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BackgroundTherapeutic drug monitoring (TDM) by measuring infliximab (IFX) trough levels and antibodies to infliximab (ATI) is used to optimise treatment in inflammatory bowel disease. We aimed to explore the clinical outcomes of TDM for patients with Crohn’s disease on IFX in real life setting.MethodsThis is a retrospective observational study. Primary outcomes were the clinicians’ response to each TDM result and the rate of IFX discontinuation due to secondary loss of response or serious adverse event. Secondary outcomes included the intestinal surgery rate after IFX initiation and remission 6 months after TDM. Multivariate logistic regression was performed to identify factors associated with IFX discontinuation and abdominal surgery.Results291 patients were included. 238 (81.8%) patients were tested for TDM at least once during their follow-up with 672 TDM results. 95/238 patients (39.9%) had undetectable levels and 76 (31.9%) had positive ATI at least once. The median infliximab trough level was 3.4 µg/mL. IFX was discontinued in 109 patients (37.5%). 526/672 (78.3%) TDMs results were not followed by altered patient management. Treatment was discontinued in 40 (75.5%) patients never tested for TDM compared with 69 (29.0%) of those tested (p<0.01). Fewer TDM tested patients (29; 12.2%) required intestinal surgery post IFX initiation compared with TDM not-tested (15; 28.3%). Not being TDM tested was independently associated with IFX discontinuation and abdominal surgery.ConclusionsIFX discontinuation and intestinal surgery were significantly less frequent with TDM. TDM requested to investigate loss of response resulted in change in patient management.

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Percutaneous endoscopic gastrostomy tubes are replaced due to clogging, breaking, and dislodgement. There are potential complications associated with these procedures, including intraperitoneal placement of the tube and peritonitis, which can occur even in the presence of a well established stoma site. Herein we present a case series of 3 patients with mature gastrocutaneous tracks, who developed peritonitis following tube replacement. In the absence of a consensus or international guidelines regarding the management of patients requiring percoutaneous endoscopic gastrostomy tube replacement, emphasis should be given on prevention of severe adverse events and on early anticipation of their occurrence. Clinical experience indicates that recognition of high-risk procedures, selection of the appropriate replacement method and confirmation of correct tube placement can improve patients' safety and reduce the complications rate.

Background and aims: Endoscopic submucosal dissection (ESD) is the preferred technique for en bloc resection of superficial colorectal neoplasms. Resection of extensive lesions with ESD can be challenging, owing to loss of orientation in the submucosal space. In this case series, we describe the double-tunneling (DoT) butterfly method for ESD of extensive rectal neoplasms. Methods: The key feature of the DoT butterfly method is the creation of 2 tunnels that are transformed into bilateral flaps, leaving a submucosal septum between them. Results: Four rectal neoplasms measuring (maximum diameter) 7 cm, 8 cm, 9 cm, and 18 cm, respectively, were resected in 4 patients by use of the DoT butterfly method. The lesions included recurrent adenoma (n Z 1) and dysplasia (n Z 1) in longstanding ulcerative colitis. Curative R0 resection was confirmed in all 4 cases. Histologic examination showed tubular adenomas with low-grade dysplasia in 1 of 4 patients and focal high-grade dysplasia in 3 of 4 patients. One patient experienced postprocedural bleeding that required endoscopic reintervention. Conclusion: The DoT butterfly method appears to be useful for the resection of extensive rectal neoplasms. A prospective study is required to assess whether these results can be reproduced in a large cohort of patients.

Methods This prospective single-centre study included patients with symptomatic ZD undergoing flexible endoscopic septal division (FESD) as day case procedures between 2014-2018. Patients underwent Barium swallow imaging; ZD dimensions (figure 1) were measured and agreed by two expert radiologists using a predefined protocol. Symptom severity pre-and post-FESD was recorded using the Dysphagia, Regurgitation, Complications (DRC) scale. 1 Procedural difficulty was rated on a three-point scale: easy, moderate, difficult. The primary outcome was therapeutic success, defined as remission following single episode FESD with a DRC score of 1 or less art 6 months of follow-up. ZD dimensions were subjected to Mann-Whitney tests and logistic regression analyses. Results In total, 68 patients (mean age 74.2, SD 11.8) underwent barium radiology. Male gender comprised 60.9% of the cohort and was associated with larger pouch height (P=0.008), width (P=0.004) and depth (P=0.045). A positive correlation was identified between baseline DRC score and pouch depth (rho 0.319, P=0.012), particularly the symptom of regurgitation (P=0.009). No significant associations were found between ZD dimensions and procedural difficulty. Overall, each patient underwent an average of 1.4 FESD procedures. The outcome of therapeutic success at 6-months was achieved in 69% and was associated with shorter pouch height (median 14.5 mm vs. 19 mm, P=0.030) and pouch width (median 20 mm vs. 28 mm, P=0.046), with smaller cricopharyngeal length tending towards significance (median 20.8 mm vs. 26.3 mm, P=0.051). On multivariable analysis using a forward stepwise approach, pouch height was the sole dimension affecting the study outcome, with each additional mm in pouch height associated with a decrement in the probability of therapeutic success (OR 0.946, 95% CI: 0.897-0.997, P=0.031). Conclusions ZD dimensions may be feasibly evaluated using Barium radiology. Specific parameters, especially those relating to the pouch, appear to correlate with baseline severity and post-FESD patient outcomes. These results may inform the planning of FESD in day case patients with ZD.

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