Endoscopic clips versus overstitch suturing system device for mucosotomy closure after peroral endoscopic pyloromyotomy (G-POEM): a prospective single-center study.

BACKGROUND AND AIMS: G-POEM is an emerging method for treatment of severe gastroparesis. Safe mucosal closure is necessary to avoid adverse events. The aim of this study was to compare the efficacy of two closure methods: clips and endoscopic suturing (ES) after G-POEM. METHODS: We performed a single center, prospective study. The closure method was assigned at the discretion of an endoscopist prior to the procedure. The main outcome was the proportion of subjects with successful closure. Unsuccessful closure was defined as a need for a rescue method, or a need for an additional intervention or incomplete closure-related adverse events. Secondary outcomes were the easiness of closure (VAS score 1 = very difficult, 10 = easy), closure time, and cost. RESULTS: A total of 40 patients [21 female; mean age, range 47.5; (20-74)] were included; 20 received ES and 20 clips [mean number of clips 6; range (4-19)]. All 20 patients with ES (100%, 95% CI 84-100%) and 18 patients with clips (89%, 95% CI 70-97%) had successful closure (p = 0.49). One patient needed a rescue method (KING closure) and the other patient an additional clipping on POD1. Closure with clips was quicker [mean time 9.8 (range 4-20) min vs. 14.1 (5-21) min; p = 0.007] and cheaper [mean cost 807 USD (± 402) vs. 2353 USD (± 145); p < 0.001]. Endoscopist assessed the easiness of ES and clips as comparable [mean VAS, range 7.5 (3-10) (ES) vs. 6.9 (3-10) (clips); p = 0.3]. CONCLUSIONS: Both ES and clips are effective methods for mucosal closure in patients undergoing G-POEM. However, centres using clips should have a rescue closure method available as clips may fail in some patients. Closure with ES is more costly than with clips.

Successful repeated gastric peroral endoscopic myotomy (re-G-POEM) in the treatment of postsurgical gastroparesis.

INTRODUCTION: Gastric peroral endoscopic myotomy (G-POEM) is a promising but still experimental endoscopic method for the treatment of gastroparesis. CASE REPORT: We describe the case of a 31 years old female patient with severe refractory postsurgical gastroparesis preceded by fundoplication done for reflux disease. She has had digestive problems since childhood. In 2018, the first G-POEM was performed but did not lead to any clinical improvement. We proposed to perform a repeated G-POEM given that impedance planimetry measurement showed persistent pylorospasm. The patient agreed and the second G-POEM was performed in February 2021 (the first re-G-POEM in the Czech Republic) with a satisfactory clinical result; a subsequent gastric emptying study also showed a significant improvement. CONCLUSION: This case report shows the feasibility of performing a repeated endoscopic pyloromyotomy in patients with gastroparesis and proven pylorospasm. One can only hypothesize whether the lack of effect of the first procedure was caused by an incomplete myotomy (failure of the procedure) or the need for a double myotomy, which is considered a standard in some centers.

Confocal laser endomicroscopy in diagnosing indeterminate biliary strictures and pancreatic lesions a prospective pilot study.

INTRODUCTION: An accurate histopathological diagnosis of indeterminate biliary strictures and pancreatic lesions is challenging because of insufficient quali-ty of tissue specimen taken during ERCP (brush cytology), cholangioscopy (biopsies) or endosonography (EUS, FNAB). Confocal laser endomicroscopy (CLE) allows virtual histopathological diagnosis with the potential to either replace or increase the diagnostic yield of standard histopathological diagnosis in patients presenting with biliary strictures and pancreatic lesions. The aims of our prospective pilot study were to: 1. Assess the diagnostic yield of standard histopathology compared to CLE in patients referred for cholangioscopy or for EUS of the pancreas; 2. Evaluate the cost of CLE in these indications. METHODS: CLE was performed (during cholangioscopy or EUS), followed by standard tissue sampling. CLE-based diagnosis was compared with standard histopathology/cytology. CLE probe was introduced through the working channel of the cholangioscope or through the FNAB needle. RESULTS: A total of 23 patients were enrolled (12 women, mean age 61 years); 13 patients underwent cholangioscopy and 10 patients underwent EUS. Cholangioscopy: CLE diagnosed correctly all 4 malignant strictures (histology 2 of them only as 2 patients had insufficient quality of the tissue specimen). Agreement between standard histopathology and CLE was achieved in 85 %. EUS: All 3 cases of pancreatic cancer were correctly diagnosed by both CLE and FNAB. All remaining (premalignant and benign) lesions were also correctly diagnosed by both methods. The cost of CLE examination is higher compared to FNAB but comparable with tissue sampling during digital cholangioscopy. CONCLUSION: CLE demonstrated sufficient diagnostic accuracy in patients with indeterminate biliary strictures or pancreatic lesions and, therefore, might improve diagnostic accuracy or even replace standard histopathology in these indications.

