P-BN12 Impact of covid-19 on ugi (upper gastrointestinal) tract stenting and dilatation services- prioritise, keep scoping and training

Background The COVID-19 pandemic profoundly affected endoscopy services including therapeutic gastroscopy across the UK. The BSG (British Society of Gastroenterology) issued guidance for managing endoscopy services safely throughout this period. At the beginning of the pandemic in March 2020, a symptom-based questionnaire was used to screen patients for COVID-19 prior to their endoscopic procedures in our hospital (COVID-19 swabs were only carried out if patients presented with COVID-19 symptoms). From 18 May 2020 onwards, in addition to the above approach, all patients attending endoscopic procedures underwent a SARS-CoV-2 nasopharyngeal swab 1-3 days prior to the procedure. We describe our experience of UGI stenting and dilatation during the initial wave of COVID-19 pandemic in the UK. Aims To assess the impact of COVID-19 pandemic on technical and clinical success of luminal dilatation and stenting in the UGI tract and ascertain the risk of procedure related complications. Methods A retrospective audit of a prospectively maintained endoscopy database was carried out between 18th March and 31st July. All patients were followed for 30 days. Full PPE were used. Results 42 procedures [31 were oesophageal dilatation (21 peptic stricture, 9 radiotherapy stricture, 1 achalasia), 8 oesophageal stent insertion (6 for primary oesophageal cancer, 1 metastatic cancer and 1 secondary to external compression from lung cancer) and 3 pyloric dilatation all benign] were carried out-mean age 65 years, 64.3% males, 81% of procedures were carried out as outpatients. All procedures were performed under fluoroscopy. 41/42(97.6%) patients had a confirmed histology prior to their procedure – one patient who underwent oesophageal dilatation had a peptic stricture on endoscopy (no biopsy or imaging). 39/42(92.9%) patients had undergone CT scan and/or barium swallow prior to their first procedure. All procedures were technically and clinically successful (100%).There were no procedure related complications or mortality. There were no COVID positive swabs in the 30-day post procedure period during the entire study period. Trainees were present in 21/42 (50%) of the procedures. None of the endoscopists who were involved with these procedures were diagnosed with COVID-19 during this period. One of the nursing staff, who regularly assisted in the fluoroscopy room, was involved in a non-fluoroscopic endoscopic procedure in a COVID-19 patient (not known at the time of the procedure) and subsequently tested positive. Conclusions Our study confirms that a high quality stenting and dilatation service of the upper gastrointestinal tract together with specialist registrar training can be delivered safely and effectively during the COVID-19 pandemic in appropriately prioritised symptomatic patients.

THERAPEUTIC TACTICS FOR PEPTIC STRICTURES OF THE ESOPHAGUS. LITERATURE REVIEW

The work is based on the analysis of literature data devoted to the choice of treatment for peptic esophageal strictures. The main goal of this review is to identify treatment tactics for patients with stenosing reflux esophagitis. Researchers point out that the main causes of GERD are a decrease in pressure in the lower esophageal sphincter, the action of the damaging properties of the refluctant. Untimely treatment of GERD can lead to complications such as peptic stricture, Barrett's esophagus. The appearance of GERD stricture is most often promoted by: persistent heartburn after bougienage, erosion of the lower third of the esophagus, shortening of the II degree esophagus, and inadequate antisecretory therapy.Various methods of treatment at all stages of the appearance of peptic stricture are presented, depending on the degree of dysphagia and the length of the stricture, the use of adequate conservative therapy regimens for PPIs, bougienage, as well as a description of various methods of antireflux operations. Endoscopic dilation is the first treatment option for all symptomatic benign esophageal strictures. There are treatments for benign refractory esophageal strictures such as endoscopic dilatation with intraluminal steroid injection, endoscopic postoperative therapy or stricturoplasty, esophageal stenting, self-bougienage, as well as surgery - antireflux surgery, esophagectomy with replacement of the esophagus by the stomach or colon [1].The main goal in the treatment of peptic esophageal strictures, according to most authors, is to eliminate the progression of GERD, conduct bougienage or balloon dilatation, and select the optimal antireflux surgery. Treatment for peptic strictures should minimize the risk of re-stricture of the esophagus.

