Digestive Diseases and Sciences最新文献

Introduction: Roux-en-Y gastric bypass (RYGB) related late gastro-jejunal (GJ) strictures are often resistant to endoscopic balloon dilations. Lumen-apposing metal stents (LAMSs) have been used to treat benign strictures with favorable results. However, the data remains limited to justify LAMS use for management of post-RYGB late GJ strictures. We aim to evaluate the safety and efficacy of LAMS placement for the management of late GJ strictures that are refractory to balloon dilations in post-RYGB patients.

Methods: This was a single center retrospective study that included all post-RYGB patients who underwent LAMS placement for management of late GJ strictures that had previously failed balloon dilations. Primary outcomes were technical and clinical success, and secondary outcomes were LAMS-related adverse events.

Results: A total of 28 patients underwent LAMS placement for management of GJ strictures. Median age was 60.5 (IQR 50.5, 67.0) years and majority were females (27, 96.4%). Median interval between surgery and first diagnosis of GJ stricture was 13 years (IQR 7, 17.5). 20 × 10 mm LAMS was the most used stent (n = 24, 85.7%). The median procedure time was 23.5 (IQR 14.5, 32.0) minutes. Technical and short-term clinical success of LAMS placement was 100% (95% CI 87.9-100.0). Long-term success was achieved in 19 out of 25 patients (76.0%, 95% CI 56.6-88.5) that had over 3 months follow-up after LAMS removal. Stent migration was noted in 2 (7.1%) patients, and 1 (3.6%) patient each experienced pain and minor bleeding without the need for additional interventions. No patient in our cohort required surgical revision of GJ anastomosis.

Conclusion: Placement of LAMS is safe, technically feasible, and associated with a high clinical success rate in patients with late GJ strictures after RYGB who have failed prior balloon dilations. Placement of LAMS can be considered early in patients requiring multiple balloon dilations.

Five to 10% of the annual liver transplants in the United States are performed in prior liver recipients with 70% occurring within 1 year of transplantation. Fortunately, the incidence of primary non-function (PNF) has significantly decreased from 8% in the 1980's to < 2%, but PNF and hepatic artery thromboses remain the leading reasons for early emergency retransplantation. Other indications for early retransplantation include severe biliary or vascular complications and refractory rejection. Fortunately, the need for late retransplantation (> 1 year) has also declined due to improved immunosuppression, earlier detection of recurrent disease, and use of oral antiviral agents for recurrent hepatitis C. Patient survival with retransplantation is consistently lower than with primary liver transplantation. Risk factors for poor outcomes with retransplantation include a higher MELD score, ICU status, renal failure, and use of marginal allografts. Therefore, most centers use younger, whole deceased brain-dead donor organs whenever possible. However, increased use of machine perfused livers has expanded the donor pool for these more complex and technically challenging cases. Retransplant recipients have a higher rate of early technical, infectious, and cardiovascular complications compared to primary LT recipients. Going forward, LT recipients with recurrent steatotic and alcoholic liver disease will likely pose ethical, medical, and surgical challenges to the transplant community.

Background: Predicting fibrostenotic complications prior to endoscopy in eosinophilic esophagitis (EoE) is challenging and esophageal strictures and narrowing are commonly missed on endoscopy.

Aim: To develop and validate a score to predict fibrostenosis in EoE patients prior to endoscopy.

Methods: We leveraged a large database of newly diagnosed EoE patients. Fibrostenosis was defined as esophageal stricture, luminal narrowing, or dilation performed during the diagnostic endoscopy. Patients were randomly divided into a development and validation set. We compared features between patients with and without fibrostenosis to inform the initial model and assess predictive ability, as measured by area under curve (AUC). We tested the model in the independent validation set and generated a score to predict low, medium and high fibrostenosis risk.

Results: In 655 newly diagnosed EoE patients in the development set, fibrostenosis was associated with age ≥ 18 years (OR 10.64; 95% CI 5.61-20.17), symptoms for ≥ 5 years prior to diagnosis (OR 2.07; 1.32-3.24), dysphagia (OR 3.72; 1.68-8.22), food impaction (OR 1.68; 1.07-2.62), and lack of abdominal pain (OR 0.28; 0.14-0.60). The model predicted fibrostenosis (AUC = 0.841). In the validation set (n = 654), AUC was preserved (0.831). A scoring system was generated, with scores of ≤ 2 being low risk (< 10% chance of stricture), 2.5-4.5 medium risk (10-50% stricture), and 5-6 high risk (> 50%).

Conclusions: We developed and validated the PICK-UP-STRICS score to increase suspicion and detection of fibrostenotic disease in EoE using readily available clinical features prior to endoscopy. This score may guide clinical decisions on the need of endoscopic dilation.

Background: Crohn's disease (CD) is a chronic inflammatory condition affecting the gastrointestinal tract, characterized by complications such as strictures, fistulas, and neoplasia. Despite medical advancements, a significant number of patients with Crohn's disease require surgery, and many experience post-operative complications and recurrence. Previous studies have analyzed gene expression to study recurrence and post-operative complications independently. This study aims to identify overlapping differentially expressed genes and pathways for recurrence and post-operative complications.

