Indian Journal of Gastroenterology最新文献

Background and aims: Peroral endoscopic myotomy (POEM) is an established treatment for achalasia. Conventionally, esophageal myotomy of 6-10 cm length is performed, although its necessity in type-I and type-II achalasia remains debatable. Recent studies suggest that a shorter myotomy may offer similar efficacy with potential advantages. We performed a systematic review and meta-analysis of randomized controlled trials (RCTs) comparing short vs. standard (long) esophageal myotomy during POEM in patients with type-I and type-II achalasia.

Methods: This review was conducted in accordance with PRISMA 2020 guidelines and registered with PROSPERO (CRD42024611252). A systematic search of PubMed, Embase and Scopus was performed to identify RCTs comparing short and long esophageal myotomy during POEM. The primary outcome was clinical success at ≥ 1 year (Eckardt score ≤ 3). Secondary outcomes included procedure time, adverse events, post-POEM integrated relaxation pressure (IRP), barium column height and gastroesophageal reflux disease (GERD). Risk of bias was assessed using the Cochrane RoB 2.0 tool and the certainty of evidence was evaluated using the GRADE framework.

Results: Four RCTs including 419 patients (short, n = 206; long, n = 213) were analyzed. Clinical success at one year was comparable between the two groups (OR 2.17; 95% CI = 0.76-6.23; p = 0.15; I2 = 12%). Procedure time was significantly shorter with short myotomy (MD - 17.69 min; p < 0.001). Rates of adverse events and physiological outcomes (IRP, barium retention) were similar. While overall GERD rates were comparable, esophageal acid exposure was significantly lower in the short myotomy group (OR 0.69; p = 0.04).

Conclusion: Short esophageal myotomy is non-inferior to long myotomy in clinical efficacy with the added benefit of shorter procedure time and potentially reduced acid exposure. These findings support the use of short myotomy as a safe and efficient alternative in type-I and type-II achalasia.

Background and aims: Difficult biliary cannulation with unintentional pancreatic duct cannulation is a challenging issue, even for experienced endoscopists. This prospective, randomized, single-center trial aims to evaluate the safety and efficacy of two advanced rescue cannulation methods in this context: transpancreatic biliary sphincterotomy and pancreatic guidewire-assisted fistulotomy.

Methods: Patients with intact papilla who were planned to undergo bile duct cannulation were screened and those who experienced difficult cannulation with at least two inadvertent pancreatic duct cannulations following unsuccessful double guidewire technique attempts were randomly assigned one of two rescue cannulation techniques: pancreatic guidewire-assisted fistulotomy and transpancreatic biliary sphincterotomy. The primary outcome was the cannulation success rate and the secondary outcome was the frequency of cannulation-related adverse events (trial registration number: IRCT20230314057717N1).

Results: Total 730 patients were screened and 194 were recruited according to the study protocol (97 in each group). Successful biliary cannulation was achieved in 93.8% (n = 91) of the pancreatic guidewire-assisted fistulotomy group and 81.4% (n = 79) of the transpancreatic biliary sphincterotomy group (p-value = 0.01). Multivariate analysis revealed that the transpancreatic biliary sphincterotomy technique and a normal common bile duct diameter were independently associated with unsuccessful cannulation. No significant differences were observed regarding pancreatitis and other adverse events between the two groups (p = 0.31).

Conclusions: In difficult biliary cannulation accompanied by inadvertent pancreatic duct cannulation, following unsuccessful double guidewire technique, pancreatic guidewire-assisted fistulotomy is superior to transpancreatic biliary sphincterotomy for biliary cannulation, with similar rates of adverse events.

Acute pancreatitis is an acute inflammatory disease, which may be associated with pancreatic and peri-pancreatic necrosis and development of (peri)pancreatic fluid collections (PFCs). Interventions in acute pancreatitis have evolved over the years with a paradigm shift from open surgical drainage and necrosectomy to minimally invasive approaches. Depending on the presence of necrosis, the PFCs may be acute necrotic collections or acute pancreatic fluid collections, which evolve over a period of three to four weeks to walled-off necrosis and pseudocysts, respectively. Patients with symptomatic and infected PFCs require drainage. In general, drainage should be delayed beyond three to four weeks when the collection wall has matured and the necrotic debris is liquefied. However, some patients may merit early drainage (within the first three to four weeks), if they have suspected infected pancreatic necrosis and worsening organ dysfunction despite antibiotics and supporting therapy. Endoscopic transmural drainage and necrosectomy have now emerged as the most favored treatment modality in suitable pancreatic collections located predominantly in the lesser sac. Being minimally invasive, per-oral endoscopic direct necrosectomy is as effective as surgical necrosectomy in patients with infected necrotic collections but with fewer adverse events. Percutaneous endoscopic necrosectomy is an important addition to our armamentarium for laterally placed collections as an effective alternative to surgical video-assisted retroperitoneal debridement. The current review provides an overview of the evolution, indications, approaches, techniques and outcomes of endoscopic interventions in the management of pancreatic fluid collections associated with acute pancreatitis. Future direction for better outcomes has been highlighted.