Per-oral endoscopic pyloromyotomy (g-poem) for the treatment of gastroparesis - a pilot single-centre study with mid-term follow-up.

INTRODUCTION: Endoscopic pyloromyotomy (G-POEM) is an emerging therapeutic method for the treatment of gastroparesis (GP). So far, only limited case-series suggesting its effectivity have been published. The aim of our study was to assess the effectivity of G-POEM in patients with refractory GP. METHODS: Consecutive patients with severe and refractory GP were offered the procedure. An abnormal gastric emptying study (GES) was necessary for inclusion. The main outcome was treatment success defined as a decrease of the total GSCI symptom score by at least 40% from baseline at 3, 6, 12 and 24 months. RESULTS: G-POEM was performed in 9 patients (5 women, mean age 56.3): 5 post-surgical, 2 diabetic, 1 idiopathic and 1 combined post-surgical and diabetic. The median follow-up was 23M (range 12-31). All procedures were successfully completed. One patient experienced delayed bleeding from gastric ulceration, which was successfully treated endoscopically; all remaining patients recovered uneventfully. Treatment success was achieved in 8/9 patients (88.9%) at 3, 6 and 12M and in 3/4 (75%) at 24M. The mean GSCI decreased from 3.16 to 0.86 (p=0.008), 0.74 (p=0.008), 1.07 (p=0.008) and 1.31 (p=0.11) at 3, 6, 12 and 24M after the procedure. The Quality of Life Index improved from the baseline value of 77 (range 48102) to 113 (86-138, p=0.03) and 96 (50-124, p=0.4) at 12 and 24M. In patients with treatment success, no recurrences have occurred so far. GES improved/normalized in all the patients. CONCLUSION: G-POEM was effective in 88.9% of patients with refractory GP and the effect seems to be long-lasting.

Two types of autologous cells in stricture development prevention after complete circular endoscopic dissection in minipig.

INTRODUCTION: Complete circular endoscopic dissection (CED) is frequently accompanied with post-operative strictures formation in the esophagus. Various types of therapeutic approaches have recently been tested to prevent these strictures, e.g. cell therapy or stenting. METHODS: Miniature pigs of Gottingen/Minnesota origin (n=10) were used in the study. First, we made the complete CED in the mid esophagus; next, the defect was left untreated or covered with mesenchymal stem cells (MSCs) or a mixture of MSCs and primary oral keratinocytes (pOKs) suspension without/with fully covered self-expandable metallic stent (SEMS). Consequently, we performed a control endoscopy with a stent removal, and necropsy was performed 17-36 days after cells application. RESULTS: All CED procedures were completed successfully without serious complications. Although we were able to detect MSCs or pOKs in the post-CED defects up to the 36th day after transplantation, the combination of MSCs or MSCs/pOKs with or without SEMS application did not prevent post-CED strictures development. The mixture of MSCs and pOKs resulted in the formation of cellular aggregates, which were mainly observed in submucosa, and the post-CED defect was covered with collagen fibers containing a thin scarred epithelium, accompanied by various degrees of reconstruction and integrity. CONCLUSION: Suspension application of autologous MSCs alone or in combination with pOKs with or without SEMS was ineffective in the prevention of strictures formation after complete CED. Nevertheless, the presence of MSCs or pOKs in the post-CED defect was confirmed even 5 weeks after transplantation.

Fixation of biomaterial to metallic stent and fixation of stents after circular endoscopic dissection in the esophagus on an animal model.

