Implementation of European Society of Gastrointestinal Endoscopy (ESGE) recommendations for small-bowel capsule endoscopy into clinical practice: Results of an official ESGE survey.

BACKGROUND: We aimed to document international practices in small-bowel capsule endoscopy (SBCE), measuring adherence to European Society of Gastrointestinal Endoscopy (ESGE) technical and clinical recommendations. METHODS: Participants reached through the ESGE contact list completed a 52-item web-based survey. RESULTS: 217 responded from 47 countries (176 and 41, respectively, from countries with or without a national society affiliated to ESGE). Of respondents, 45 % had undergone formal SBCE training. Among SBCE procedures, 91 % were performed with an ESGE recommended indication, obscure gastrointestinal bleeding (OGIB), iron-deficiency anemia (IDA), and suspected/established Crohn's disease being the commonest and with higher rates of positive findings (49.4 %, 38.2 % and 53.5 %, respectively). A watchful waiting strategy after a negative SBCE for OGIB or IDA was preferred by 46.7 % and 70.3 %, respectively. SBCE was a second-line exam for evaluation of extent of new Crohn's disease for 62.2 % of respondents. Endoscopists adhered to varying extents to ESGE technical recommendations regarding bowel preparation ( > 60 %), use in those with pacemaker holders (62.5 %), patency capsule use (51.2 %), and use of a validated scale for bowel preparation assessment (13.3 %). Of the respondents, 67 % read and interpreted the exams themselves and 84 % classified exams findings as relevant or irrelevant. Two thirds anticipated future increase in SBCE demand. Inability to obtain tissue (78.3 %) and high cost (68.1 %) were regarded as the main limitations, and implementation of artificial intelligence as the top development priority (56.2 %). CONCLUSIONS: To some extent, endoscopists follow ESGE guidelines on using SBCE in clinical practice. However, variations in practice have been identified, whose implications require further evaluation.

High-definition colonoscopy for improving adenoma detection: a systematic review and meta-analysis of randomized controlled studies.

BACKGROUND AND AIMS: Previous meta-analysis showed marginal benefit of high-definition white-light endoscopy (HD-WLE) over standard-definition colonoscopy (SDC) for adenoma detection, but with residual uncertainty due to inclusion of nonrandomized studies. We aimed to further assess the effect of HD-WLE on adenoma detection by including only randomized controlled trials (RCTs). METHODS: A literature search was performed for RCTs evaluating HD-WLE versus SDC in terms of adenoma, advanced adenoma, and serrated sessile adenoma detection rates as well as the mean number of adenomas per colonoscopy (MAC), the mean number of advanced adenomas per colonoscopy (MAAC), and the mean number of sessile serrated adenomas per colonoscopy (MSSAC). The effect size on study outcomes is presented as the risk ratio (RR; 95% confidence interval [CI]) or mean difference (MD; 95% CI). We assessed the strength of evidence using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. RESULTS: Six RCTs involving 4594 individuals (HD-WLE, 2323; SDC, 2271) were included. Clinical indications were screening (1 study), positive result for fecal occult blood test, personal/family history of colorectal cancer (1 study), and mixed indications (4 studies). Withdrawal time was similar between the 2 arms (MD, -0.06; 95% CI, -0.25 to 0.12; P = .50). The adenoma detection rate was significantly higher in the HD-WLE arm compared with the SDC arm (40% vs 35%; RR, 1.13; 95% CI, 1.05-1.22; P = .001; I2 = 0%; GRADE, low). This effect was consistent for advanced and sessile serrated adenoma detection rates (RR, 1.33; 95% CI, 1.03-1.72; P = .03; I2 = 0%; GRADE, low; and RR, 1.55; 95% CI, 1.05-2.28; P = .03; I2 = 0%; GRADE, low, respectively). In contrast, the difference was not significant for MAC, MAAC, and MSSAC. CONCLUSIONS: Meta-analyses of RCT data support the use of HD-WLE in clinical practice, although the additional benefit is limited.

The role of surgical treatment in isolated organ recurrence of esophageal cancer-a systematic review of the literature.

