We retrospectively studied vancomycin taper and pulse treatment on 100 consecutive, evaluable patients with recurrent Clostridium difficile infection. Following taper to once-daily vancomycin dosing, 22 of 36 patients (61%) who received every-other-day dosing (QOD) and 50 of 64 (81%) who received QOD followed by every-third-day dosing were cured (P = .03).

Background and Aims Walled-off pancreatic necrosis is a well-known serious adverse event of severe acute pancreatitis. EUS-guided transluminal access followed by direct endoscopic necrosectomy is increasingly used to remove necrosis, with good efficacy and a superior safety profile when compared with surgery. However, a percentage of patients is too critically ill to undergo this procedure or lack an appropriate transluminal window for access. Here we describe the use of percutaneous flexible endoscopic necrosectomy (PEN) with use of standard-sized upper endoscopes and accessories in a retrospective single-institution experience with a video demonstration of 1 patient in the series. Methods The authors present a 23-patient retrospective case series of PEN with standard-sized endoscopes. The series includes 12 patients from a previously published analysis in 2016 and 11 additional patients from 2013 to 2018. A representative case illustrates the described technique in a patient with severe acute pancreatitis complicated by multisystem organ failure who required immediate drainage of a pancreatic fluid collection and placement of a percutaneous drain into the collection for decompression. The drain was serially upsized to 28F, and its tract was used for PEN. Results A total of 23 patients have undergone PEN at our institution. On average, the size of the pancreatic fluid collection was 11.6 cm in cross-sectional diameter. Of those 23 patients, 11 presented with symptoms of severe disease. The median time from onset of symptoms to PEN was 84 days. The median number of procedures per patient was 2.1. The median time to complete resolution of symptoms and fluid collections was 67 days. In total, resolution was reached in 22 of 23 patients. Two patients died of unrelated causes. Conclusion PEN is a minimally invasive and effective treatment approach to walled-off pancreatic necrosis in patients who are not amenable to transluminal drainage and in whom percutaneous drains have been successfully placed. This case series demonstrates the efficacy and safety of this approach. A randomized prospective trial would be warranted to validate these results.

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BACKGROUND AND AIMS: Endoscopic mucosal resection (EMR) has become the standard for removing large colon polyps but has a 10%-30% recurrence rate using standard techniques. Data shows improved recurrence rates with focal therapy of the edge of the resection base using cautery. We examine a novel technique, hybrid APC assisted EMR, which treats both the edge and the base with cautery to assess its effect on local recurrence. METHODS:We reviewed all EMRs of polyps >2 cm by a single endoscopist with 6-month follow-up from May 2018 to November 2019 using both standard EMR as well as hybrid APC assisted EMR to assess local recurrence as well adverse events.RESULTS: Forty-eight patients with 59 polyps removed by EMR had full 6 month follow up with a mean age of 66.1 years of age, 45% were female. Thirty polyps were removed by hybrid APC assisted EMR and 29 removed with standard EMR. Overall, 0 (0%) polyps in the h-APC arm had local recurrence while 6 (20.7%) in the standard group had histological proven local recurrence (P = 0.01). Postresection bleeding occurred in 6 patients, 2 in the hAPC arm and 4 in the standard arm (P = 0.41). CONCLUSION:In this retrospective pilot study, hybrid APC assisted EMR was superior to conventional EMR for local recurrence after removal of large colon polyps and trended towards a less post-EMR bleeds.

Acute, high-grade esophageal perforation and postoperative leak after esophagogastrostomy are associated with high morbidity and mortality due to the development of mediastinitis and thoracic contamination. Endoscopic vacuum therapy has proven to be a feasible, safe therapy for management of esophageal wall defects, but with limited success. We describe a retrospective single-center analysis of two patients who underwent endoscopic vacuum therapy for significant esophageal disruptions with a median cross-sectional diameter of 10.7 cm. The technique involved the use of a standard upper video endoscope, nasogastric tube, and vacuum-assisted closure dressing kit, with endoscopic placement of a polyurethane sponge and nasogastric tube assembly into the mediastinal or thoracic cavity. Serial washout and debridement were performed prior to each sponge insertion. Data were collected on indication, size of the cavities, time to intervention, number of procedures, time to resolution, outcomes, and adverse events. Two patients underwent therapy with a mean age of 69.5. The median size of the collections via longest cross-sectional diameter was 10.7 cm. The average number of endoscopic vacuum therapy performed was six and average duration of therapy was 49 days. Complete resolution was achieved in both patients. One patient died 6 weeks later due to severe sepsis from aspiration pneumonia. Endoscopic washout and debridement followed by endoscopic vacuum therapy can be effective for large, even multiple, thoracic and mediastinal contaminations following esophageal perforation and gastroesopagheal anastomotic dehiscence and leaks in appropriately selected patients.

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Question: A 54-year-old woman with no known past medical history presented to our hospital with a 2-week history of left flank pain radiating to her left leg. The pain was sharp in nature, constant, and it was exacerbated by any movement. The patient had no urinary symptoms, no nausea or vomiting, and no change in her bowel habits. She denied any fevers, chills, or night sweats, but she did endorse losing 20 lbs over the past 1 year. On physical examination, the patient was alert and oriented, but slightly lethargic. She seemed to be cachectic. Her vital signs showed a heart rate of 62 bpm, blood pressure of 115/89 mm Hg, and weight was 78 lbs (baseline 100 lbs). Abdominal examination revealed left lower quadrant abdominal pain with no rebound tenderness or guarding. The tenderness was extending from her lower left abdomen to her left anterior thigh and she had a positive left psoas sign. She also had costovertebral angle tenderness noted over her left flank. Serum labs revealed a mildly elevated amylase of 54 U/L (upper limit of normal, 65) and lipase 94 U/L (upper limit of normal, 70), but otherwise the remainder of her blood work was normal. Urinalysis was unremarkable. A contrast-enhanced computed tomography scan of the abdomen and pelvis showed a large, rim-enhancing fluid collection within the entire left psoas muscle (22.36 cm), extending from the iliac fossa into the left upper quadrant displacing the kidney and the pancreatic tail anteriorly (Figure A, B). Punctate calcifications in the pancreas and mild dilation of the pancreatic duct were also noted on the computed tomography scan. The patient was started on broad-spectrum antibiotics and intravenous fluids to treat the complex abscess seen. Despite that, the patient's clinical condition was deteriorating. What is the underlying etiology of this large fluid collection and what should the next steps be to treat this patient? Look on page 34 for the answer and see the Gastroenterology website (www.gastrojournal.org) for more information on submitting your favorite image to Clinical Challenges and images in GI.

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