Role of surveillance biopsy frequency post intestine transplant: A tertiary care experience

Background: With only 81 intestine transplant (IT) in the U.S. in 2019, the literature on this type of solid organ transplant remains scarce. Frequent surveillance biopsy is required on the first month post IT due to high-risk of acute rejection, however, the frequency of surveillance biopsy 1-month post IT is often determined by the physician and the institutions\u27 preference. Aims: Report IT outcomes and clinical impact of surveillance biopsy at a single tertiary care center. Methods: This is a retrospective review of patients that underwent IT during the time-period between 08/2010 and 03/2020. Primary outcome was the correlation between increased protocol biopsies and mortality. Secondary outcomes included correlation between increased protocol biopsies and hospital re-admissions, length of hospital stay, and rate of biopsy proven rejection detection. Kaplan-Meier curves was used to perform the survival analysis at 6-month, 1-year, and 2-years post-transplant. Results: A total of 35 patients (mean age 47.6 ± 12.9 years, F 22 (63%) underwent IT for: ischemic bowel 11 (31%), Chron\u27s disease 9 (25%), neuroendocrine tumor 6 (17%), trauma 3 (9%) and \u27others\u27 6 (17%), of which 14 (40%) were part of multivisceral organ transplant. During the first-year posttransplant, the median number of biopsies was 12 (IQR 6-30), with evidence of definite acute graft rejection in 40%, 27%, and 41% at the 1-3, 3-6, and 6-12 post IT time intervals, respectively. During the duration of the study, the mortality rate was 18/35 (51%) at a median time of 37 (12-60) months post IT, and a total of 8/35 (23%) patients underwent enterectomy at a median time of 12 (8-36) months post IT (Table 1). In general, there was survival benefit for patients who had a total number of biopsies of ≥ 10 as compared to \u3c 10 biopsies at the time interval of 6-months post IT, (p=0.008) (Table 2). There was a non-significant trend with longer median length of hospital stay in patients with greater number of biopsies. Conclusion: Our results indicate evidence of survival benefit of increased protocol biopsies. Studies with larger sample sizes are required to validate our results

EUS-guided jejuno-enterostomy in a patient with total gastrectomy with Roux-en-Y esophagojejunostomy to facilitate cholangioscopy with electrohydraulic lithotripsy

Video 1EUS-guided jejuno-jejunostomy in a 67-year-old male patient with total gastrectomy with Roux-en-Y esophagojejunostomy to facilitate cholangioscopy with electrohydraulic lithotripsy

Role of gastric per-oral endoscopic myotomy (G-POEM) in post-lung transplant patients: a multicenter experience

Background and study aims: Gastroparesis post-lung transplant (LTx) can lead to increased risk of gastroesophageal reflux (GER) and accelerated graft dysfunction. We aimed to evaluate the efficacy and safety of gastric per-oral endoscopic myotomy (G-POEM), a promising tool in patients with refractory gastroparesis, for managing refractory gastroparesis and GER in post-LTx patients. Patents and methods  This was a multicenter retrospective study on post-LTx patients who underwent G-POEM for management of gastroparesis and GER that were refractory to standard medical therapy. The primary outcome was clinical success post-G-POEM. Secondary outcomes included the rate of post-G-POEM objective esophageal pH exam normalization, rate of gastric emptying scintigraphy (GES) normalization, technical success, and adverse events. Results: A total of 20 patients (mean age 54.7 ± 14.1 years, Female 50 %) underwent G-POEM at a median time of 13 months (interquartile range 6.5-13.5) post-LTx. All G-POEM procedures were technically successful. Clinical success was achieved in 17 (85 %) patients during a median follow-up time of 8.9 (IQR: 3-17) months post-G-POEM. Overall GCSI and two of its subscales (bloating and postprandial fullness/early satiety) improved significantly following G-POEM. Two patients (10 %) developed post-procedural AEs (delayed bleeding 1, pyloric stenosis 1, both moderate in severity). Post-G-POEM GES improvement was achieved in 12 of 16 patients (75 %). All 20 patients were on proton pump inhibitors pre-G-POEM, as opposed to five post-G-POEM. Post-G-POEM PH study normalization was noted in nine of 10 patients (90 %) who underwent both pre- and post-G-poem pH testing. Conclusions: G-POEM is a promising noninvasive therapeutic tool for management of refractory gastroparesis and GER post-LTx

An international experience with single-operator cholangiopancreatoscopy in patients with altered anatomy

