality assessment of diagnostic studies tool was used to assess the risk of bias. RESULTS: Four studies (n=245) were included. The pooled sensitivity was 83.5% (95% CI: 75% - 89%, I2: 0) and specificity was 91.7% (95% CI: 79% - 97%, I2: 58%). The pooled accuracy was 89.2% (95% CI: 83% - 94%, I2: 38%). There was a low risk of bias. CONCLUSIONS: ECS is an accurate diagnostic modality and has the potential to serve as a complimentary tool in screening for GC. Larger prospective studies are needed to validate these findings before its further widespread use.

The Natural History of Pancreatic Cystic Lesions in Liver Transplant Recipients: A Systematic Review and Meta-analysis.

OBJECTIVES: The management of incidentally discovered pancreatic cystic lesions (PCLs) with surveillance or resection often requires shared decision-making. Patients with cirrhosis are more likely to have PCLs discovered due to increased imaging, and those undergoing liver transplantations (LTs) may be at increased risk of carcinogenesis due to immunosuppressive medications. Our study aimed to characterize the outcomes and risk of malignant progression of PCLs in post-LT patients. METHODS: Multiple databases were searched for studies looking at PCLs in post-LT patients from inception until February 2022. Primary outcomes were the incidence of PCLs in LT recipients and progression to malignancy. Secondary outcomes included development of worrisome features, outcomes of surgical resection for progression, and change in size. RESULTS: A total of 12 studies with 17,862 patients with 1411 PCLs were included. The pooled proportion of new PCL development in post-LT patients was 68% (95% confidence interval [CI], 42-86; I2 = 94%) over the follow-up of 3.7 (standard deviation, 1.5) years. The pooled progression of malignancy and worrisome features was 1% (95% CI, 0-2; I2 = 0%) and 4% (95% CI, 1-11; I2 = 89%), respectively. CONCLUSIONS: Compared with nontransplant patients, incidental PCLs do not carry a higher risk of malignancy.

A Rare Case of Mass-Like Hypertrophic Cardiomyopathy.

Mass-like hypertrophic cardiomyopathy (HCM) is a unique variant of HCM. HCM predominantly causes mid-ventricular, concentric hypertrophy, and asymmetric septal hypertrophy; however, focal hypertrophy mimicking a cardiac fibroma is rare. A 29-year-old female with a past medical history of recurrent orthostatic hypotension and syncope presented to the emergency department (ED) complaining of lightheadedness, dizziness, and generalized weakness associated with a syncopal episode. The patient reported a history of recurrent pre-syncope and syncope since her teenage years, as well as a family history of sudden cardiac death. Three years prior to her current presentation, the patient had an exercise stress test, 24-hour Holter monitor, and two echocardiograms that were unremarkable. Three weeks prior to presentation, the patient had a cardiac MRI that revealed focal mass hypertrophy of the basal anterior to mid anterior wall measuring up to 2.5 cm. In the ED, the patient was treated with intravenous fluid and beta-blockers; however, beta-blocker therapy had to be discontinued because the patient was experiencing presyncopal episodes and orthostatic hypotension. The patient was started on midodrine with partial improvement lightheadedness, dizziness, and presyncope. The patient was transferred to a tertiary center with the plan to do serial imaging and place an implantable cardioverter-defibrillator (ICD) if the focal mass thickness reached 3 cm and explore surgical intervention if symptoms worsened. Identifying and reporting anomalous variants of HCM is critical for optimal management of patient care and to improve outcomes.

Sustained Resolution of Multifocal Low-Grade Dysplasia in Ulcerative Colitis.

In inflammatory bowel disease, prolonged disease duration, pancolitis, histological inflammation, and subsequent dysplasia are associated with an increased risk for colorectal cancer. Recommendations regarding treatment of low-grade dysplasia (LGD) indicate an individualized approach between colectomy and surveillance. We present a unique case of a patient with ulcerative colitis who had multifocal LGD on 2 consecutive colonoscopies. However, after 10 years and 16 surveillance colonoscopies, she had no further evidence of dysplasia. This appears to be the first case of proven, permanently resolved multifocal LGD in inflammatory bowel disease that challenges our understanding of the natural history of LGD.

Spontaneous Bacterial Peritonitis in Cardiac Ascites: A Rare but Deadly Occurrence.

BACKGROUND Spontaneous bacterial peritonitis is frequently described in cirrhotic patients who develop infected ascitic fluid. However, ascites can be cardiac in origin. The phenomenon of spontaneous bacterial peritonitis in cardiac ascites is an extremely rare but deadly occurrence. CASE REPORT Here we present a unique case of a patient who was admitted for advanced cardiorenal syndrome in the setting of a viral colitis that likely promoted a bacterial translocation resulting in spontaneous bacterial peritonitis. CONCLUSIONS This case tends to shed light on a few quintessential points for clinicians to be aware of, including the potential intersection between the microbiota and metabolic effects of congestive heart failure and the necessity to lower the diagnostic threshold for spontaneous bacterial peritonitis cardiac ascites in patient's presenting for a congestive heart failure exacerbation.