Comprehensive Analysis of Adverse Events Associated with Gastric Peroral Endoscopic Myotomy: An International Multicenter Study.

BACKGROUND: Gastric peroral endoscopic myotomy (G-POEM) has emerged as an effective management approach for patients with refractory gastroparesis. This study aims to comprehensively study the safety of G-POEM and describe the predictive factors of adverse events (AEs) occurrence. METHODS: This study is a retrospective study involving 13 tertiary care centers (7 USA, 1 South America, 4 Europe, and 1 Asia). Patients who underwent G-POEM for refractory gastroparesis were included. Cases were identified by the occurrence of AEs. For each case, two controls were randomly selected and matched for age (± 10 years), gender, and etiology of gastroparesis. RESULTS: A total of 216 patients underwent G-POEM for gastroparesis. Overall, 31 (14%) AEs were encountered [mild 24 (77%), moderate 5 (16%), and severe 2 (6%)] during the duration of the study. The most common AE was abdominal pain (n = 16), followed by mucosotomy (n = 5) and capnoperitoneum (n = 4), and AEs were most commonly identified within the first 48-h post-procedure 18 (58%). The risk of adverse event occurrence was significantly higher for endoscopists with experience of < 20 G-POEM procedures (OR 3.03 [1.03-8.94], p < 0.05). CONCLUSION: G-POEM seems to be a safe intervention for refractory gastroparesis. AEs are most commonly mild and managed conservatively. Longitudinal mucosal incision, use of hook knife, use of clips for mucosal closure and endoscopist's experience with > 20 G-POEM procedures is significantly associated with decreased incidence of AEs.

The usefulness of SpyGlass™ choledochoscopy in the diagnosis and treatment of biliary disorders.

Peroral choledochoscopy was first described in the 1970s, but the use of earlier generation choledochoscopes was significantly limited by complex equipment setup and fragility resulting in high repair costs. In late 2006, the SpyGlass Direct Visualization System (Boston Scientific Corp, Natick, MA, USA) was introduced to the market. It is a single-operator cholangioscopy platform and improves upon many shortcomings of the dual-operator systems. Currently, the two main indications for its use are evaluation of indeterminate biliary strictures and lithotripsy for difficult-to-remove biliary stones. Recently published prospective data reconfirm that the overall success rates for adequate tissue sampling and bile duct stone clearance are around 90 %, with an acceptable safety profile. The sensitivity for detecting cancer in intrinsic biliary strictures (e.g., cholangiocarcinoma) is superior to that of standard ERCP sampling modalities, but a limited yield has been noted when sampling extrinsic malignant biliary strictures (e.g., pancreatic cancer). The two main limitations of the SpyGlass system are image quality that is impeded by the use of fiberoptic technology and a relatively small accessory channel providing passage only for dedicated miniaccessories. Nevertheless, the SpyGlass platform has made single-operator cholangioscopy feasible and refined the technique in a number of important ways. This innovation has significantly expanded our diagnostic and therapeutic ERCP armamentarium. An upgraded digital imaging version is currently in development.

Prospective evaluation of gastroenterologist-guided, nurse-administered standard sedation for spiral deep small bowel enteroscopy.