Background and study aims: The utility of digital single- operator cholangiopancreatoscopy (D-SOCP) in surgically altered anatomy (SAA) is limited. We aimed to evaluate the technical success and safety of D-SOCP in patients SAA. Patients and methods: Patients with SAA who underwent D-SOCP between February 2015 and June 2020 were retrospectively evaluated. Technical success was defined as completing the intended procedure with the use of D-SOCP. Results: Thirty-five patients underwent D-SOCP (34 D-SOC, 1 D-SOP). Bilroth II was the most common type of SAA (45.7 %), followed by Whipple reconstruction (31.4 %). Twenty-three patients (65.7 %) patients had prior failed ERCP due to the presence of complex biliary stone (52.2 %). A therapeutic duodenoscope was utilized in the majority of the cases (68.6 %), while a therapeutic gastroscope (22.7 %) or adult colonoscope (8.5 %) were used in the remaining procedures. Choledocholithiasis (61.2 %) and pancreatic duct calculi (3.2 %) were the most common indications for D-SOCP. Technical success was achieved in all 35 patients (100 %) and majority (91.4 %) requiring a single session. Complex interventions included electrohydraulic or laser lithotripsy, biliary or pancreatic stent placement, stricture dilation, and target tissue biopsies. Two mild adverse events occurred (pancreatitis and transient bacteremia). Conclusions: In SAA, D-SOCP is a safe and effective modality to diagnose and treat complex pancreatobiliary disorders, especially in cases where standard ERCP attempts may fail

Gastric per-oral endoscopic myotomy (G-POEM) for refractory gastroparesis: results from an international prospective trial

OBJECTIVE: Although gastric per-oral endoscopic myotomy (G-POEM) is considered a promising technique for the management of refractory gastroparesis, high-quality evidence is limited. We prospectively investigated the efficacy and safety of G-POEM in unselected patients with refractory gastroparesis. DESIGN: In five tertiary centres, patients with symptomatic gastroparesis refractory to standard medical therapy and confirmed by impaired gastric emptying were included. The primary endpoint was clinical success, defined as at least one score decrease in Gastroparesis Cardinal Symptom Index (GCSI) with ≥25% decrease in two subscales, at 12 months. GCSI Score and subscales, adverse events (AEs) and 36-Item Short Form questionnaire of quality of life were evaluated at baseline and 1, 3, 6 and 12 months after G-POEM. Gastric emptying study was performed before and 3 months after the procedure. RESULTS: Of 80 enrolled patients, 75 patients (94%) completed 12-month follow-up. Clinical success at 12 months was 56% (95% CI, 44.8 to 66.7). GCSI Score (including subscales) improved moderately after G-POEM (p\u3c0.05). In a regression model, a baseline GCSI Score \u3e2.6 (OR=3.23, p=0.04) and baseline gastric retention \u3e20% at 4 hours (OR=3.65, p=0.03) were independent predictors of clinical success at 12 months, as was early response to G-POEM at 1 month after therapy (OR 8.75, p\u3c0.001). Mild procedure-related AEs occurred in 5 (6%) patients. CONCLUSION: G-POEM is a safe procedure, but showed only modest overall effectiveness in the treatment of refractory gastroparesis. Further studies are required to identify the best candidates for G-POEM; unselective use of this procedure should be discouraged. TRIAL REGISTRATION NUMBER: ClinicalTrials.gov Registry NCT02732821

Use of lumen apposing metal stents in patients with altered gastrointestinal anatomy

PURPOSE OF REVIEW: Lumen apposing metal stents (LAMS) have been increasingly used to manage patients with surgically altered anatomy (SAA), who would have otherwise required percutaneous or surgical interventions. Via the creation of de-novo anastomoses, LAMS provides a conduit to access distal parts of the gastrointestinal tract to perform various interventions. RECENT FINDINGS: Pancreatobiliary (PB) and non-PB interventions are challenging in patients with SAA. Endoscopic ultrasound-directed transgastric endoscopic retrograde cholangiopancreatography (ERCP) (EDGE) and endoscopic ultrasound (EUS)-directed transenteric ERCP (EDEE) are effective procedures that are being increasingly utilized to perform ERCP in patient with Roux-en-Y gastric bypass (RYGB) and non-RYGB SAA, respectively. Furthermore, EUS-directed trans-gastric intervention (EDGI) is a collective term for the non-PB procedures that could be performed in patients with SAA. EDGE/EDEE/EDGI are considered relatively safe procedures, however, intra-procedural stent misdeployement, and long-term ramifications of persistent fistula and stent migration could require endoscopic or, in rare instances, surgical management. SUMMARY: The advent of LAMS has revolutionized the therapeutic capabilities of EUS, by allowing the creation of new gastrointestinal anastomoses. With the growing body of literature, it is expected that such techniques will be more commonly performed in the community, providing less invasive and more effective treatment options for patients with SAA