Initial multicenter experience with nitrous oxide cryoballoon for treatment of flat duodenal adenomas (with video)

© 2020 American Society for Gastrointestinal Endoscopy Background and Aims: EMR is the preferred endoscopic therapy for duodenal adenomas (DAs) but is associated with an overall adverse event rate of 26%. Cryotherapy using a Cryoballoon Focal Ablation System (CbFAS) can safely and effectively eradicate esophageal intestinal metaplasia. We report our first experience with cryoballoon ablation for treatment of flat DAs. Methods: This was an American, multicenter, retrospective study involving 5 centers. DAs (Paris 0-IIa and 0-IIb) were treated with nitrous oxide for 5 to 12 seconds using CbFAS. Follow-up EGD was performed at 3 to 12 months. Results: Seventeen DAs (mean size, 22.7 ± 14.3 mm; 12 tubular, 5 tubulovillous) from 13 patients (mean age, 66.5 ± 9.99 years; 61.5% males) were included in the study. Thirteen of 17 DAs (76.5%) had failed previous treatment, and 4 of 17 (23.5%) were treatment naÏve. All procedures were technically successful and achieved a \u3e50% decrease in size after cryoballoon ablation There was no increase in size or progression of disease for any lesions. Overall, treatment was completed in 15 of 17 patients, and recurrence-free survival was achieved in 12 of 17 (71%) after a median follow-up of 15.5 months (interquartile range [IQR], 6.8-19.4). The median cryoablation time per polyp was 4 minutes (IQR, 1-7.5 minutes), and the median total procedure time was 25 minutes (IQR, 22-30.5 minutes). There were no intra- or postprocedural adverse events. Conclusions: Nitrous oxide cryoballoon ablation of nonpolypoid DAs is feasible, with promising safety and efficacy

International multicenter study on digital single operator pancreatoscopy for the management of pancreatic stones.

Background: The role of the digital single-operator cholangioscopy (D-SOC) system for the treatment of pancreatic ductal (PD) stones in patients with chronic pancreatitis (CP), using electrohydraulic (EHL) and laser lithotripsy (LL), is not well known. Aims: (1)To study the technical success (complete ductal clearance) and safety (rate/ severity of adverse events (AE) per ASGE lexicon) of D-SOC system with EHL/LL in the treatment of pancreatic stones;(2)To compare the performance of EHL vs. LL. Methods: International, multicenter, retrospective study at 17 tertiary centers between 02/2015 and 09/2017. All patients who underwent D-SOC with EHL/LL for the treatment of PD stones were included. Logistic regression analysis was performed to identify factors associated with technical failure and the need for more than one D-SOC EHL/LL session. Results: 103 (30% F, mean age 54 yr.) patients were included. Most frequent cause of CP was alcohol (60%), 96% had abdominal pain, 49% diabetes, 77% were on narcotics and 45% on pancreatic enzymes. Overall, 12% of patients had previous extracorporeal shock wave lithotripsy (ESWL), 87% previous failed ERCP attempts to clear the PD, and 67% prior indwelling stents. Location of stones was: head 51%, neck 22%, body 15%, tail 4%, and multifocal 8%. The mean main PD diameter was 9.19±3.17 mm. A total of 59 patients were treated with EHL and 44 with LL. The mean procedure time was 64.2±23.2 min. Technical success was achieved in 92 (89%) patients, in a single session in 69 (75%) of patients, whereas 20 (21.7%) required 2-3 sessions and only 3 (3.3%) required more than 3 sessions. A total of 11 (11%) patients failed EHL/LL and were treated with ESWL (n=6), surgery (n=1), combined treatment (n=1) or other (n=3). Nine (8.7%) AEs occurred, 3 pancreatitis, 3 abdominal pain, 1 pancreatic duct perforation, 1 fever and 1 bleeding (mild 6 and moderate 3). Incomplete pancreatic stone removal/stone recurrence occurred in 7 (8%) patients during a median follow-up time of 214 days (IQR 66-403). Technical success was significantly higher in the LL group (81% vs 100%,p=0.002) and procedure time was shorter (55min vs. 74min, p\u3c0.001). AEs (8% vs 9%,pZ1) were similar between the two groups. On univariable analysis, the only factor associated with technical failure was the presence of a PD stricture (OR 3.68 (1.00-13.47),p=0.05). There were no significant predictors of the need for more than one D-SOC EHL/LL on logistic regression analysis Conclusion: D-SOC using EHL or LL is highly effective and safe in treating PD stones, although LL appears to be more effective and efficient when compared to EHL. Only a minority of patients will require additional treatment with ESWL or surgery to achieve ductal clearance. This is the first large multicenter study on D-SOC for PD stones and suggests its major role in the treatment of PD stones