A comprehensive examination of small-bowel capsule endoscopy in Spanish centers to meet European Society of Gastrointestinal Endoscopy standards.

Background and study aims In 2019, the European Society of Gastrointestinal Endoscopy (ESGE) created a working group to develop technical and quality standards for small-bowel capsule endoscopy (SBCE) to improve the daily practice of endoscopy services. They developed 10 quality parameters, which have yet to be tested in a real-life setting. Our study aimed to evaluate the accomplishment of the quality standards in SBCE established by the ESGE in several Spanish centers. Materials and methods An online survey of 11 multiple-choice questions related to the ESGE performance measures was sent to Spanish centers with experience in SBCE. In order to participate and obtain reliable data, at least 100 questionnaires had to be answered per center because that is the minimum number established by ESGE. Results 20 centers participated in the study, compiling 2049 SBCEs for the analysis. Only one of 10 performance measures (cecal visualization) reached the minimum standard established by the ESGE. In five of 10 performance measures (Indication, lesion detection rate, terminology, and retention rate) the minimum standard was nearly achieved. Conclusions Our study is the first multicenter study regarding SBCE quality performance measures in a real setting. Our results show that the minimum standard is hardly reached in most procedures, which calls into question their clinical applicability in real life. We suggest performing similar studies in other countries to evaluate whether there is a need for quality improvement programs or a need to reevaluate the minimum and target values published so far.

Comparison of the Mayo Endoscopy Score and the Ulcerative Colitis Endoscopy Index of Severity and the Ulcerative Colitis Colonoscopy Index of Severity.

Background and study aims: Endoscopy plays an essential role in managing patients with ulcerative colitis (UC), as it allows us to visualize and assess the severity of the disease. As such assessments are not always objective, different scores have been devised to standardize the findings. The main aim of this study was to assess the interobserver variability between the Mayo Endoscopy Score (MES), Ulcerative Colitis Endoscopy Index of Severity (UCEIS) and Ulcerative Colitis Colonoscopy Index of Severity (UCCIS) analyzing the severity of the endoscopic lesions in patients with ulcerative colitis. Patients and methods: This was a single-cohort observational study in which a colonoscopy was carried out on patients with UC, as normal clinical practice, and a video was recorded. The results from the video were classified according to the MES, UCEIS and UCCIS by three endoscopic specialists independently, and they were compared to each other. The Mayo Endoscopy Score (MES) was used to assess the clinical situation of the patient. The therapeutic impact was analyzed after colonoscopy was carried out. Results: Sixty-seven patients were included in the study. The average age was 51 (SD ±â€Š16.7) and the average MES was 3.07 (SD ±â€Š2.54). The weighted Kappa index between endoscopists A and B for the MES was 0.8; between A and C 0.52; and between B and C 0.49. The intraclass correlation coefficient for UCEIS was 0.92 among the three endoscopists (CI 95 %: 0.83-0.96) and 0.96 for UCCIS among the three endoscopists (CI 95 % 0.94-0.97). A change in treatment for 34.3 % of the patients was implemented on seeing the results of the colonoscopy. Conclusions: There was an adequate, but not perfect, correlation between the different endoscopists for MES, UCEIS, UCCIS. This was higher with the last two scores. Thus, there is still some subjectivity to be minimized through special training, on assessing the seriousness of the endoscopic lesions in patients with UC.

Index of the Mayo Endoscopy and Ulcerative Colitis Endoscopy Index of Severity: are they equally valid?

INTRODUCTION: endoscopy plays an essential role in the management of patients with ulcerative colitis (UC), as it allows us to visualize and assess the severity of the disease. Different scores have been devised to standardize the findings because such assessments are not always objective. AIMS: the aim of this study was to assess the interobserver variability between the Index of Mayo Endoscopy (IME) and the Ulcerative Colitis Endoscopy Index of Severity (UCEIS), analyzing the severity of the endoscopic lesions in patients with UC. The secondary aim was to analyze if the cathartic preparation affected the degree of concordance amongst the endoscopists. MATERIAL AND METHODS: this was a single-cohort observational, comparative study in which a colonoscopy was performed in patients with UC, as the normal clinical practice. The results were classified according to the IME and the UCEIS by three endoscopic specialists. In order to assess the degree of interobserver correlation, the Kappa index for IME was used and the intraclass correlation coefficient was used for UCEIS. RESULTS: sixty-seven patients were included in the study. The average age was 51 (SD ± 16.7) and the average Mayo Clinic index was 3.07 (SD ± 2.54). The weighted Kappa index between endoscopists A and B for the IME was 0.8, 0.52 between A and C and 0.49 between B and C. The intraclass correlation coefficient for UCEIS was 0.922 between the three endoscopists (95 % CI: 0.832-0.959). A better interobserver correlation was found when the cathartic preparation was ≥ 8 based on the Boston Scale. CONCLUSIONS: there was a higher correlation between the different endoscopists for the UCEIS than for the IME. Thus, this should be considered to be the best index to use in the clinical practice. A good cleansing preparation is important to improve the interobserver correlation.