BACKGROUND: Despite the improvements in the early detection and treatment of non-metastatic esophageal cancer, more than half of patients undergoing a curative treatment for esophageal cancer will develop recurrence within three years. The prognosis of these patients is poor. However, a wide range in overall survival has been reported, depending on the pattern of recurrence, and no optimal treatment strategy following recurrence has yet been uniformly accepted. AIM: In this article, we aimed to systematically review the literature for the role of surgical resection of metachronous distant metastasis following primary treatment of esophageal cancer. Furthermore, we discuss possible factors that could possibly predict which patients may benefit from a surgical approach. A comprehensive literature search was conducted in PubMed using combinations of keywords. RESULTS: Patients with recurrence may benefit of a multimodality treatment. Regarding the isolated recurrence of esophageal cancer in solid visceral organs, operative intervention has been proposed as a treatment that may offer a survival benefit in an individual basis. No definitive conclusions regarding the potential survival advantage offered by the surgical treatment of solitary recurrent lesions can be drawn. However, recent improvements in surgical treatment and optimization of perioperative management guarantee an acceptable operative risk, making surgical resection of solitary recurrence lesions a considerable therapeutic option. CONCLUSIONS: It can be conferred from the available studies that the surgical treatment of isolated recurrence from esophageal cancer may offer a survival benefit for properly selected patients. Prospective, multicenter studies might be useful to gain a better insight into those factors that affect selection of patients to take benefit from an operative intervention.

Gastric carcinosarcoma: a rare clinical entity looking for an identity.

Carcinosarcoma of the stomach represents a rare variant of gastric malignancies. It is composed of intimately mixed epithelial and mesenchymal elements. Only few cases of gastric carcinosarcoma have been reported in the literature. Surgical treatment is the only curative modality, but the disease progress is usually aggressive and its prognosis remains poor even afer curative treatment. The defnitive diagnosis is usually made by histopathological and immunohistochemical analysis of the resected tumor. This review summarizes the available data concerning epidemiology, pathogenesis, clinical characteristics, diagnosis, histopathology, treatment and prognosis of gastric carcinosarcoma.

Activation of NLRP3 Inflammasome in Inflammatory Bowel Disease: Differences Between Crohn's Disease and Ulcerative Colitis.

BACKGROUND: NLRP3 inflammasome is a multimolecular cytosol complex that, when activated, contributes to the cleavage of pro-interleukin (IL)-1ß to IL-1ß. AIMS: To investigate NLRP3 inflammasome activation in inflammatory bowel disease. METHODS: Peripheral blood mononuclear cells from Crohn's disease (CD), ulcerative colitis (UC) patients and controls were stimulated with LPS in the absence or presence of MSU. After incubation, concentrations of IL-1ß, IL-6, and TNFα were measured in cell supernatants and concentration of pro-IL-1ß was measured in cell lysates. NLRP3 activation was defined as more than 30% increase in IL-1ß production after MSU addition. In separate experiments, PBMCs were lysed for RNA isolation transcripts of IL-1ß, TNFα, NLRP3, and CASP1 were measured by RT-PCR. DNA was isolated from CD patients for ATG16L1 gene genotyping. RESULTS: NLRP3 inflammasome was activated in 60% of CD patients compared to 28.6% of controls (p = 0.042); no significant difference was detected between UC and controls. Among UC patients, NLRP3 activation was associated (p = 0.008) with long-standing disease (>1.5 years). IL-1ß levels were significantly higher in CD patents in comparison with controls (p = 0.032). No difference was detected in the levels of IL-6, TNFα, pro-IL-1ß and in the numbers IL-1ß, TNFα, NLRP3, and CASP1 transcripts among groups. IL-1ß production was similar between carriers of wild-type and of SNP alleles of the rs2241880. CONCLUSIONS: NLRP3 inflammasome is activated in CD patients and in UC patients with long-standing disease.

Impact of COVID-19 pandemic on the healthcare and psychosocial well-being of patients with inflammatory bowel disease.

COVID-19 pandemic has resulted in unprecedented disruptions to several aspects of gastroenterology healthcare services worldwide. In particular, patients with inflammatory bowel disease (IBD) represent a sensitive population that must retain access to healthcare services to avoid potential disease exacerbation under the continuous threat of viral infection. Emerging evidence also highlights the severe impact on these patients' mental well-being, leading to a constant cycle of stress/depression and disease activity relapse. In an effort to circumvent these healthcare challenges in a newly-shaped environment, physicians implemented telemedicine consultative care programs as a novel alternative follow-up method highly favored by the patients. The situation is still far from perfect, since a large proportion of patients are lost to follow up and/or lose adherence to their medication, especially when the exact timeframe or optimal strategy for the post-COVID era remains to be defined. Cancelation of elective endoscopic procedures has led to a significant decline of new IBD diagnoses. This review summarizes the data on the global impact of COVID-19 on IBD patients' healthcare and their psychosocial status.

