TorontoGiFellow

  Source: https://doi.org/10.1016/j.gie.2023.01.038

Japanese multicentre retrospective study, comprising of 4,700 patients with T1 CRC and LN data.  Of these, nearly 3/4th had undergone oncologic resection, while remainder 1/4th were treated locally with endoscopic (or surgical resection) and had a median follow-up of 5 years Source: https://doi.org/10.1016/j.gie.2023.01.022

Source: Primary prophylaxis of gastric variceal bleeding comparing cyanoacrylate injection and beta-blockers: A randomized controlled trial - Sarin et al In a trial of 89 patients with >20 mm size of GOV2 (after eradication of EV) or IGV1, patients treated with CyA had significantly low risk of bleeding at median follow-up of 26 months (13%), compared to patients randomized to NSBB (28%) or controls (45%)  Main criticism: Majority of patients were GOV2. Only 13 patients out of 89 had IGV1, therefore, difficult to draw conclusions at management of IGV1.

  Gastrorenal shunts:  Vast majority of IGVs are Gastro-renal shunts (and rarely Gastro-caval shunts). Gastro-renal shunts, at haemodynamic level, are truly spleno-(gastro)-renal shunts. The Afferent to the GRS shunt is usually - either a LGV (left gastric vein) which is either the first branch of portal vein, or can arise from splenic vein just after the portal confluence, a posterior gastric vein (arising from Splenic vein) or Short gastric veins (arising from splenic vein).  The GRS empties in to Left renal vein. A true splenic-renal shunt, while will give rise to plenty of encephalopathy, but will not cause Gastric varix in its own right, as an SRS does not go through the GIT wall.  One of the important concepts to understand, as highlighted in the figure below, is each Gastric varix, has 'True gastric varix' component, which is the intraluminal component (and the one, that is prone to bleeding), and often a larger, 'False gastric varix' or an Extra-luminal componen

In pigs, Thoracic and abdominal aorta , celiac axis, superior mesenteric and splenic artery, splenic, portal, and hepatic veins were injected with contrast by using FNA needles under fluoroscopy under EUS guidance. Immediate Necropsy The 25-gauge FNA needle did not cause any visible vascular injury or bleeding.  The 22-gauge needle left a visible puncture mark without active bleeding.  In 1 of 5 pigs, the 19-gauge needle caused a localized vascular hematoma around Thoracic and Abdomial aorta and 150 mL of intra-abdominal blood. Mind - it was an FNA needle (not FNB)  Source: :10.1016/j.gie.2007.01.011

  Any volume of Glue can be injected, to achieve total obliteration of varix.  Normal saline is NOT preferred, as it delays polymerisation, compared to distlled water. Source: Management of fundic varices. Endoscopic aspects Javier Martínez-González, Sergio López-Durán, Enrique Vázquez-Sequeiros and Agustín Albillos-Martínez https://doi.org/10.1053/j.gastro.2021.12.277

 EUS: Keep 0.5 ml Glubran + 0.5 ml sterile water ready in Syringe A. Keep 10 ml of sterile water ready in Syringe B. Step 1 - Confirm the varices are 'intraluminal' Decide target of intervention (feeder / main varix) Step 2: Stab the varix with 19G FNB needle. Attach a 10 ml syringe with sterile water to FNB needle Step 3: To confirm location inside varix, flush some water. Then aspirate to confirm blood. Then flush back to 'wash blood' from the needle lumen Step 4: Attach white hub of the Nester  loading cannula to needle tip. Using Needle stylet, advance the coil from the Nester catheter to, inside the needle lumen. Then detach the Nester catheter from FNB needle. Insert the stylet again, to continue to push the coil across the needle lumen in to varix Step 5: By continuing to advance the needle stylet, push the coil in to the varix under EUS guidance. Once completely deployed, remove the needle stylet.  Step 5a - further coil can be deployed based on size of varix, b

Atleast 18-19 G Needle -     for 0.035 wire Atleast   22 G     Needle    -   for 0.018 wire

 Cephazolin 2g IV + Tobramycin 80mg IV STAT  OR Ciprofloxacin 400mg IV STAT OR  Vancomycin x dose

Multicentre - single blinded RCT across 6 centres in China 2600 patients with average and high-risk for pancreatitis, randomly assigned to:  Universal rectal indomethacin 100mg 30min before procedure  OR   post-ERCP selective rectal indomethacin in high-risk patients only 23% trainee participation, 15% patients required dual wire or pre-cut Only 18% high-risk patients also received pancreatic stent (discretionary to endoscopists) In high-risk patients, pre-procedure indomethacin reduced overall and Mod-sev pancreatitis by half ( 6% and 1% vs 12% and 2%) In Avg-risk patients, pre-procedure indomethacin reduced overall and Mod-severe pancreatitis by half (3% and 1% vs 6% and 2%) compared to no indomethacin Overall, pre-procedure rectal indomethacin was MORE effective than post-procedure indomethacin in high-risk patients, and was MORE effective than no indomethacin in average risk patients. DOI:  http://dx.doi.org/10.1016/S0140-6736(16)30310-5

 DOI:  10.1097/MPA.0000000000002090 Consecutive 321 patients with native papilla,  were randomly assigned to Pancreatic stent, 50mg rectal diclofenac or stent + diclofenac at a single centre in Japan from 2014 to 2019. Pancreaitc injection performed in nearly half of all patients! 75% of all patients were considered high risk (either F<40, difficult cannulation, pancreatic cannulation, pancreatic injection, pre-cut, pancreatic sphincteortomy, balloon sphincteroplasty, IDUS, choledochoscopy)  Procedure time was >30 mins in half of all patients. 5 patients in total developed pancreatitis (all mild), with no difference in any of the 3 sub-groups.

Keywords: VTE, venous thrombembolism, PE, pulmonary embolism, Clexane, LMWH DOI: ( https://doi.org/10.1097/SLA.0000000000004646 ) In a retrospective cohort study, Michigan investigators used a statewide collaborative of 63 hospitals to identify symptomatic postoperative VTEs among nonorthopedic surgical patients who received (≈22,000 patients) or did not receive (≈11,000 patients) postop pharmacologic VTE prophylaxis during hospitalizations between 2013 and 2017. Low-molecular-weight heparin or thrice-daily unfractionated heparin was considered to be appropriate pharmacologic prophylaxis. In propensity-matched analysis, 30-day VTE rates were low (≈1.2%) and similar in postop patients who received or who didn't receive pharmacologic prophylaxis. Results were unchanged for low-, moderate-, and high-risk patients analyzed separately, and even very high–risk postop patients (i.e., Caprini score, >8) had no statistical difference in VTE rate (3.7% and 4.2%;  P =0.09). Thirty-day mort

Keywords: Chromogranin A , CgA, NET, neuroendocrine tumor, neuroendocrine tumour, pNET DOI: 10.1097/MPA.0000000000002132

  Keywords: Microsatellite instability, MSI, MMR, dMMR, mismatch repair, Lynch syndrome Doi: ( https://doi.org/10.1200/JCO.22.00686 ) Landmark Phase 2 trial from France of 33 patients with advanced (T3N+M0) GEJ / Gastric cancer, with MSI-H, (22% of patients had Lynch syndrome) - achieved excellent clinical response with Ipilimumab / Nivolumab - with 60% patients achieving complete pathologic response found at planned surgery, 100% patients achieving R0 reponse!