Small-bowel hemangioma as a cause of chronic anemia.

Small intestine hemangiomas are benign vascular tumors that usually present with occult gastrointestinal bleeding. Endoscopic capsule and enteroscopy are two tools that help in your preoperative diagnosis.

Endoscopic submucosal dissection in management of colorectal tumors near or involving a diverticulum: a retrospective case series.

Background and study aims Surgery is the standard treatment for colon tumors associated with diverticulum. U se of endoscopic submucosal dissection (ESD) to treat such tumors is controversial. The aim of this study was to assess the safety and feasibility of ESD in treating superficial colorectal tumors situated near or involving diverticulum. Patients and methods Consecutive patients from two referral centers who had colorectal tumors near or involving diverticulum treated by ESD were retrospectively studied. Clinicopathological characteristics and clinical outcomes were analyzed. Results Of the 12 patients studied, six had tumors near diverticulum and six had tumors involving diverticulum. The overall en-bloc R0 resection rate, median tumor size and procedure time were 67 %, 26.5 mm (range, 15 - 80 mm) and 110 minutes (range, 50 - 220 minutes), respectively. For tumors near diverticulum group, the en-bloc R0 resection rate was 100 % and no adverse events (AEs) or residual/recurrent tumors were observed. In contrast, for intradiverticular tumors group, the en-bloc R0 resection rate was low at 33 %, and one AE (perforation) was observed. The diverticula were ≥ 6 mm in diameter in the patients with incomplete resection. However, all but one diverticulum was unrecognized before ESD. Two residual tumors were detected at the 12-month surveillance and one required surgery. Conclusions This case series indicates that ESD is safe and feasible for treating colorectal tumors near a diverticulum and might be feasible for tumors involving a diverticulum smaller than 6 mm. Selection for smaller diverticulum size may contribute to higher en-bloc R0 resection rates.

Role of capsule endoscopy in alarm features and non-responsive celiac disease: A European multicenter study.

BACKGROUND AND AIM: The role of capsule endoscopy (CE) in established celiac disease (CD) remains unclear. Our objective was to analyze the usefulness of CE in the suspicion of complicated CD. METHODS: This was a retrospective multicenter study. One hundred and eighty-nine celiac patients (mean age: 46.6 ± 16.6, 30.2% males) who underwent CE for alarm symptoms (n = 86, 45.5%) or non-responsive CD (n = 103, 54.5%) were included. Diagnostic yield (DY), therapeutic impact and safety were analyzed. RESULTS: Capsule endoscopy was completed in 95.2% of patients (small bowel transit time: 270.5 ± 100.2 min). Global DY was 67.2%, detecting atrophic mucosa (n = 92, 48.7%), ulcerative jejunoileitis (n = 21, 11.1%), intestinal lymphoma (n = 7, 3.7%) and other enteropathies (n = 7, 3.7%, six Crohn's disease cases and one neuroendocrine tumor). The DY of CE was significantly higher in patients presenting with non-responsive disease compared to patients with alarm symptoms (73.8% vs 59.3%, P = 0.035). The new findings of the CE modified management in 59.3% of the cases. There were no major complications. CONCLUSION: Capsule endoscopy may be a moderately helpful and safe diagnostic tool in the suspicion of complicated CD, modifying the clinical course of these patients.

Endoscopic ultrasound-guided placement of plastic pigtail stents for the drainage of refractory malignant ascites.

Endoscopic ultrasound (EUS)-guided drainage is now the treatment of choice in cases of pancreatic pseudocysts and walled-off necrosis, especially in the absence of luminal bulging and in patients with portal hypertension. Malignant refractory ascites usually heralds a poor prognosis and substantially impairs the quality of life of patients because of the symptoms experienced and the need for repeated paracentesis. EUS-guided placement of lumen-apposing, fully covered, self-expandable metal stents (FCSEMS) has been reported for the drainage of malignant ascites. Herein, we present the results of EUS-guided placement of plastic pigtails stents for the drainage of refractory malignant ascites in three patients. The aim was to improve symptoms and minimize the possible drawbacks of large-caliber FCSEMS. In this preliminary experience, EUS-guided placement of plastic stents was feasible and avoided further paracentesis.