An educational intervention to optimize use of proton pump inhibitors in a Greek university hospital.

BACKGROUND: Misuse of proton pump inhibitors (PPIs) is an alarming issue for patients and healthcare systems. METHODS: We conducted a 3-phase interventional, prospective study in a Greek university hospital. During Phase I, we collected data from patients' records to evaluate the appropriate use of PPIs. During Phase II, educational seminars about the proper use of PPIs were offered to the medical staff. In Phase III we collected data from the records of patients admitted to the hospital department with the highest rate of inappropriate PPI administration during Phase I, to evaluate the efficacy of the intervention. Inappropriate use was defined as either PPI administration without indication, or lack of use despite adequate indication. Appropriateness of PPI use was measured at admission, during hospitalization and at discharge. RESULTS: The rate of inappropriate PPI use was higher (51.7% and 48.6%) during hospitalization than at admission (34.9% and 21.9%), but at discharge was similar to pre-hospitalization levels (26.9% and 23.6%), in Phases I and III, respectively. At discharge during Phase I, the inappropriate use of PPIs was significantly higher (odds ratio 3.79, 95% confidence interval 1.98-7.19) for internal medicine patients than for surgical patients. The educational intervention failed to reduce the inappropriate use of PPIs during hospitalization (51.7% vs. 48.6%, P=0.478) or at discharge (26.9% vs. 23.6%, P=0.391) in the internal medicine patients. CONCLUSIONS: The rate of inappropriate PPI use is almost double during hospitalization compared to the rates at admission and at discharge. Implementation of an educational intervention failed to reduce the inappropriate use of PPIs in internal medicine patients.

Two Needle Passes Achieve Similar Diagnostic Yield Compared to Three Passes Regarding Diagnosis of Solid Pancreatic Lesions in Endoscopic Ultrasound-Guided Fine Needle Aspiration.

Current guidelines advocate 3-4 passes with a fine-needle aspiration (FNA) to achieve high rates of diagnostic samples for malignancy when performing endoscopic ultrasound (EUS)-guided sampling of solid pancreatic lesions, in the absence of on-site cytologic evaluation. The aim of this study is to compare 2 vs. 3 needle passes in EUS-FNA for solid pancreatic lesions in terms of incremental diagnostic yield and to identify factors associated with the procedure's outcome. In this retrospective study, 2 passes of EUS-FNA were found to have similar diagnostic yield compared to 3 passes for the diagnosis of solid pancreatic masses, suggesting that there might be no significant incremental tissue yield when 3 passes are performed.

Association between genotypes of rs34436714 of NLRP12 and serum tumor necrosis factor-alpha in inflammatory bowel disease: A case-control study.

We aimed to investigate the impact of the single nucleotide polymorphisms of rs34436714 of the NOD-like receptor protein 12 gene on the production of tumor necrosis factor-alpha (TNFα) in patients with inflammatory bowel disease (IBD)In a matched case-control study 90 patients with IBD, 56 with Crohn disease (CD) and 34 with ulcerative colitis, were genotyped and compared to 98 healthy comparators matched for age and gender. Expression level of TNFα, interleukin (IL)-6, IL-12, and soluble triggering receptor expressed on myeloid cells were measured in patients' sera. Peripheral blood mononuclear cells (PBMCs) were isolated and stimulated for TNFα production.Serum TNFα was greater among carriers of GT/TT genotypes than GG genotypes of rs34436714. Stimulated TNFα production was also higher in carriers of GT/TT genotypes. The frequency of CD with fistulizing behavior and with CD involving the small intestine was greater among carriers of GT/TT genotypes than of the GG genotype. Distribution of the GG, GT, and TT genotypes of rs34436714 were in Hardy-Weinberg equilibrium in both groups. The genotype distribution was the same in both groups.Carriage of minor frequency alleles of rs34436714 was accompanied by greater circulating levels of TNFα and by greater capacity for stimulated TNFα production by PBMCs. These alleles had an impact on the phenotype of patients with CD.