INTRODUCTION: Complete circular endoscopic (submucosal) resection (CER) performed using the endoscopic submucosal dissection (ESD) technique is burdened with a high incidence of post-operative strictures in the esophagus. The most effective method of preventing them is not known so far; one of the possible methods is to prevent these strictures directly at the site of their formation by covering the defect with a stent. The aim of the study was to find a way to fix a selected biomaterial to a stent, and subsequently, to fix the stent at the CER site to prevent esophageal strictures in an animal model. METHOD: Miniature piglets from the Czech Academy of Sciences breeding unit in Libechov (N=10) were used. Endoscopy was performed using a single-channel endoscope. First, we made two circular mucosal cuts spaced 5 cm apart in the middle esophagus and we performed the CER between them using the endoscopic submucosal dissection technique. After that, we covered the defect with a stent coated with biomaterial (Xe-Derma®) while we tried to prevent stent migration into the stomach. For stent fixation, we tested endo-clips (N=3), the Apollo endoscopic system (N=1) and the suspension technique using two polyamide threads (N=6) anchored in the nasal septum. We performed a control endoscopy, stent removal and subsequent autopsy after 12 weeks. RESULTS: All procedures were completed successfully without serious complications or deaths. Although stents covered with Xe-Derma® were applied to the entire resection area, one case of mediastinitis and one paraesophageal abscess were found during autopsy, most likely due to microperforations caused during the procedure. Histological analysis showed that after contact with the biomaterial, re-epithelisation took place within one week of application to the resection area. Stent migration occurred in each case when the stent was attached to the esophageal wall by endo-clips or with the endoscopic suture system (Apollo). There was no stent dislocation in the cases where the stent was suspended by two polyamide threads. CONCLUSION: We developed a technique of fixing biomaterial to the surface of metallic stents which we used to prevent the formation of esophageal strictures after CER. Distal suspension fixation of the stent with a polyamide thread proved to be the most effective, while fixations by endo-clips or with the endoscopic suture system were ineffective.Key words: benign esophageal strictures circular endoscopic resection endoscopic submucosal dissection complication prevention.

Confocal laser endomicroscopy in the diagnostics of gastrointestinal lesions literary review and personal experience.

INTRODUCTION: Confocal laser endomicroscopy (CLE) is a new method enabling real-time histopathological diagnosis. Two platforms of CLE are used standardly: the so called probe-based CLE in which an endomicroscopic probe is inserted through an endoscope, and so-called needle-based CLE inserted through a needle. METHODS: CLE enables evaluation of epithelial and subepithelial structures with 1000x magnification in any part of the gastrointestinal system. The main advantage over conventional biopsies can be immediate diagnosis and larger area evaluated. CLE might play a promising role in indeterminate biliary lesions where biopsies are often not sufficient and fail to allow for accurate diagnosis. CLE can also have a promising potential in pancreatic lesions where it is used along with the needle designed for tissue aspiration during endosonography. It is also possible to use CLE in other organ systems and medical specialties, e.g. in pneumology, neurosurgery, ENT and others. CONCLUSION: CLE is a promising diagnostic method; however, it is unlikely to replace standard biopsies currently since these are still considered a gold standard of histopathological diagnosis. High purchase price is a main disadvantage of the method, hampering its expansion in medicine. Key words: confocal laser endomicroscopy CLE biliary strictures pancreatic lesions esophageal carcinoma Rozhl Chir 2018;97:531-538.

Crohns disease of the appendix - a case report.

INTRODUCTION: Crohns disease is a chronic inflammatory autoimmune disease with unknown etiology. Although the disease may involve any part of the gastrointestinal tract, the most frequently affected site is the terminal ileum. Crohns disease itself is more common in women and in younger patients. Typical symptoms of the condition are diarrhoea, abdominal pain, weight loss and fever. A part of patients may present with extraintestinal symptoms like exanthema, joint pain, conjunctivitis or less often a hepatic lesion. In our publication, we have reported a rare case of Crohns disease with isolated involvement of the appendix, in which the definitive diagnosis was established after the surgery. CASE REPORT: Our patient presented with atypical symptoms and endoscopy findings. The majority of patients with Crohns disease of the appendix present as if they had acute appendicitis. CONCLUSION: Appendiceal form of Crohns disease is a relatively rare variety of Crohns disease and is less aggressive than in the other locations. Surgical resection (appendectomy) is considered to be curative and the risk of relapse is very low. Key words: Crohns disease - appendix differential diagnosis - treatment surveillance.

[The possibilities for the implementation of whole genome sequencing (WGS) of Neisseria meningitidis in molecular surveillance of invasive meningococcal disease in the Czech Republic]. / Moznosti implementace sekvenace celého genomu (WGS) Neisseria meningitidis do molekulární surveillance invazivního meningokokového onemocnení v Ceské republice.

The implementation of the surveillance of invasive meningococcal disease is recommended worldwide. The Whole Genome Sequencing (WGS) method increasingly comes to the fore, which provides the possibilities for further detailed characterization of Neisseria meningitidis and makes it possible to integrate all conventional sequencing approaches into one method. Six N. meningitidis isolates from 2013 and 2015, characterized previously by Sanger amplicon sequencing, were selected to be studied by the novel WGS method. WGS data analysis has confirmed the accuracy of this method in determining epidemiological markers. The aim of this communication is to point out the possibility for the implementation of WGS into molecular surveillance of invasive meningococcal disease in the Czech Republic. The National Reference Laboratory for Meningococcal Infections (NRL/MEN) will continue to use WGS for molecular characterization of selected isolates of N. meningitidis and for the improvement of molecular surveillance of invasive meningococcal disease in the country.