Capsule endoscopy in young patients with iron deficiency anaemia and negative bidirectional gastrointestinal endoscopy.

BACKGROUND: Recent data imply young patients (age ≤50 years) undergoing small-bowel (SB) capsule endoscopy (CE) for iron deficiency anaemia (IDA) show higher diagnostic yield (DY) for sinister pathology. We aimed to investigate DY of CE in a large cohort of young IDA patients, and evaluate factors predicting significant SB pathology. MATERIALS AND METHODS: This was a retrospective, multicentre study (2010-2015) in consecutive, young patients (≤50 years) from 18 centres/12 countries, with negative bidirectional gastrointestinal (GI) endoscopy undergoing SBCE for IDA. Exclusion criteria: previous/ongoing obscure-overt GI bleeding; age <19 or >50 years; comorbidities associated with IDA. Data retrieved: SBCE indications; prior investigations; medications; SBCE findings; final diagnosis. Clinical and laboratory data were analysed by multivariate logistic regression. RESULTS: Data on 389 young IDA patients were retrieved. In total, 169 (43.4%) were excluded due to incomplete clinical data; data from 220 (122F/98M; mean age 40.5 ± 8.6 years) patients were analysed. Some 71 patients had at least one clinically significant SBCE finding (DY: 32.3%). They were divided into two groups: neoplastic pathology (10/220; 4.5%), and non-neoplastic but clinically significant pathology (61/220; 27.7%). The most common significant but non-neoplastic pathologies were angioectasias (22/61) and Crohn's disease (15/61). On multivariate analysis, weight loss and lower mean corpuscular volume(MCV) were associated with significant SB pathology (OR: 3.87; 95%CI: 1.3-11.3; p = 0.01; and OR: 0.96; 95%CI: 0.92-0.99; p = 0.03; respectively). Our model also demonstrates association between use of antiplatelets and significant SB pathology, although due to the small number of patients, definitive conclusions cannot be drawn. CONCLUSION: In IDA patients ≤50 years with negative bidirectional GI endoscopy, overall DY of SBCE for clinically significant findings was 32.3%. Some 5% of our cohort was diagnosed with SB neoplasia; lower MCV or weight loss were associated with higher DY for SB pathology.

Corrigendum: Fecal Gluten Peptides Reveal Limitations of Serological Tests and Food Questionnaires for Monitoring Gluten-Free Diet in Celiac Disease Patients.

This corrects the article DOI: 10.1038/ajg.2016.439.

Role of capsule endoscopy in suspected celiac disease: A European multi-centre study.

AIM: To analyze the diagnostic yield (DY), therapeutic impact (TI) and safety of capsule endoscopy (CE). METHODS: This is a multi-centre, observational, analytical, retrospective study. A total of 163 patients with suspicion of celiac disease (CD) (mean age = 46.4 ± 17.3 years, 68.1% women) who underwent CE from 2003 to 2015 were included. Patients were divided into four groups: seronegative CD with atrophy (Group-I, n = 19), seropositive CD without atrophy (Group-II, n = 39), contraindication to gastroscopy (Group-III, n = 6), seronegative CD without atrophy, but with a compatible context (Group-IV, n = 99). DY, TI and the safety of CE were analysed. RESULTS: The overall DY was 54% and the final diagnosis was villous atrophy (n = 65, 39.9%), complicated CD (n = 12, 7.4%) and other enteropathies (n = 11, 6.8%; 8 Crohn's). DY for groups I to IV was 73.7%, 69.2%, 50% and 44.4%, respectively. Atrophy was located in duodenum in 24 cases (36.9%), diffuse in 19 (29.2%), jejunal in 11 (16.9%), and patchy in 10 cases (15.4%). Factors associated with a greater DY were positive serology (68.3% vs 49.2%, P = 0.034) and older age (P = 0.008). On the other hand, neither sex nor clinical presentation, family background, positive histology or HLA status were associated with DY. CE results changed the therapeutic approach in 71.8% of the cases. Atrophy was associated with a greater TI (92.3% vs 45.3%, P < 0.001) and 81.9% of the patients responded to diet. There was one case of capsule retention (0.6%). Agreement between CE findings and subsequent histology was 100% for diagnosing normal/other conditions, 70% for suspected CD and 50% for complicated CD. CONCLUSION: CE has a high DY in cases of suspicion of CD and it leads to changes in the clinical course of the disease. CE is safe procedure with a high degree of concordance with histology and it helps in the differential diagnosis of CD.

Extracolonic findings with the PillCam Colon: is panendoscopy with capsule endoscopy closer?