Acute pancreatitis (AP) is a burgeoning challenge. The first week of the disease is generally considered early AP. Events that occur during this phase can determine the magnitude of subsequent events. Even after decades of research, there is still no curative therapy for early AP. One of the earliest events of clinical AP is the co-localization of zymogen and trypsinogen within autophagolysosome which is followed by trypsin activation. The resulting acinar injury releases damaged-associated molecular patterns (DAMPs) that trigger cytokine production by the resident immune cells. Concurrently, there will be neutrophil infiltration, endothelial dysfunction and capillary leak. The local intra-pancreatic inflammation will activate the circulating mononuclear cells traversing the inflamed pancreas and in turn, get activated and perpetuate the systemic inflammatory response syndrome (SIRS). This eventually triggers organ damage. Concurrently, another phenomenon called compensatory anti-inflammatory response syndrome (CARS) ensues, that makes the patient susceptible to infections including infected necrosis. CARS is characterized by the downregulation of human leukocyte antigen (HLA)-DR and results in immunosuppression. The intestine also has a substantial role in determining the severity progression of systemic events in AP. The three components of the intestine that have been implicated include gut mucosal barrier, the microbiota and intestinal lymph. Intestinal inflammation occurs as a part of SIRS and results in the loss of tight junctions and apoptosis of the intestinal epithelial cells thereby increasing the mucosal permeability. Meanwhile, there will be gut microbial dysbiosis resulting in the translocation of pathogens and pathogen-associated molecular patterns (PAMPS) into the circulation. This would result in infections, which was already facilitated by CARS. In addition, the intestinal lymph could also result in translocation of intestinal toxins to the systemic circulation thereby contributing to the severity of AP. This narrative review discusses the current understanding of the mechanisms of early AP and the clinical implications.

Exocrine pancreatic insufficiency (EPI) frequently occurs following gastric resection, although it remains underdiagnosed and insufficiently managed. While pancreatic enzyme supplementation (PES) is the cornerstone of the management of EPI, substantial evidence endorsing its application post-gastric surgery is scarce. This scoping review assesses the occurrence of EPI following gastric resection and the influence of PES in managing these patient populations. All relevant studies related to EPI and PES in patients with gastric resection were reviewed until November 2024. Patient demographics, clinical profiles, method of assessment and prevalence of EPI and the effect of PES were analyzed. Total 14 studies reported EPI after gastric resection and three analyzed the outcome of PES after gastric resection. There was considerable variability in the methodologies employed to evaluate EPI following gastric resection. Earlier studies employed direct tests; however, newer studies have utilized indirect tests, predominantly the fecal elastase test. Both studies employing direct tests indicated an EPI prevalence rate of 100%, whereas those utilizing indirect tests revealed a prevalence rate between 26.8% and 100% (26.8% to 63.8% with fecal elastase). Only four studies reported on the severity of EPI following stomach resection, with significant variability. Lastly, there was a lack of high-quality evidence indicating the benefits of PES following gastric resection. Future studies are needed to develop criteria that facilitate the diagnosis of EPI in individuals who have undergone gastrectomy. Robust clinical trials are necessary to provide definitive proof of PES's efficacy in enhancing patient outcomes.

Background and aims: In chronic pancreatitis, fully covered self-expanding metal stents (FCSEMS) are used to treat refractory pancreatic duct strictures. However, the FCSEMS design, effectiveness, safety, optimal stent indwelling time and patient selection remain unclear. This study aimed at evaluating technical success, clinical success and adverse events with FCSEMS in patients with symptomatic pancreatic duct stricture.

Methods: The prospective study was conducted between May 2017 and May 2021 at a tertiary care center for chronic pancreatitis with refractory pancreatic duct stricture using controlled radial expansion (CRE) endoscopic retrograde cholangiopancreatography (ERCP) with FCSEMS (Niti-S, Bumpy stent, Taewoong Medical, Gimpo-Si, South Korea).

Results: During the study period, a total of 11 patients underwent ERCP with FCSEMS for refractory pancreatic duct stricture. The mean age (± standard deviation, [SD]) was 32.36 ± 10.98 years and nine patients (81%) were male. Technical and clinical success rates were 100% and 90.9%, respectively. All patients had a history of prior pancreatic endotherapy. The median (inter quartile range, [IQR]) stent indwell time was seven (6-10) months. The median visual analogue scale (VAS) pain score pre and post-FCSEMS was 8 (5-8) and 1 (0-2), respectively (p-value 0.003). Median (IQR) follow-up after stent removal was 48 (40-60) months. One patient (9%) developed de novo main pancreatic duct (MPD) stricture, which was asymptomatic. None of the patients had cholangitis, pancreatitis, perforation, proximal migration or stent fracture.

Conclusion: The FCSEMS treatment appears to be safe, feasible and possibly an effective option for patients who have not responded to endoscopic plastic stenting.