Table 1. Results of comparison of technical success, clinical success, and rate of adverse events between the transgastric and transduodenal/transjejunal approach METHOD 1-Including studies with patients in both arms N of studies Pooled odds ratio (TG vs. TD/TJ) 95% CI p-value Adverse events 6 1.58 0.46-5.45 0.47 Clinical success 3 0.30 0.06-1.48 0.14 Technical success 3 0.30 0.05-1.89 0.20 METHOD 2-: Including all the studies N of Studies (TG vs TD/TJ) AE(%) 95% CI p-value Adverse events 9 vs 15 27.5% vs 15.2% 17.1%-41.1%) vs (9.5%-23.6%) 0.07 Clinical success 6 vs 13 83.3% vs 91.7% (71.0%-91.0%) vs (82.4%-96.3%) 0.16 Technical success 9 vs 15 91.3% vs 95.6% 83.6%-95.6%) vs 90.7%-97.7%) 0.22 S1118 Safety and Efficacy of the Novel EndoRotor Device for the Treatment of Walled-Off Pancreatic Necrosis (WOPN): A Systematic Review and Meta-Analysis
Introduction: Spontaneous isolated celiac artery dissection (SICAD) is a unique pathology with unclear management guidelines. Complications include hematoma formation and rarely intestinal ischemia. Gastric outlet obstruction (GOO) may occur because of luminal narrowing from ischemic duodenitis or extrinsic compression from hematoma. EUS-guided gastroenterostomy (EUS-GE) is an accepted approach in the management of malignant obstruction however currently there is no guidance for benign obstruction. We describe a case of SICAD complicated by GOO requiring bypass with EUS-GE. Case Description/Methods: A 56 year-old man presented with a weeklong history of epigastric abdominal pain. A computed tomography angiography (CTA) of the abdomen demonstrated a 1.3cm dissection of the celiac artery with associated hemorrhage. He was managed with intravenous anti-hypertensive medications and discharged 2 days later. He returned in 1 week with intractable nausea and vomiting. Repeat CT abdomen demonstrated duodenitis, dilation of the stomach and proximal duodenum and resolving hemorrhage surrounding the celiac artery. Nasogastric decompression returned 1100ml bilious output. Esophagogastroduodenoscopy (EGD) demonstrated edematous mucosa within the proximal duodenum with luminal narrowing preventing passage of the scope. The decision was made to proceed with EGD-EUS. EUS demonstrated a dilated. Celiac artery with a areas of hemorrhage within the celiac axis and adjacent to the duodenum. After successful creation of an EUS-GE the patient was discharged on oral intake a day later. Surveillance imaging 2 months later demonstrated improvement of hemorrhage. (Figure ) Discussion: Our case Illustrates a rare case of GOO as a result of a hematoma causing duodenal compression. Until the recently, the only option for management for benign GOO was radical surgical intervention. Endoscopic management with either ballon dilation or intraduodenal stents are poor choices due to risk of perforation and durable patency is not guaranteed. Current guidelines do not provide recommendations on EUS-GE for benign etiologies of GOO. Small retrospective studies have illustrated success however prospective and randomized trials are needed to demonstrate efficacy and safety in benign causes of GOO.[2823] Figure 1. Panel A. EGD with duodenal narrowing. B. EUS demonstrating celiac artery dissection. C. Lumen-apposing metal stent (LAMS).
Introduction: Incidental elevations in Carbohydrate Antigen 19-9 (CA19-9) can trigger extensive medical evaluations for malignancy. Though classically associated with pancreatic cancer, CA19-9 is a nonspecific manifestation of multiple benign and malignant disease processes. Case Description/Methods: An asymptomatic, healthy 50-year-old female presented to primary care for an elevated CA19-9 level obtained for pancreatic cancer screening in Asia in 2019. Her evaluation in 2019 included abdominopelvic CT and magnetic retrograde cholangiopancreatography, which were normal. She was offered endoscopic ultrasonography to further evaluate pancreaticobiliary etiologies but was lost to follow-up amid the COVID-19 pandemic. She returned to the US in 2021, and basic laboratory testing and routine cervical cancer screening were performed. She was referred to Gastroenterology (GI) for further evaluation. Cervical cytology revealed atypical endometrial cells, and endometrial biopsy by gynecology was concerning for gastric-type endocervical adenocarcinoma. Transvaginal ultrasound revealed a thickened endometrial stripe, and pan CT revealed duodenal thickening, for which GI performed bidirectional endoscopy without significant abnormalities and no pancreatic or metastatic disease. Repeat CA19-9 increased. She was referred to gynecologic oncology, where cervical biopsy and pelvic MRI confirmed an endocervical mass. She was diagnosed with Stage IIB gastric-type endocervical adenocarcinoma and underwent hysterectomy and left salpingectomy with adjuvant chemoradiation. Discussion: CA19-9 is synthesized in multiple organ systems. Elevations in asymptomatic patients are rarely predictive of pancreatic cancer but may expose patients to unnecessary testing and inadvertent harms without identifying malignancy. Thus, CA19-9 is not recommended for pancreatic cancer screening. Incidental elevations do warrant repeat testing. Benign processes will yield stable or decreasing levels, while rising levels suggest progressive or malignant processes. If concern for pancreatic malignancy is low, a reasonable investigation includes chest X-ray or CT, metabolic studies, hemoglobin A1c, liver and thyroid function panels, abdominopelvic CT or gynecologic cancer evaluation, and any other age-indicated cancer screening. In this case, prior imaging studies suggested low concern for pancreatic cancer. Her subsequent evaluation aligned with this suggested work-up and revealed gynecologic cancer as the ultimate etiology for her elevated CA19-9.
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