Outcomes of esophagoplasty in children (a 14-year experience)

Introduction. The authors analyze the effectiveness of one-stage esophageal plasty in children. They consider -from different points of view- possible problems accompanying such surgical interventions as well as complications and high mortality.Material and methods. The article summarizes outcomes after esophagoplasty in 61 patient who were at the surgical department of the Center for Pediatrics and Pediatric Surgery (Almaty, Kazakhstan) during 2006–2020 (June). Among them there were 24 (38%) children after the first stage of cervical esophagostomy combined with gastrostomy in esophageal atresia; 34 (56%) children had decompensated post-burn esophageal stricture and after ineffective conservative treatment; 1 (2%) patient had esophageal varicose veins because of the portal hypertension syndrome with formed cicatricial esophageal stricture and with high risk for bougienage; 2 (4%) patients had an extended peptic stricture of the esophagus as a complication of gastroesophageal reflux disease (Barrett esophagus).Results. One-stage coloesophagoplasty was performed in 44 (72%) children. Gastroesophagoplasty with the whole stomach transposition was performed in 12 (20%) children with esophageal atresia; in 3 (5%) - replacement for post-burn cicatricial stenosis and in 1 (2%) - because of varicose veins in the esophagus.Conclusion. The choice of esophagoplasty technique should be individualized depending on patient’s general state, on pathological lesions in the esophagus as well as on previous surgeries on the abdominal organs, if any.

Combined Bile Duct and Pancreatic Duct Injuries during Distal Gastrectomy for Obstructing Peptic Ulcer Disease

A combination of bile and pancreatic duct injuries is very rare. Anomalous ductal anatomy, distorting duodenal fibrosis, and pancreatic atrophy predispose to this untoward complication during performance of distal gastrectomy for benign peptic stricture. The technical challenges posed by this complication and experience gained by managing it are shared.

A Case of Zenker’s Diverticulum in a Patient with Tight Esophageal Peptic Stricture

Zenker’s diverticulum (ZD) is a posterior Sac like outpouching of the hypopharyngeal mucosa and submucosa through Killian’s triangle, which is an area of muscular weakness between the transverse fibers of the cricopharyngeus muscle and the oblique fibers of the lower inferior constrictor muscle. ZD usually presents with swallowing difficulties, regurgitation of undigested food, choking, halitosis, weight loss, and respiratory symptoms due to chronic aspiration. Several esophageal pathologies have been reported in association with ZD. These include cervical esophageal webs, upper esophageal stenosis, and hiatus hernia. Herein, we report a case of ZD in association with severe gastroesophageal reflux disease and tight lower esophageal peptic stricture.

An integrated approach to treatment of patients with complicated forms of gastroesophageal reflux disease

Aim. To justify the appropriateness of applying the integrated algorithm of treatment, including the sequential application of conservative antireflux treatment and antireflux surgery, in patients with complicated forms of gastroesophageal reflux disease. Methods. The main group of the study included 554 patients with complicated forms of gastroesophageal reflux disease (erosive esophagitis in 301, peptic stricture in 36, Barrett's esophagus in 90 and a combination of several complications in 127 patients), and the control group included 229 patients with uncomplicated gastroesophageal reflux disease and indications for surgical treatment. At the diagnostic stage, fiberoptic esophagogastroduodenoscopy with chromoendoscopy using a double dye staining technique (Lugol and methylene blue) and biopsies of areas suspicious for metaplasia, as well as a barium contrast multi-positional radiographic examination of the esophagus and gastroesophageal junction were used. At the treatment stage, both groups received conservative antireflux treatment lasting 48 weeks, comprising lifestyle regulation, diet, antisecretory drug therapy (proton pump inhibitors omeprazole or rabeprazole 20 mg orally twice a day, antispasmodic agent domperidone 20 mg orally 3 times a day or itopride 50 mg orally 3 times a day), followed by either laparotomic or laparoscopic antireflux surgery. In the main group, antireflux surgery was supplemented with endoscopic argon plasma coagulation during the postoperative period in the patients with Barrett's esophagus and esophageal bougienage under endoscopic control during the pre- and postoperative period in the patients with a peptic stricture. Results. The frequency of intraoperative [6.3% (95% CI 1.45.8%), p=0.0462] and early postoperative complications [41.5% (95% CI 37.445.7%), p=0.0011] in the main group were statistically significantly higher than in the control group. There was no clinically important difference. Frequency of late postoperative complications in the main group [5.4% (95% CI 3.77.6%)] did not have statistically significant differences from the control (p=0.1239). The integrated algorithm of treatment has proven to be safe with provision for the need to develop measures to reduce the overall incidence of early postoperative complications. Excellent and satisfactory immediate treatment results were achieved in 91.7% (95% CI 89.193.9%), and excellent and satisfactory long-term results were achieved in 91.3% (95% CI 88.793.5%) patients of the main group, and were statistically significantly worse than in the control group, p=0.0008 and p=0.0021 for the immediate and long-term results, respectively. The difference was attributable to the extremely high efficiency of the treatment algorithm in the control group and had no clinical significance. Conclusion. The use of the integrated algorithm of treatment based on the implementation of antireflux surgery is appropriate in all patients with complicated forms of gastroesophageal reflux disease.