Background and study aims: Colon capsules display images from the moment they are ingested, making the study of other extracolonic areas possible. The aim of this study was to analyze the significance of these extracolonic findings. Patients and methods: In this single-center, prospective study, 165 patients underwent colon capsule endoscopy (CCE) between September 2009 and October 2012 to rule out colonic pathology. Images were recorded, without interruptions, from the moment the capsule was ingested until its battery ran out. The study was deemed complete when the capsule had traveled from the esophagus to excretion or until the hemorrhoidal plexus was observed. Results: CCE was used for colorectal cancer (CRC) screening (81.2 %), to investigate for chronic diarrhea (9.7 %) and chronic iron deficiency anemia (6.1 %), and for patients with incomplete colonoscopy (3.0 %). The capsule returned findings in the esophagus in 52.1 % of patients, in the stomach in 45.5 % of patients, and in the small bowel in 70.7 % of patients, with the findings being considered relevant in 4.9 %, 9.7 %, and 22.6 % of patients, respectively. The whole extent of the digestive tract was fully recorded in 86.1 % of patients and the Z line could be fully observed in 57.6 % of patients. There were no adverse events. Conclusions: CCE allows the recording of images from almost the whole extent of the digestive tract in most patients, enabling relevant pathologies to be identified in extracolonic areas, particularly the small bowel. Technical and procedural improvements are still necessary in order to achieve better observation of the stomach and esophagus.

Fecal Gluten Peptides Reveal Limitations of Serological Tests and Food Questionnaires for Monitoring Gluten-Free Diet in Celiac Disease Patients.

OBJECTIVES: Treatment for celiac disease (CD) is a lifelong strict gluten-free diet (GFD). Patients should be followed-up with dietary interviews and serology as CD markers to ensure adherence to the diet. However, none of these methods offer an accurate measure of dietary compliance. Our aim was to evaluate the measurement of gluten immunogenic peptides (GIP) in stools as a marker of GFD adherence in CD patients and compare it with traditional methods of GFD monitoring. METHODS: We performed a prospective, nonrandomized, multicenter study including 188 CD patients on GFD and 84 healthy controls. Subjects were given a dietary questionnaire and fecal GIP quantified by enzyme-linked immunosorbent assay (ELISA). Serological anti-tissue transglutaminase (anti-tTG) IgA and anti-deamidated gliadin peptide (anti-DGP) IgA antibodies were measured simultaneously. RESULTS: Of the 188 celiac patients, 56 (29.8%) had detectable GIP levels in stools. There was significant association between age and GIP in stools that revealed increasing dietary transgressions with advancing age (39.2% in subjects ≥13 years old) and with gender in certain age groups (60% in men ≥13 years old). No association was found between fecal GIP and dietary questionnaire or anti-tTG antibodies. However, association was detected between GIP and anti-DGP antibodies, although 46 of the 53 GIP stool-positive patients were negative for anti-DGP. CONCLUSIONS: Detection of gluten peptides in stools reveals limitations of traditional methods for monitoring GFD in celiac patients. The GIP ELISA enables direct and quantitative assessment of gluten exposure early after ingestion and could aid in the diagnosis and clinical management of nonresponsive CD and refractory CD. Trial registration number NCT02711397.

Application of colon capsule endoscopy (CCE) to evaluate the whole gastrointestinal tract: a comparative study of single-camera and dual-camera analysis.

BACKGROUND AND STUDY AIMS: Colon capsule endoscopy (CCE) was developed for the evaluation of colorectal pathology. In this study, our aim was to assess if a dual-camera analysis using CCE allows better evaluation of the whole gastrointestinal (GI) tract compared to a single-camera analysis. PATIENTS AND METHODS: We included 21 patients (12 males, mean age 56.20 years) submitted for a CCE examination. After standard colon preparation, the colon capsule endoscope (PillCam Colon™) was swallowed after reinitiation from its "sleep" mode. Four physicians performed the analysis: two reviewed both video streams at the same time (dual-camera analysis); one analyzed images from one side of the device ("camera 1"); and the other reviewed the opposite side ("camera 2"). We compared numbers of findings from different parts of the entire GI tract and level of agreement among reviewers. RESULTS: A complete evaluation of the GI tract was possible in all patients. Dual-camera analysis provided 16% and 5% more findings compared to camera 1 and camera 2 analysis, respectively. Overall agreement was 62.7% (kappa = 0.44, 95% CI: 0.373-0.510). Esophageal (kappa = 0.611) and colorectal (kappa = 0.595) findings had a good level of agreement, while small bowel (kappa = 0.405) showed moderate agreement. CONCLUSION: The use of dual-camera analysis with CCE for the evaluation of the GI tract is feasible and detects more abnormalities when compared with single-camera analysis.