[Clonal analysis of the meningococcal populations from invasive disease and healthy carriers isolated in the Czech Republic in 1971-2014 (May)]. / Klonální analýza populace meningokoku z invazivního onemocnení a od zdravých nosicu izolovaných v Ceské republice v období 1971--2014 (kveten).

OBJECTIVE: To present the results of clonal analysis of the meningococcal populations isolated from invasive disease and healthy carriers in the Czech Republic over four decades. MATERIAL AND METHODS: A total of 2179 isolates of Neisseria meningitidis from 1971-2014 (May) were studied: 1093 isolates from patients with invasive meningococcal disease (IMD) and 1086 isolates from healthy carriers. All study isolates were analysed by multilocus sequence typing (MLST), one of the major methods used in molecular epidemiology of IMD. RESULTS: More than 94 % of N. meningitidis isolates from IMD were assigned to serogroups B or C. The strains of the leading serogroup B were genetically highly heterogeneous: 1093 isolates were assigned to 25 clonal complexes. Similarly, the strains of the second leading serogroup C appeared genetically heterogeneous and were classified into 19 clonal complexes. The third leading serogroup Y of IMD isolates showed an opposite tendency and appeared highly homogeneous, with only three clonal complexes being detected. Over 75% of the predominant clonal complexes of IMD isolates of both serogroup Y (cc23) and serogroup C (cc11) were classified as hypervirulent and, as such, posed the highest risk to the host population. Over 80% of IMD isolates of serogroup B were assigned to hypervirulent clonal complexes (cc32, cc41/44, cc18, cc269, and cc11). Of 1086 N. meningitidis isolates from healthy carriers, 41.4% were non-serogroupable, i.e. designated N. meningitidis NG. Classification of these isolates into clonal complexes was highly heterogeneous. In total, 28 clonal complexes were identified of which only a minority were hypervirulent. CONCLUSIONS: The analysis of MLST data on strains collected over four decades revealed that the population of N. meningitidis strains involved in IMD differ genetically from N. meningitidis strains isolated from healthy carriers. These results are relevant to both the optimal use of preventive measures in a focus of IMD and to the development of an effective meningococcal vaccine and vaccination strategy guidelines.

[Real-time PCR detection of Neisseria meningitidis, Haemophilus influenzae, and Streptococcus pneumoniae DNA in clinical specimens]. / Detekce DNA Neisseria meningitidis, Haemophilus influenzae a Streptococcus pneumoniae v klinickém materiálu metodou real-time PCR.

The study aim was to implement a molecular real-time polymerase chain reaction (PCR) assay recommended by the CDC (Centers for Disease Control and Prevention) for the detection of Neisseria meningitidis, Haemophilus influenzae, and Streptococcus pneumoniae in clinical (culture negative) specimens from patients with suspected invasive bacterial disease. Clinical specimens are referred to the National Reference Laboratory (NRL) for Meningococcal Infections, Unit for Airborne Bacterial Infections, Centre for Epidemiology and Microbiology, National Institute of Public Health from various regions of the Czech Republic. Clinical specimens are, in particular, cerebrospinal fluid, anti-coagulated blood or serum and, exceptionally, post-mortem specimens. The NRL has implemented molecular diagnosis of these bacterial pathogens involved in meningitis and sepsis from clinical specimens since 1999. The first diagnostic method was semi-nested PCR followed by electrophoretic analysis. In 2014, a molecular qualitative real-time PCR assay was implemented.

Predicted strain coverage of a new protein-based meningococcal vaccine in the Czech Republic.

BACKGROUND: Recent data indicate that Neisseria meningitidis B strains cause about 70% of invasive meningococcal disease (IMD) cases in Europe and the availability of a vaccine effective against N. meningitidis B is desirable. A new protein-based MenB vaccine was licensed for use in Europe in January 2013. Meningococcal antigen typing system (MATS) was developed to predict strain coverage of this vaccine. Reports have recently been published for a European consortium, including aggregated data for the Czech Republic. The aim of this paper is to provide a detailed breakdown of MATS results for the Czech N. meningitidis B isolates. MATERIALS AND METHODS: One hundred and eight N. meningitidis B isolates from IMD collected in the Czech Republic during 2007-2010 were selected. MATS analysis was done according to the method previously published. RESULTS: Based on MATS analysis, the overall estimate of strain coverage of the new MenB vaccine for a panel of 108 Czech N. meningitidis B strains is 74% (95% CI: 59-87%). Thirty-nine strains (36%) are predicted to be covered by a single antigen and 41 strains (38%) by more than one antigen. For 28 strains (26%), no antigen coverage was found. CONCLUSIONS: MATS analysis showed that the new protein-based MenB vaccine could protect against a substantial proportion of IMD caused by N. meningitidis B in the Czech Republic. Continued detailed surveillance of IMD will be essential if the MenB vaccine is introduced to the country.

