Effectiveness and adverse events of endoscopic clipping versus band ligation for colonic diverticular hemorrhage: A large-scale multicenter cohort study

Background and study aims: Prior studies have shown the effectiveness of endoscopic band ligation (EBL) and clipping for colonic diverticular hemorrhage (CDH) but have been small and conducted at single centers. Thus, we investigated which was the more effective and safe treatment in a multicenter long-term cohort study. Patients and methods: We reviewed data for 1,679 patients with CDH who were treated with EBL (n=638) or clipping (n=1,041) between January 2010 and December 2019 at 49 hospitals across Japan (CODE BLUE-J Study). Logistic regression analysis was used to compare outcomes between the two treatments. Results: In multivariate analysis, EBL compared with clipping was independently associated with reduced risk of early rebleeding (adjusted odds ratio [AOR] 0.46; p<0.001) and late rebleeding (AOR 0.62; p<0.001). These significantly lower rebleeding rates with EBL were evident regardless of active bleeding or early colonoscopy. No significant difference was found between the treatments in the rate of initial hemostasis or mortality. EBL compared with clipping independently reduced the risk of need for interventional radiology (IVR) (AOR 0.37; p=0.006) and prolonged length of hospital stay (LOS) (AOR 0.35; p<0.001), but not need for surgery. Diverticulitis developed in 1 patient (0.16%) following EBL and 2 patients (0.19%) following clipping. Perforation occurred in 2 patients (0.31%) following EBL and none following clipping. Conclusions: Analysis of our large endoscopy dataset suggests that EBL is an effective and safe endoscopic therapy for CDH offering the advantages of lower early and late rebleeding rates, reduced need for IVR, and shorter LOS.

Management of Acute Anastomotic Leaks

Management of the acute anastomotic leak is complex and patient-specific. Clinically stable patients often benefit from a nonoperative approach utilizing antibiotics with or without percutaneous drainage. Clinically unstable patients or nonresponders to conservative management require operative intervention. Surgical management is dictated by the degree of contamination and inflammation but includes drainage with proximal diversion, anastomotic resection with end-stoma creation, or reanastomosis with proximal diversion. Newer therapies, including colorectal stenting, vacuum-assisted rectal drainage, and endoscopic clipping, have also been described.

757 AN APPROACH TO ACCELERATE HEALING AND SHORTEN THE HOSPITAL STAY OF PATIENTS WITH ANASTOMOTIC LEAKAGE AFTER ESOPHAGECTOMY

To explore the comprehensive role of systemic endoscopic intervention in healing esophageal anastomotic leak. To our knowledge, this paper is the first to discuss the outcome of anastomotic leaks and the association with healing time rather than whether the leak was fully healed. Methods In total, 3919 consecutive patients with esophageal cancer who underwent esophagectomy and immediate esophageal reconstruction between January 2012 and August 2019 at Sun Yat-Sen University Cancer Center were screened. In total, 203 patients (5.10%) diagnosed with postoperative anastomotic leakage were included. The participants were divided into three groups according to differences in diagnosis and treatment procedures. Ninety-four patients received conventional management, 87 patients received endoscopic diagnosis only, and the remaining 22 patients received systematic endoscopic intervention, including transnasal inner drainage, endoscopic fibrin glue repair and endoscopic clipping. The primary endpoint was overall healing of the leak after oncologic esophageal surgery. Results In total, 173 (85.2%; 95% CI, 80.3–90.1%) of the 203 patients were successfully healed, with a mean healing time of 64.42 ± 3.82 days (median: 51 days; range: 13 368 days), and the overall healing rates differed significantly among the three groups according to the stratified log-rank test (P &lt; 0.001). The median healing time of leakage was 44 days (95% CI: 27.15–60.86 days) in the endoscopic intervention group, 51 days (95% CI: 44.86–57.14 days) in the endoscopic diagnostic group, and 66 days (95% CI: 58.09–73.91 days) in the conventional group. Conclusion Tailored endoscopic treatment for postoperative esophageal anastomotic leakage based on endoscopic diagnosis is feasible and effective. Systematic endoscopic intervention shortened the treatment period and reduced mortality and should therefore be considered in the management of this disease.