BACKGROUND: Sedation of patients for deep small bowel enteroscopy presents unique challenges and is traditionally provided by anesthesiologists. No study has directly evaluated gastroenterologist-guided, nurse-administered sedation for deep enteroscopy. Further, no comparison exists between gastroenterologist-guided versus anesthesiologist-guided sedation during deep enteroscopy. AIMS: To evaluate safety and efficacy of performing deep (spiral) enteroscopy using gastroenterologist-guided sedation and compare outcomes between patients receiving gastroenterologist-guided and anesthesiologist-guided sedation. METHODS: This prospective case series contains 91 consecutive patients who underwent deep enteroscopy with spiral Endo-Ease Discovery SB overtube. Of the patients, 64 received gastroenterologist-guided and 27 received anesthesiologist-guided sedation. RESULTS: In the 64 patients receiving gastroenterologist-guided sedation, successful completion occurred in 59 of 64 enteroscopies (92.2%). Mean insertion depth was 231.0+/-85.8 cm beyond the ligament of Treitz. Total procedure time was 39.9+/-15.7 min (diagnostic time 34.7+/-12.3 min; therapy time 5.2+/-8.9 min). Positive findings were noted in 32 cases (50.0%), with therapy performed in 27 cases (42.2%). Six minor complications occurred. Compared to the anesthesiologist-guided sedation group, there was no difference in patient characteristics except mean American Society of Anesthesiologists score (2.5+/-0.5 in gastroenterologist-guided group versus 2.7+/-0.6 in anesthesiologist-guided group; p=0.046) and presence of adhesions (ten in gastroenterologist-guided group and zero in anesthesiologist-guided group; p=0.030). Outcomes for both groups were not significantly different except for shorter times in the gastroenterologist-guided group (39.9+/-15.7 min versus 46.0+/-12.1 min; p=0.047) and more frequent findings in the anesthesiologist-guided group (50.0% vs. 74.1%; p=0.034). CONCLUSIONS: Deep enteroscopy using the spiral overtube can be successfully and safely accomplished with gastroenterologist-guided, nurse-administered standard sedation.

The spiral enteroscopy training initiative: results of a prospective study evaluating the Discovery SB overtube device during small bowel enteroscopy (with video).

BACKGROUND AND AIM: Indications for small-bowel enteroscopy are increasing, but advancing the endoscope to the ileum remains challenging, especially for less experienced operators. The aim was to evaluate the ease of use, safety, and efficacy of the Discovery SB overtube (Spirus Medical, Stoughton, Massachusetts, USA) during SB enteroscopy by physicians with no experience of the device. PATIENTS AND METHODS: Thirty-three "untrained" endoscopists performed spiral enteroscopy during one of four 2-day training modules. Data were prospectively collected. Patient demographics, depth and time to maximal insertion, total procedure time, and findings were recorded. Trauma was documented during scope withdrawal. Day 1 and day 2 results were compared. RESULTS: Ninety procedures were successfully performed in 95 patients (72.6 % women, age = 48.8 +/- 14.2 years). Endoscopists each performed a mean of five procedures. Mean time to maximal insertion was 20.9 +/- 6.4 minutes. Mean depth achieved was 262.0 +/- 57.4 cm. Total procedure time was 33.6 +/- 8.0 minutes. In 90.3 %, 94.6 %, and 83.9 % of patients, respectively, a trauma score less than 3 was recorded in the esophagus, stomach, and intestine (scale = 0 - 5). There were no perforations, nor significant associations between trauma score and patient age, body mass index, depth of insertion, time to maximal insertion, total procedure time, or day 1 vs. day 2 procedures. Depth of insertion was greater on day 2 than on day 1 (276.9 +/- 53.7 cm vs. 252.0 +/- 58.0 cm, P = 0.043). CONCLUSIONS: Discovery SB provides safe advancement of the enteroscope into the distal small bowel. Maximum depth of insertion appears comparable to that of balloon enteroscopy while taking less time. The device is easy to use and may be effectively operated in as few as five training cases.

[HPV and spontaneous abortion: results from a virological study].

Human papillomavirus (HPV) infection is common among sexually active individuals and in some cases this infection could coincide with pregnancy in women. In this study, we present our results from investigation for HPV presence in the samples of 50 women with spontaneous abortions. Detection and typing of HPV were carried out by polymerase chain reaction (PCR), using the primers designed to amplify E6/E7 gene sequences of HPV-16, 18 and L1 gene region of HPV-6, 11. HPV DNA was found in 1.5% (3/50) of the clinical samples tested (HPV-16 in one patient, HPV-18--in another one and HPV-16 and HPV-18--in the third patient. Our results support the hypothesis that HPV might be associated with some cases of spontaneous abortions. However, a bigger number of cases are needed for further studies to assess the actual risk of this virus in pregnancy.

EUS-guided celiac block and neurolysis.