Haplotypes composed of minor frequency single nucleotide polymorphisms of the TNF gene protect from progression into sepsis: A study using the new sepsis classification.

OBJECTIVES: Several articles have provided conflicting results regarding the role of single nucleotide polymorphisms (SNPs) in the promoter region of the TNF gene in susceptibility to sepsis. Former articles have been based on previous definitions of sepsis. This study investigated the influence of TNF haplotypes on the development of sepsis using the new Sepsis-3 definitions. METHODS: DNA was isolated from patients suffering from infection and systemic inflammatory response syndrome. Haplotyping was performed for six SNPs of TNF. The serum levels of tumour necrosis factor alpha (TNF-α) of these patients were measured using an enzyme immunosorbent assay. Patients were classified into infection and sepsis categories using the Sepsis-3 definitions. Associations between the TNF haplotypes and the clinical characteristics and serum TNF-α levels of the patients were examined. RESULTS: The most common TNF haplotype h1 was composed of major alleles of the studied SNPs. Carriage of haplotypes composed of minor frequency alleles was associated with a lower risk of developing sepsis (odds ratio 0.41, 95% confidence interval 0.19-0.88, p=0.022), but this did not affect the 28-day outcome. Serum TNF-α levels were significantly higher among patients homozygous for h1 haplotypes who developed sepsis compared to infection (p=0.032); a similar result was not observed for patients carrying other haplotypes. CONCLUSIONS: Haplotypes containing minor frequency SNP alleles of TNF protect against the development of sepsis without affecting the outcome.

Improved bowel preparation increases polyp detection and unmasks significant polyp miss rate.

AIM: To retrospectively compare previous-day vs split-dose preparation in terms of bowel cleanliness and polyp detection in patients referred for polypectomy. METHODS: Fifty patients underwent two colonoscopies: one diagnostic in a private clinic and a second for polypectomy in a University Hospital. The latter procedures were performed within 12 wk of the index ones. Examinations were accomplished by two experienced endoscopists, different in each facility. Twenty-seven patients underwent screening/surveillance colonoscopy, while the rest were symptomatic. Previous day bowel preparation was utilized initially and split-dose for polypectomy. Colon cleansing was evaluated using the Aronchick scale. We measured the number of detected polyps, and the polyp miss rates per-polyp. RESULTS: Excellent/good preparation was reported in 38 cases with previous-day preparation (76%) vs 46 with split-dose (92%), respectively (P = 0.03). One hundred and twenty-six polyps were detected initially and 169 subsequently (P < 0.0001); 88 vs 126 polyps were diminutive (P < 0.0001), 25 vs 29 small (P = 0.048) and 13 vs 14 equal or larger than 10 mm. The miss rates for total, diminutive, small and large polyps were 25.4%, 30.1%, 13.7% and 6.6%, respectively. Multivariate analysis revealed that split-dose preparation was significantly associated (OR, P) with increased number of polyps detected overall (0.869, P < 0.001), in the right (0.418, P = 0.008) and in the left colon (0.452, P = 0.02). CONCLUSION: Split-dose preparation improved colon cleansing, enhanced polyp detection and unmasked significant polyp miss rates.

Virtual reality simulators for gastrointestinal endoscopy training.

The use of simulators as educational tools for medical procedures is spreading rapidly and many efforts have been made for their implementation in gastrointestinal endoscopy training. Endoscopy simulation training has been suggested for ascertaining patient safety while positively influencing the trainees' learning curve. Virtual simulators are the most promising tool among all available types of simulators. These integrated modalities offer a human-like endoscopy experience by combining virtual images of the gastrointestinal tract and haptic realism with using a customized endoscope. From their first steps in the 1980s until today, research involving virtual endoscopic simulators can be divided in two categories: investigation of the impact of virtual simulator training in acquiring endoscopy skills and measuring competence. Emphasis should also be given to the financial impact of their implementation in endoscopy, including the cost of these state-of-the-art simulators and the potential economic benefits from their usage. Advances in technology will contribute to the upgrade of existing models and the development of new ones; while further research should be carried out to discover new fields of application.