245 A RETROSPECTIVE ANALYSIS OF ADVERSE EVENTS OF PERORAL ENDOSCOPIC MYOTOMY

Peroral endoscopic myotomy (POEM) has rapidly vindicated its position within the spectrum of achalasia treatment methods due to its excellent efficacy and safety. Nevertheless, POEM remains an invasive intervention which still carries risk of potential complications. The aim of our detailed analysis was to assess the perioperative and early postoperative adverse events in patients undergoing POEM at our institution. Methods We retrospectively evaluated the prospectively collected data from all consecutive patients who underwent POEM 12/2012–5/2018 at our institution and searched for periprocedural complications. Surgical classification Clavien Dindo (C-D) was used to assess the severity of adverse events. Results A total of 243 POEM procedures were performed. 73 procedures (30.0%) passed uneventfully while in 170 procedures (70.0%), 208 adverse events occurred. Minor AEs (C-D I,II) were as follows: allergic reaction to antibiotics (2/243; 0.8%), anaesthesia-related complications (14; 5.8%), pain requiring analgesics (158; 65%), fever (20; 8.2%), pneumonia (3; 1.2%) and irreversible loss of taste and smell (1; 0.4%). Major adverse events (CD III and more) included: post-POEM leak from mucosal incision requiring endoscopic clipping (5; 2.0%), pneumothorax (2; 0.8%), pleural effusion (1; 0.4%), scrotum emphysema (1; 0.4%) and death due to sudden cardiac arrest (1; 0.4%). Conclusion Minor POEM-related adverse events are rather common. Although being rare, severe complications, and even fatal, may still occur. Overall, POEM can be considered a safe procedure.

Saint-Petersburg I.I. Dzhanelidze Research Institute of Emergency Medicine

Rectal wound occurs in 1 to 5 % of cases among wounds of the abdominal organs. In patient B., 32 years old, 3 days after a stab wound to the left gluteal region and after ligation of the internal iliac artery with an extraperitoneal approach to stop ongoing bleeding, rectoromanoscopy and chromovulneroscopy revealed damage to the rectal wall measuring 1.2×0.7 cm at a height of 15 cm from the anus. The defect in the rectal wall was closed using endoscopic clips (6 pcs.). The wound canal of the left gluteal region was overdrained. At the control examination of the rectum on the 20th day after suturing the defect with endoscopic clips, the intestinal wall was sealed. The wound in the gluteal region healed by secondary intention. The patient was discharged from the hospital after 3 weeks. This method of endoscopic clipping of a rectal wound with external drainage of the wound canal is a modern minimally invasive method of treatment and can be used as an alternative to sigmoidostomy. The obvious advantages of this method of treatment are: improving the patient’s quality of life, the absence of the need for additional surgical interventions in order to restore the continuity of the colon.

Paradigm shift in management of acute iatrogenic colonic perforations: 24-year retrospective comprehensive study

Background and study aims Through advanced endoscopic clipping techniques, endoscopic treatment of both diagnostic and therapeutic acute iatrogenic colonic perforations has been shown effective. The main purpose of this study was to compare the management of acute iatrogenic perforations (AIPs) of the colon before and after the introduction of advanced clipping techniques. Methods We conducted a retrospective study from July 1996 to February 2020. The period was divided into two sub periods, Period 1: from July 1996 to December 2012 and Period 2: from January 2013 to March 2020. All AIPs occurring during a colonoscopy and detected during or immediately (< 4 hours) after the procedure, were included in the study. Results The total number of colonoscopies performed at our hospital was 33055 and 36831 during Periods 1 and 2 respectively. Fifteen perforations were observed in Period 1 and 11 in Period 2. The rate of surgery was 93.3 % % (14/15) in Period 1 and 27.2 % (3 /11) in Period 2 (P < 0.01). The mean hospital stay in Period 1 was 6.9 days and 4 in Period 2 (P < 0.01). Conclusions Data from this historical cohort have clearly shown a decrease in the surgery rate and the length of hospitalization of AIPs in Period 2 compared to Period 1.