Abdominal pain related to pancreatic cancer or chronic pancreatitis can be a disabling and difficult symptom to treat for patients, their families, and physicians. Pharmacologic therapy with nonsteroidal anti-inflammatory drugs is usually ineffective. Opiate analgesics may not be well tolerated and can lead to dependence. Endoscopic ultrasound-guided celiac plexus block offers a potential adjunct treatment for pain control.

Chronic pancreatitis: controversies in etiology, diagnosis and treatment.

The pathogenesis of idiopathic chronic pancreatitis remains poorly understood despite the high expectations for ascribing the pancreatic damage in affected patients to genetic defects. Mutations in the cationic trypsinogen gene, pancreatic secretory trypsin inhibitor, and the cystic fibrosis conductance regulator gene do not account for the chronic pancreatitis noted in most patients with idiopathic chronic pancreatitis. Small duct chronic pancreatitis can be best diagnosed with a hormone stimulation test. Endoscopic ultrasonography can detect abnormalities in both the parenchyma and ducts of the pancreas. The true value of endoscopic ultrasonography in diagnosing small duct chronic pancreatitis remains to be fully defined and is under active investigation. It is not clear whether endoscopic ultrasonography is more sensitive for early structural changes in patients with small duct disease or is over diagnosing chronic pancreatitis. Pancreatic enzyme supplementation with non-enteric formulation along with acid suppression (H2 blockers or proton pump inhibitors) is an effective therapy for pain in patients with small duct chronic pancreatitis. The role of endoscopic ultrasonography-guided celiac plexus block should be limited to treating those patients with chronic pancreatitis whose pain has not responded to other modalities. Total pancreatectomy followed by autologous islet cell autotransplantation appears to be potential therapeutic approach but for now should be considered experimental.

[Molecular techniques for detection, identification and analysis of human papillomaviruses (HPVs)]. / Molekuliarni tekhniki za otkrivane, identifitsirane i analiz na choveshki papilomni virusi (HPVs).

The review presents the main molecular virology techniques for detection, identification and analysis of human papillomaviruses (HPVs). Theoretical and practical bases of hybridization techniques (Southern blot, Dot blot, In situ hybridization, Filter in situ hybridization FISH, Hybrid Capture Assay, HCA), amplification techniques (polymerase chain reaction, PCR and variants--multiplex PCR, reverse transcription PCR, real-time PCR) and sequencing techniques(sequencing analysis, single-strand conformation polymorphism--SSCP) are discussed.

Iodinated contrast sensitivity in ERCP.

Iodine contrast media are detectable in the bloodstream after ERCP, and sensitivity reactions have been described. The risk is very small, and the phenomenon is therefore difficult to study. This review discusses the possible need for preventative strategies, and recommends that endoscopists consider the issue and define their own policies.

Therapeutic ERCP in the management of pancreatitis in children.

BACKGROUND: The use of diagnostic and therapeutic endoscopic retrograde cholangiopancreatography (ERCP) is increasing in the management of pancreatobiliary diseases in children. METHODS: Over a 32-month period, we performed 34 ERCP procedures for the treatment of pancreatitis in 22 children at two university hospitals. Demographics and clinical data and ERCP findings were documented. Clinical status was assessed 6 months before the first ERCP and 6 months after the last ERCP, according to general condition, severity and frequency of pain, and health care encounters (emergency department visits, clinic visits, and hospital admissions related to the pancreatitis). RESULTS: Mean age of the patients was 10.7 years (range 1.5 to 17 years). Abdominal pain was the main presenting symptoms with hyperamylasemia and hyperlipasemia. Clinical diagnoses included acute pancreatitis (6), recurrent pancreatitis (5), and chronic pancreatitis (11). The mean follow-up was 16.4 months. Nine patients had sphincter manometry, with abnormal results leading to biliary sphincterotomy in 4. Fifteen patients underwent a total of 23 therapeutic ERCP procedures unrelated to sphincter dysfunction. There were 2 complications of 34 procedures (6%), both being mild pancreatitis after sphincter manometry. There were no deaths. There was a significant reduction in frequency (p < 0.01) and severity of pain (p < 0.01) after intervention. Patients without pancreatographic changes of chronic pancreatitis had the most marked clinical improvement (p < 0.05). In those with ductal changes of chronic pancreatitis, clinical improvement was not predicted by the extent of ductal changes. There was a significant decrease in health care encounters (p < 0.05) and improvement in general condition (p < 0.01) after endoscopic therapy, especially in those with a normal pancreatogram. CONCLUSIONS: Therapeutic ERCP is safe in pediatric patients with pancreatitis. Significant clinical improvement is achieved in patients with biliary or pancreatic stone disease. Prospective studies with long-term follow-up are needed to determine the impact of endoscopic therapy in patients with chronic pancreatitis and sphincter of Oddi dysfunction.

