Background and Aim Fecal microbiota transplantation (FMT) has been proposed as a treatment option for patients with recurrent Clostridium difficile ( C. difficile ) infection but remains a novel option. We examined if FMT is an effective means of treating recurrent C. difficile infection. Methods A retrospective review of 35 patients who underwent FMT was completed. Demographics and other variables, including the use of proton pump inhibitor therapy and history of inflammatory bowel disease, were collected. Results Twenty‐five patients (71.4%) belonged to a high‐risk population (working in a hospital setting, rehabilitation center, or nursing facility) and a total of 74.3% of patients ( n = 26 patients) had no history of proton pump inhibitor use. Twenty‐five patients (71.4%) had used metronidazole prior to transplantation, 35 patients (100%) had used vancomycin, and 7 patients (20%) had used fidaxomicin for prior infection. Four patients (11.4%) had used all three antibiotics during prior treatment. Of the eight patients who had a history of inflammatory bowel disease, six (75%) experienced resolution of symptoms after transplantation. A total of 30 patients (85.7%) had resolution of their symptoms 6–8 weeks’ posttransplant, while 5 patients (14.3%) continued to have symptoms. Conclusions Our retrospective chart review supports that patients benefit from FMT in the setting of recurrent C. difficile infection.
uncovered SEMS (Two-in-one stentÒ) in patients with inoperable malignant distal biliary obstruction, and compare its outcomes with conventional partially covered SEMS. Materials and methods: Two-in-one stentÒ is made of a combination of two metal stents; inner silicone-covered stent and outer uncovered stent. When the inner stent become clogged, it can be removed leaving the outer stent in place by pulling the inner stent out using grasping forceps. Two-in-one stents were prospectively inserted in 58 patients from May 2016 to April 2019. Conventional partially covered SEMSs were inserted from January 2010 to October 2014. Results: The patient survival times were 163 days and 219 days in the Two-in-one and conventional groups (PZ0.957). The covered stent (inner stent) dysfunction occurred in 14 patients (24.1%) in the Two-in-one group and 17 (33.3%) in the conventional group (PZ0.288). Inner covered stent removal was successful in all 14 patients. The third quartile covered stent patency time was 197 days in the Two-in-one group and 184 days in the conventional group (PZ0.112). Overall stent patency was significantly longer in the Two-in-one than in the conventional group (mean: 891 vs. 299 days, P<0.001). Conclusions: Endoscopic placement of a newly developed Two-in-one covered and uncovered SEMS is feasible and effective and may be a promising option for inoperable malignant distal biliary obstruction.
Introduction: Candy cane syndrome is an underrecognized complication of Roux-en-Y gastric bypass resulting from a long blind afferent Roux limb at the gastrojejunostomy causing nausea, vomiting, reflux and pain due to food accumulation. We present a case of novel endoscopic treatment of candy cane syndrome. Case Description/Methods: 67-year-old female with vertical banded gastroplasty revised to Roux-en-Y gastric bypass and multiple open abdominal surgeries presented with worsening of persistent post prandial epigastric pain. Upper endoscopy showed Roux-en-Y anatomy. Also noted was gastro-gastric (GG) fistula (A) and an embedded over the scope clip (OTSC) in this area (B). There were no medical records of placement of the clip or patient recall of OTSC clip. A fluoroscopic upper GI series showed candy cane loop and gastro-gastric (GG) fistula (D). Her bariatric surgeon felt that her acute symptoms were likely from candy cane syndrome. Given that she had a fairly extensive surgical history she was deemed high risk for surgery, decision made to offer endoscopic therapy for candy cane syndrome. APC (1L/min, 50W) was used to coagulate the mucosal layer of the entire afferent limb (F) and then the enteric walls of the afferent limb were approximated by placing three purse string sutures using endoscopic suturing device attached to a 2-channel therapeutic upper endoscope (G). Sutures started from the end of the blind limb towards the GJ anastomosis leading to total closure of the afferent limb (Pic 1H). One month follow up upper GI series showed direct transit of most of the contrast into efferent limb with redemonstration of a much smaller though persistent candy cane limb (I and J). (Figure ) Discussion: Candy cane syndrome results from creation of a long nonfunctional limb during creation of gastro-jejunostomy at time of gastric bypass. This causes intestinal dysmotility resulting in stasis, and gradual expansion of the limb over time. Upper GI series has been used traditionally to diagnose this condition though endoscopic demonstration of off-axis orientation of roux limb using a simple guide wire has also been proposed. Historically, it has been managed surgically. We present an interesting case of endoscopic reduction of candy cane loop using advanced endoscopic suturing technique. [2853] Figure 1. (A) Roux-en-Y anatomy with afferent limb (blue), efferent limb (yellow). (B) Metallic prong seen in the lumen of gastric pouch. (C) Metallic FB identified as OTSC clip on x ray. (D) Upper GI series demonstratingrapid pooling of contrast in candy cane limb (blue) and the Roux limb (yellow). (E) fistula seen adjacent to the clip. (F) ablated afferent limb mucosa. (G) purse string suturing of the ablated afferent limb. (H) completely obliterated of afferent limb after sutures. (I) upper GI series 1 month later shows transit of most contrast from gastric pouch (red) into Roux limb (yellow) but a persistent cany cane limb (blue). (J) one month post suturing endoscopic view of closed afferent limb.
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