[Sequencing analysis of the antigens included in the four-component vaccine against serogroup B meningococcus in Czech isolates of Neisseria meningitidis from 2007-2013]. / Sekvenacní analýza antigenu zarazených v ctyrkomponentní vakcíne proti meningokoku B v ceských izolátech Neisseria meningitidis v období 2007-2013.

OBJECTIVE: Study of the antigens included in the newly registered four-component vaccine against meningococcus B (MenB vaccine) produced by the reverse vaccinology method and assessment of the potential of the vaccine for use in the Czech Republic. MATERIAL AND METHODS: Czech isolates of Neisseria meningitidis were screened for four antigens: fHbp (factor H binding protein), NHBA (Neisseria heparin binding antigen), NadA (neisserial adhesin A), and PorA P1.4 outer membrane protein. A total of 304 N. meningitidis isolates from 2007-2013 were included in the study: 262 isolates from invasive meningococcal disease (IMD) (203 serogroup B isolates and 59 non-B isolates) and 42 isolates from healthy carriers. RESULTS: The gene encoding the fHbp peptide was detected in all study isolates from both IMD cases and healthy carriers. The two types of isolates differed in the distribution of fHbp variants. The fHbp1 variant prevailed in the IMD isolates (both B and non-B) while the fHbp2 variant was expressed more often in the carrier isolates. The presence of the nhba gene encoding the NHBA peptide was revealed in all study isolates from both IMD cases and healthy carriers. The serogroup B isolates from IMD cases differed from the non-B isolates from IMD cases and from the carrier isolates in the distribution of NHBA variants. The presence of the nadA gene encoding the NadA peptide was only found in 26.6% of serogroup B isolates from IMD cases in comparison to 40.7% of non-B isolates from IMD cases. As few as 4.8% of isolates from healthy carriers harboured the nadA gene. The PorA P1.4 protein included in the new MenB vaccine was only detected in two serogroup B isolates from IMD cases (of the total of 262 serogroup B and non-B isolates from IMD cases) and in none of the isolates from healthy carriers. Isolates from both B and non-B IMD cases were positive most often for the combination of the antigens NHBA + fHbp1, followed by the NHBA antigen alone and then by the combination NHBA + fHbp1 + NadA-1+2/3. Isolates from healthy carriers showed a different antigen distribution pattern: the NHBA antigen alone was the most widespread, followed by the combination NHBA + fHbp1. CONCLUSIONS: The antigens included in the four-component MenB vaccine were revealed by sequencing in a large proportion of the Czech isolates of N. menin-gitidis from both IMD cases and healthy carriers. This four-component vaccine registered in Europe since January 2013 has proven suitable for use in the Czech Republic.

Reciprocal changes in maternal and fetal metabolism of corticosterone in rat during gestation.

OBJECTIVE: The objective of this study was to investigate the role of 11beta-hydroxysteroid dehydrogenases (11HSD1 and 11HSD2) in determining the fetal concentration of glucocorticoids. METHODS: The expression patterns for mRNA abundance, protein level, and enzyme activities of placental and fetal 11HSD1 and 11HSD2 were assessed from embryonic day 13 (E13) to day 21 (E21; term E22). The transplacental passage of maternal corticosterone and its contribution to fetal glucocorticoids was also studied. RESULTS: Placental 11HSD1 mRNA decreased between days E13 and E14 and then remained at much lower values up to E21. Similarly, NADP+-dependent 11beta-oxidation and 11-reduction were lower in late gestation. In contrast, placental 11HSD2 mRNA and protein decreased between E13 and E21. Dithiothreitol increased the activity of 11HSD2 and the output of 11-dehydrocorticosterone into fetal circulation.The fetal activity of 11HSD1 increased and 11HSD2 decreased between E16 and E21. CONCLUSIONS: The final third of gestation is accompanied by reciprocal changes in placental and fetal metabolism of corticosterone due to changes in 11HSD1 and 11HSD2 not only at the level of transcription but also at a posttranslational level.