Alcohol-acetaminophen syndrome. Even moderate social drinkers are at risk.

In long-term alcohol users, the syndrome of hepatotoxicity from acetaminophen taken in therapeutic or modestly excessive doses is distinctive. It is characterized by striking elevation of transaminase levels and the potential for acute liver failure with high morbidity and mortality rates. A high index of suspicion should be maintained; in any patient with evidence of acute hepatic injury, a complete history of over-the-counter drug use should be obtained and acetaminophen levels checked. If there is doubt about the dose or time of ingestion, one should err on the side of treatment with acetylcysteine, because it is both effective and safe. Therapy should be initiated as early as possible, but even late administration may be of benefit. Timely contact with a medical center that has liver transplantation capabilities should be made before encephalopathy becomes advanced. Heightened awareness of this preventable and treatable condition is needed by healthcare providers and acetaminophen users alike. Because the minimum safe dose of acetaminophen is not known in the setting of chronic alcohol use, it seems prudent in such situations to avoid acetaminophen altogether, especially during brief periods of abstinence.

Mesenteric vein thrombosis secondary to protein S deficiency.

Mesenteric vein thrombosis is an uncommon condition. Diagnosis is often difficult because of the nonspecific clinical presentation and findings on routine laboratory and radiological evaluation. Endoscopy is usually unrevealing. An underlying hypercoagulable state is often present, but protein S deficiency has rarely been implicated. We describe a case in which chronic inferior mesenteric vein thrombosis, with remarkable endoscopic findings, occurred as the initial presentation of type I protein S deficiency.

[Clinical and immunological studies of an experimental series of vaccines against hepatitis B]. / Klinicheskie i immunologicheskie issledovaniia éksperimental'nykh serii vaktsiny protiv gepatita B.

Two experimental lots of hepatitis B vaccine were prepared by purification of HBsAg from human plasma, inactivation at 100 degrees C for 2 min and at 37 degrees C for 72 hours with formalin in a concentration of 1:4000. The former lot comprises purified HBsAg (40 mg/ml) adsorbed with 0.32 mg % Al(OH)3, the latter consists of purified HBsAg stabilized with 0.1% human albumin and adsorbed with 1 mg% Al(OH)3. The immune response after vaccination with the first lot was observed in 54.54% of the vaccinees. The second vaccine after 3 administrations of 80 micrograms/ml each produced a very good primary and a very good secondary immune response. Both vaccines are nonreactogenic and well tolerated by the vaccinees.

[Antibody formation in type A viral hepatitis]. / Izuchenie antiteloobrazovaniia pri virusnom gepatite tipa A.

Immune response to hepatitis type A antigen (HAAg) was measured by the passive hemagglutination test (PHA) and by the immune adherence test (IAHA). Specific antibodies found by PHA are of the IgM class which indicates a recent exposure to hepatitis A virus. The antibodies found by IAHA reflect the level of postinfectious immune status. The antibody curve is highest in the age group of 30--49 years (95%). The above-mentioned serological tests were carried out with purified by gel filtration in Sepharose 6B Botevgrad faecal morphologically consisting of 27 nm particles with the buoyant density in CcCl of 1.40 g/ml. The same particles were aggregated with sera positive for antibody to hepatitis type A antigen in immune electron microscopy (IEM).