Methods: A dataset including 45 patients with Crohn's disease, including gene expression from ileum and colon tissue, endoscopic recurrence, and intra-abdominal septic complications was analyzed. Gene set enrichment analysis was used to identify gene pathways associated with the outcomes. Finally, a multi-variable logistic regression model was created to assess whether gene pathways were independently associated with both outcomes.

Results: In ileum tissue, several inflammatory pathways, including interferon alpha and gamma response were upregulated in patients with endoscopic recurrence and intra-abdominal septic complications. In addition, there was upregulation of the epithelial mesenchymal transition pathway. In colon tissue, metabolic processes, such as myogenesis and oxidative phosphorylation were downregulated in both outcomes. In a multivariate model, downregulation of myogenesis in colon tissue was significantly associated with both endoscopic recurrence and intra-abdominal septic complications.

Conclusion: These findings shed light on the underlying biology of these outcomes and suggest potential biomarkers or therapeutic targets to reduce their occurrence. Further validation and multi-institutional studies are warranted to confirm these results and improve post-operative outcomes for patients with Crohn's disease.

Background: Most individuals who come under the care of large healthcare systems will have experienced at least one traumatic incident in their lifetime that may continue to influence their mental and physical health, disease management, and engagement with treatment and medical professionals. Histories of trauma are especially common in patients with gastrointestinal (GI) illness. Trauma reactions can arise in GI settings, but healthcare providers may not recognize these reactions or know how to respond effectively.

Aims: We aimed to increase awareness and understanding of the relationship between trauma and GI symptoms, trauma reactions in a healthcare setting, strategies for responding to patients in emotional distress, and opportunities to reduce risk of retraumatization in a GI setting.

Methods: Within a larger initiative to enhance behavioral healthcare access and engagement in a GI setting, patient and stakeholder interviews were conducted, and a needs assessment survey was administered. Interview and survey findings informed development of innovative solutions to the identified need for improved trauma services and resources using an iterative, team-based approach.

Results: Programs and resources were developed and implemented to increase recognition of the impact of trauma, improve responses to trauma reactions during encounters with patients (e.g., clinical and procedure visits, telephone calls), and provide support to patients receiving GI care.

Conclusions: Trauma-focused programming specific to the needs of patients with GI conditions is desired by patients, providers, and staff. Education, intervention, and support initiatives have potential to increase awareness of the effects of trauma and enhance experience of healthcare.

Background and aims: Risk factors of chronic hepatitis B (CHB) immune flares are poorly understood. The primary aim of this study was to discover predictors of the CHB flare in non-cirrhotic, untreated CHB patients and develop a simple risk-stratifying score to predict the CHB flare. The secondary aim was to compare different machine learning methods for prediction.

Methods: A retrospective cohort of untreated, non-cirrhotic CHB patients with normal baseline ALT was followed up over time until an immune flare as defined by ALT twice the upper limit of normal. Statistical learning and machine learning algorithms were used to develop predictive models using baseline variables. Bootstrap validation was used to internally validate the models.

Results: Of 405 patients (median age 44y; 41% male, 10% HBeAg positive), 67 (17%) experienced an immune flare by 5 years (annual incidence 4.0%). Predictors of flare included raised serum globulin, younger age, HBeAg positive status, higher viral load and raised liver stiffness. A simple predictive model "FLARE-B" had optimism-adjusted 1, 3 and 5-year AUCs of 0.813, 0.728 and 0.702, respectively. The random survival forest algorithm had the highest optimism-adjusted AUCs of 0.861, 0.766 and 0.725, respectively.

Conclusions: New, novel predictors of the CHB flare include a raised serum globulin and possibly raised liver stiffness and the absence of liver steatosis. FLARE-B can be used to risk-stratify individuals and potentially guide personalized management strategies such as monitoring schedules and proactive antiviral treatment in high-risk patients.

Background and aims: Since the overwhelmingly positive results of the 'early use of TIPS' published in 2010, studies in Europe and Asia have confirmed early/pre-emptive transjugular intrahepatic portosystemic shunt (p-TIPS) in high-risk patients with acute variceal bleed (AVB) reduces treatment failure and mortality compared to standard of care (SOC). There are no studies evaluating p-TIPS in a US cohort.

Methods: A review of patients with cirrhosis from June 2010 to June 2020 with AVB was conducted from a single large US center.

Results: Of 745 cirrhotic patients with AVB, 18% met criteria for p-TIPS. Alcohol and HCV accounted for 75% of etiology; 13% MASLD. The mean MELD-Na score in our cohort was 24, which is ten points higher than reported in the literature for over 600 p-TIPS cases. Only 9 patients underwent p-TIPS. Patients undergoing p-TIPS were less likely to have MASLD, more likely to be female and less likely to have PSE at baseline. One-year mortality in the SOC group (including patients undergoing 'rescue TIPS') was 53% versus 0% for p-TIPS (p = 0.01).

Conclusion: Our observation suggests hesitancy among providers to recommend p-TIPS, likely due to concerns regarding a 'sicker' patient population. The current SOC in high-risk patients remain suboptimal. Limited data, including our own, suggest that p-TIPS may confer a survival benefit even in patients with high MELD. However, the recommendation of p-TIPS in such patients necessitates validation of its safety and efficacy. Consequently, we advocate for a RCT in the US to conclusively assess the utility of p-TIPS in this context. Until such evidence is established, it is likely that underutilization of this life-saving intervention will persist.