Gastroenterology Elsewhere

EXTENDED RESECTION VERSUS MESENTERIC SPARING IN CROHN’S DISEASE - SPICY TRIAL van der Does de Willebois EM, Bellato V, Duijvestein M, van der Bilt JD, van Dongen K, Spinelli A, et al. Effect of mesenteric sparing or extended resection in primary ileocolic resection for Crohn’s disease on postoperative endoscopic recurrence (SPICY): An international, randomised controlled trial. Lancet Gastroenterol Hepatol 2024;9:793-801. The mesentery is no longer considered a bystander in Crohn’s disease (CD). The components of the mesentery including neural, adipose, and lymphovascular tissue are believed to influence the inflammation occurring in the bowel through proinflammatory and profibrotic mediators. Retrospective data suggested that mesenteric resection in those undergoing ileocolic resection (ICR) could be beneficial. 133 patients with CD undergoing primary ICR were randomized to undergo mesenteric resection (n = 67) or mesenteric sparing (n = 66). Endoscopic recurrence of CD (modified Rutgeerts score >i2b) after 6 months was the primary outcome. No significant difference was seen between the two groups (42% in resection and 43% in sparing). Similar findings were seen in intraoperative parameters, length of stay, and anastomotic leakage, though more distal inflammation was noted in the mesenteric sparing group (18% vs. 5%, P = 0.23). Postoperative need for medications for CD usage and class of drugs were similar across both groups. This randomized controlled trial had shown that there is no additional benefit for extended mesenteric resection in the short term which is a stark contrast to the retrospective studies. Long-term follow-up of this cohort may inform us whether the disease course varies over time. PREDICTORS OF SIGNIFICANT FINDINGS ON ENDOSCOPIC ULTRASOUND EXAMINATION FOR INCIDENTAL COMMON BILE DUCT DILATION Raza Z, Altayar O, Mahmoud T, Abusaleh R, Ghazi R, Early D, et al. Clinical predictors of significant findings on EUS for the evaluation of incidental common bile duct dilation. Gastrointest Endosc. 2024:S0016-5107(24)03161-4. doi: 10.1016/j.gie.2024.04.2902. With a growing increase in abdominal imaging, incidental findings are increasing, and isolated common bile duct (CBD) dilation remains a cause for concern and warrants further evaluation. Endoscopic ultrasound (EUS) is the preferred method for examination to rule out choledocholithiaisis and biliary pancreatic malignancy. Often, the exam does not yield significant findings. Researchers in this retrospective analysis, aim to find clinical predictors that may have a high probability for a significant finding on EUS. Out of 375 patients who had imaging evidence of CBD dilation, only 31 (8.3%) of patients had significant EUS findings. The predominant abnormal finding was choledocholithiasis followed by tumor and stricture. In univariable and multivariable analysis, age >70 years, nonright upper quadrant pain without chronicity, CBD diameter >15 mm (17 mm in post cholecystectomy) and prior history of endoscopic retrograde cholangiopancreatography had high odds ratio of finding an abnormality. These parameters were incorporated into a novel prediction model and were externally validated. A score >4 had 90% specificity for a positive finding and a score <1 had 100% (sensitivity) in predicting an almost negative exam (<2% chance of a positive finding). Given the low frequency of a positive finding in incidental CBD dilation, this score would be helpful to guide clinicians in choosing patients for EUS examinations. More studies validating the score would offer data to formulate strong recommendations. PREDICTORS OF INCOMPLETE RESECTION IN COLORECTAL ENDOSCOPIC SUBMUCOSAL DISSECTION – SYSTEMATIC REVIEW AND META-ANALYSIS Gu F, Jiang W, Zhu J, Ma L, He B, Zhai H. Risk factors for unsuccessful colorectal endoscopic submucosal dissection: A systematic review and meta-analysis. Dig Liver Dis 2024;56:1288-97. Colorectal ESD (endoscopic submucosal dissection) is being increasingly done for tumors confined to the superficial submucosa which otherwise would need surgical removal. Researchers in this systematic review (SR) and meta-analysis (MA) after screening 2800 papers, included 39 articles for analysis, mostly from Asian countries. Studies included in this SR/MA showed a wide range of partial resection rates from 0.62% to 42% and a pooled rate of 9.1%. Incomplete resection, perforation, and delayed bleeding were the aims of this analysis. Tumor size >4 cm and >5 cm, right-sided colonic lesions, and severe fibrosis had a significant odds ratio for incomplete resection. The odds ratio for perforation was significant when the tumor size was >4 cm and >5 cm and when severe fibrosis was present. Notably, no significant factor could be identified for delayed bleeding. The study is limited because earlier studies (2007–2022) during which ESD was a newer technique were also included. Nevertheless, it highlights important clinical parameters to be considered while performing ESD, as incomplete resection is an important risk factor for local recurrence. AGA PRACTICE UPDATE ON IRON DEFICIENCY ANEMIA American Gastroenterology Association clinical practice update on management of iron deficiency anemia: Expert review DeLoughery TG, Jackson CS, Ko CW, Rockey DC. AGA clinical practice update on management of iron deficiency anemia: Expert review. Clin Gastroenterol Hepatol 2024;22:1575-83. The American Gastroenterology Association (AGA) has released a practice update on iron deficiency anemia (IDA), especially for those with gastrointestinal and liver diseases. As known, no specific formulation of iron (oral or intravenous) is superior to the other in terms of efficacy and adverse effects. When evaluating patients with inflammatory bowel disease and IDA, adequate disease activity control should be ensured, and intravenous iron should be considered when intestinal absorption is compromised. For those requiring repeated iron infusion, ferric carboxymaltose is better avoided given the risk of hypophosphatemia. For patients with portal hypertensive bleeds and IDA, endotherapy and beta-blocker therapy should go hand in hand with iron supplementation. For those with compromised duodenal absorption as in celiac disease and bariatric surgeries, intravenous iron may be helpful. BIOFEEDBACK FOR BLOATING Barba E, Livovsky DM, Accarino A, Azpiroz F. Thoracoabdominal wall motion-guided biofeedback treatment of abdominal distention: A randomized placebo-controlled trial. Gastroenterology 2024;167:538-46.e1. Bloating is a common symptom in patients with disorders of gut-brain interaction and can be disabling for some. Abnormal postural tone of thoracoabdominal muscles and redistribution of intraluminal contents causes bloating. Diaphragmatic breathing exercises are often prescribed to patients, but their efficacy remains unclear. The authors of this paper compare 3 weeks of biofeedback training using inductance plethysmography of the thoracoabdominal muscles (with belts) to oral placebo in patients with visible bloating (biofeedback: n = 19, placebo: n = 19). Patients in the biofeedback group were visually shown the signals on a monitor and trained to mobilize the diaphragm. Baseline and posttreatment responses of internal oblique muscle after a meal and symptom-based questionnaire were recorded. Patients in the biofeedback group corrected their thoracoabdominal dyssynergia as evidenced by reduced intercostal activity by a mean of 82% and increased anterior abdominal wall activity by a mean of 97%. Similarly, abdominal distension scores improved in biofeedback than placebo (P < 0.002). Biofeedback seems a promising tool for those suffering from bloating and more studies on standardizing the technique and sessions would be helpful. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.