Background and Aims: Endoscopic full-thickness resection (eFTR) is a field of increasing interest that offers a minimally invasive resection modality for lesions that are not amenable for resection by conventional methods. Full-thickness resection device (FTRD) is a new device that was developed for a single-step eFTR using an over-the scope-clip. In this meta-analysis, we aim to assess the efficacy and safety of FTRD for eFTR of colorectal lesions. Methods: A Comprehensive literature review of different databases to identify studies reporting FTRD with outcomes of interest was performed. Studies with <10 cases were excluded. Rates of histologic complete resection (R0), technical success, and complications were extracted. Efficacy was assessed by using the technical and the R0 rates whereas safety was assessed by using the complications rates. Weighted pooled rates (WPRs) and the 95% confidence interval (CI) were calculated depending on the heterogeneity (I 2 statistics). Results: Nine studies including 551 patients with 555 lesions were included in this study. The WPR for overall R0 was 82.4% (95% CI: 79.0%-85.5%),with moderate heterogeneity (I 2=34.8%). The WPR rate for technical success was 89.25% (95% CI: 86.4%-91.7%), with low heterogeneity (I 2=23.7%). The WPR for total complications rate was 10.2% (7.8, 12.8%) with no heterogeneity. The pooled rate for minor bleeding, major bleeding, postpolypectomy syndrome, and perforation were 3.2%, 0.97%, 2.2%, and 1.2%, respectively. Of 44 periappendicular lesions, the pooled rate for acute appendicitis was 19.7%. Conclusions: FTRD seems to be effective and safe for eFTR of difficult colorectal lesions. Large prospective studies comparing FTRD with conventional resection techniques are warranted.
Discussion: Adults with collagenous gastritis usually present with anemia, abdominal pain, and diarrhea. It is categorized by three different inflammatory environments, a lymphocytic gastritis-like pattern, an eosinophil-rich pattern, and an atrophic gastritis-like pattern. There are many proposed treatments for collagenous gastritis that have not been substantiated with clinical trial data. Observational data suggests that topical budesonide may be efficacious for collagenous gastritis. IV vedolizumab is a monoclonal antibody against a4b7 integrin and is commonly used in inflammatory bowel disease. One proposed mechanism of collagenous gastritis is band-like collagen deposition as a result of inflammation and mucosal injury however this does not consider the active inflammatory milieu found in certain cases. A more likely explanation involves an immune-mediated phenomenon related to epithelial injury and antibody production. Therefore, the efficacy of IV vedolizumab may be related to its ability to reduce the inflammatory response in the intestinal epithelium. Further investigation is necessary to assess the response to vedolizumab in other patients with collagenous gastritis.[3570] Figure 1. Histopathology of gastric body before and after treatment with IV vedolizumab. A, Initial histopathology prior to treatment showing subepithelial collagen deposition of .10 um with sloughing of surface epithelium, loss of specialized gastric glands, and an inflammatory infiltrate of eosinophils, plasma cells, and lymphocytes. B, Initial histopathology prior to treatment with Trichrome stain highlighting collagen deposition. C, Histopathology following treatment with IV vedolizumab showing healthy surface foveolar cells and specialized gastric glands with few plasma cells and no increase in subepithelial collagen. All photomicrographs obtained at 403 original magnification.
Introduction: There are different causes and a broad spectrum of clinical presentations of upper gastrointestinal bleeding (UGIB). There are some rare causes of UGIB that can prove fatal if not identified and treated early. We present the case of a patient with known history of alcohol abuse disorder and recurrent acute pancreatitis complicated by splenic artery pseudoaneurysm causing GI bleed. Case Description/Methods: 60 years old female with past medical history of hepatitis C, recurrent acute alcoholic pancreatitis and liver cirrhosis was hospitalized for administration of intravenous antibiotics to treat infected back wound. On day 12 of hospitalization, she developed hematemesis with hemodynamic instability. She underwent esophagogastroduodenoscopy (EGD) showing a large .5 cm protuberant soft mass-like lesion with superficial ulceration and no active bleed in the gastric fundus. Appearance was concerning for a vascular lesion and CT abdomen was done. CT showed interval enlargement of a presumed previously demonstrated pancreatic pseudocyst measuring 8.6 3 9.1 3 11.1 cm. Density of the pseudocyst contents on CT ranged between 52-56 Hounsfield units consistent with recent bleeding (Figure 1A). Patient developed hematochezia after which CT angiogram with GI protocol was done which did not show active extravasation. Based on imaging, it was initially assumed that patient had hemorrhaged into the presumed pseudocyst that had eroded into the wall of fundus, as seen in the EGD. Patient underwent arterial angiogram with Interventional Radiology (IR). Splenic arteriogram found a splenic artery pseudoaneurysm, instead of a pseudocyst, with new active contrast extravasation supplied by splenic artery. The pseudoaneurysm was most likely secondary to acute recurrent pancreatitis. She underwent Gel foam coil embolization of splenic artery (Figure 1B) with resolution of UGIB. Discussion: Bleeding from splenic artery pseudoaneurysm is very rare with less than 200 cases of splenic artery pseudoaneurysm reported in literature. It may present as an upper or lower GI bleed, or as in our case, both. Suspicion is reasonable in a patient with history of pancreatitis. Bleeding from splenic artery pseudoaneurysm is essential to identify early to reduce morbidity and mortality. This case brings attention to an infrequent yet life-threatening source of GI bleed which may be overlooked as it is rarely encountered and emphasizes the role of IR in management of hemorrhagic pseudoaneurysms. [2639] Figure 1. (a) CT abdomen demonstrating the presumed pseudocyst. (b) Gel foam coil embolization of splenic artery.
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