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News from DDW

Thomas Rösch

Dept. of Interdisciplinary Endoscopy, Hamburg-Eppendorf University Hospital

The latest developments in the field of gastroenterology and endoscopy are presented every year at Digestive Diseases Week (DDW) in Chicago — although in recent years the United European Gastroenterology week has distinctly caught up with or may even have overtaken DDW. My own subjective selection of the papers presented — with no claim to completeness — is offered below.

The big four — essential randomized studies

Randomized studies are extremely praiseworthy in endoscopy, since the effort involved is usually substantial. The first study — which also happens to be from Germany — was concerned with the use of over-the-scope clips (OTSCs) in patients with recurrent bleeding in the upper gastrointestinal tract1. In the abstract, half of the 67 patients included in the study were randomly assigned to the OTSC group and the other half to the control group (with injection and conventional clips). The rate of initial hemostasis was much better in the OTSC group (97%) in comparison with the control group (62.5%), but the rates of subsequent recurrent bleeding were more similar (24% versus 33%). The mortality rates were similar in the two groups (6–7%). It remains to be seen whether these results will be sufficient for a general and guideline-suitable recommendation that OTSC should be used for this indication. In cases of difficult recurrent bleeding, however, OTSC clips are a valuable alternative.

Peroral endoscopic myotomy (POEM) has for many years been a highly promising alternative treatment for idiopathic achalasia and for spasmodic motility disturbances in the esophagus. As always with new techniques, the initial results were dazzling. The intermediate results (1 year) from a randomized study of POEM versus balloon dilation, including 133 patients, were presented in Chicago.2 The balloon procedure consisted of sequential dilations at 30 and 35 mm. Clinical remissions were achieved in 92.8% and 70% of the patients in the POEM and balloon groups, respectively (P < 0.001). One perforation occurred in the balloon group, but no significant complications developed in the POEM group. However, the endoscopically diagnosed reflux rates were also much higher in the POEM group (48.3% vs. 13.1%). It will only be possible to draw final conclusions later, after the 2-year results, and the 2-year results of the randomized study comparing POEM with Heller myotomy will then also be available. Another randomized study comparing POEM and balloon dilation is also still in progress, which allows repeated balloon dilation, as in the large randomized study on Heller myotomy versus balloon dilation.3, 4

Hemospray is a procedure for hemostasis in desperate situations when other procedures have failed. To date, however, the method has not been approved for variceal bleeding. Jacques Devière’s group in Brussels addressed this topic with an interesting approach — i.e., immediate Hemospray application at an early stage in all patients with variceal bleeding, although other methods can be carried out later electively. This approach would also be more accessible for less experienced endoscopists. In a randomized study including 86 patients, it was compared with a conventional procedure (vasoactive medication and then emergency endoscopy or later elective endoscopy, as appropriate).5 The results showed a useful advantage for Hemospray, with a clinically relevant hemostasis rate of 98% versus 70%. Interestingly, adequate treatment of four cases of spurting variceal hemorrhage in the gastric fundus could not be adequately treated with the Hemospray. In the control group, around 30% of the patients had to undergo emergency endoscopy instead of later elective endoscopy. What distinguishes this study from others on variceal bleeding is that the mortality rate was also significantly better in the Hemospray group (30 days: 7% versus 33%). If these results can be confirmed by other groups, this could mean a decisive change and improvement in the management of acute variceal bleeding.

Finally, the multicenter Dutch Pancreatitis Research Group once again presented a randomized study on step-up therapy in pancreatic necrosis in the context of acute pancreatitis. In the past, it has repeatedly been shown that initial conservative therapy is clearly superior to necrosectomy, which is already aggressive initially (the “step-up approach”).6, 7 In the present randomized study, including 98 patients, it was investigated whether endoscopic or surgical step-up leads to better results.8 In both cases, a (transgastric or percutaneous) drain was first placed, and if that was not sufficient, then a transgastric or percutaneous minimally invasive necrosectomy (videoscopy-assisted retroperitoneal debridement, VARD) was carried out. The latter was necessary in approximately half of the patients in both groups. The combined end point of major complications and mortality was reached at a similar rate in both groups — 43% in the endoscopic group and 45% in the surgical group. The endoscopic approach was only less expensive (€ 1836 instead of € 13,655), not least due to the shorter hospitalization period (53 vs. 69 days).

Further abstracts on the topics Barrett esophagus, colonoscopy and polypekcomy, ERCP and endosonogrtaphy as well as innovations will follow.

References

  1. Schmidt A, Goelder S, Messmann H, et al. 62 Over-The-Scope-Clips Versus Standard Endoscopic Therapy in Patients With Recurrent Peptic Ulcer Bleeding and a Prospective Randomized, Multicenter Trial (Sting). Gastrointestinal Endoscopy;85:AB50.
  2. Ponds FA, Fockens P, Neuhaus H, et al. Peroral Endoscopic Myotomy (POEM) Versus Pneumatic Dilatation in Therapy-Naive Patients with Achalasia: Results of a Randomized Controlled Trial. Gastroenterology;152:S139.
  3. Boeckxstaens GE, Annese V, des Varannes SB, et al. Pneumatic dilation versus laparoscopic Heller’s myotomy for idiopathic achalasia. N Engl J Med 2011;364:1807-16.
  4. Moonen A, Annese V, Belmans A, et al. Long-term results of the European achalasia trial: a multicentre randomised controlled trial comparing pneumatic dilation versus laparoscopic Heller myotomy. Gut 2016;65:732-9.
  5. Ibrahim M, El-Mikkawy A, Hamid MA, et al. 627 Multicentre Randomised Controlled Trial Comparing the Efficacy and Safety of Adding Early Hemostatic Powder Application to Endoscopic and Medical Treatment in the Management of Acute Variceal Bleeding in Cirrhotic Patients. Gastrointestinal Endoscopy;85:AB89-AB90.
  6. Bakker OJ, van Santvoort HC, van Brunschot S, et al. Endoscopic transgastric vs surgical necrosectomy for infected necrotizing pancreatitis: a randomized trial. Jama 2012;307:1053-61.
  7. van Santvoort HC, Besselink MG, Bakker OJ, et al. A step-up approach or open necrosectomy for necrotizing pancreatitis. N Engl J Med 2010;362:1491-502.
  8. van Brunschot S. 626 Endoscopic or Surgical Step-Up Approach for Necrotizing Pancreatitis, a Multi-Center Randomized Controlled Trial. Gastrointestinal Endoscopy;85:AB89.
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