[Mirizzi syndrome: experience at Spanish Hospital of Veracruz]. / Síndrome de Mirizzi. Experiencia del Hospital Español de Veracruz.

BACKGROUND: Mirizzi syndrome is a complication of gallbladder stones impacted in Hartmann's pouch or cystic duct with compression of the bile duct. The diagnosis is made by imaging studies, although most of them are found through intraoperative surgical findings. Treatment is cholecystectomy and bile duct restoration when needed. OBJECTIVE: to analyze a series of cases of Mirizzi syndrome and compare the results with those published in the literature. CLINICAL CASE: We report 4 cases with Mirizzi syndrome in a cohort of 1,034 cases studied in the Hospital Español of Veracruz over 21 years. RESULTS: In our series the frequency of Mirizzi syndrome was 0.38%, the average age was 32.1 ± 58.4 years, 50% were male gender and 25% had jaundice with a demonstrable liver profile. In 1 case, ultrasound suggested Mirizzi syndrome and percutaneous cholangiography and computed tomography confirmed the diagnosis. All patients underwent laparoscopic cholecystectomy, and 2 transcystic cholangiographies were performed. One case was classified as Type I-A and three as type I-B. (Beltran and Csendes). The postoperative evolution was satisfactory in all and no mortality was presented. CONCLUSIONS: Mirizzi syndrome should be suspected in patients with gallstones who develop obstructive jaundice and it must be confirmed with imaging studies. The surgeon must take extreme precautions to avoid accidental injury to the bile ducts.

Antecedentes: el síndrome de Mirizzi es una complicación de la litiasis vesicular por cálculos impactados en la bolsa de Hartmann o conducto cístico que comprimen la vía biliar principal; el diagnóstico se establece mediante estudios de imagen, aunque la mayor parte son hallazgos transoperatorios; su tratamiento es la colecistectomía con restauración de la vía biliar. Objetivo: analizar una serie de casos de síndrome de Mirizzi y comparar los resultados con lo publicado en la bibliografía mundial. Casos clínicos: se comunican cuatro casos con síndrome de Mirizzi de una cohorte de 1,034 casos con enfermedad litiásica vesicular del Hospital Español de Veracruz, en 21 años. La frecuencia en esta muestra es de 0.38%, con edad promedio de 32.1 ± 58.4 años; 50% son hombres y 25% tuvo ictericia y coluria con perfil hepático demostrativo. En un caso el ultrasonido sugirió síndrome de Mirizzi; el diagnóstico se corroboró por colangiografía percutánea y tomografía computada. A todos los pacientes se les realizó colecistectomía laparoscópica, y en dos se efectuó colangiografía transcística. Un caso correspondió al tipo I-A y 3 al tipo I-B según la Clasificación de Beltrán y Csendes. La evolución postoperatoria fue satisfactoria y no hubo mortalidad. Conclusiones: el síndrome de Mirizzi debe sospecharse en pacientes con litiasis vesicular con ictericia obstructiva. El cirujano debe extremar las precauciones para evitar lesionar la vía biliar.

Nuevos paradigmas en el manejo de la apendicitis / New paradigms in the management of appendicitis

Objetivo: Analizar y comparar los resultados obtenidos con las diferentes técnicas quirúrgicas que existen y el manejo conservador de la apendicitis. Sede: Instituto de Investigaciones Médico-Biológicas y Facultad de Medicina de la Universidad Veracruzana. Diseño: Revisión de la literatura. Material y métodos: Se procedió a la revisión bibliográfica de los principales artículos científicos publicados en los últimos 6 años, así como las bases de datos en las fuentes electrónicas de las bibliotecas EBSCOhost, Cochrane y UpToDate. Se analiza y presenta toda la literatura crítica sobre el tratamiento de la apendicitis complicada y no complicada por medio de cirugía convencional, cirugía laparoscópica, NOTES®, cirugía a través de un solo puerto, manejo médico y/o manejo conservador, publicadas entre los años 1996 y 2012. Resultados: La apendicetomía convencional ha sido durante muchos años el estándar de oro para su manejo. En 1982, se introdujo el abordaje laparoscópico que ha demostrado ser tan seguro y eficiente como la cirugía convencional; posteriormente, en 2004, se introdujo la cirugía endoscópica a través de orificios naturales (NOTES®), y en 2007, la cirugía a través de un solo puerto. Recientemente, han aparecido publicaciones sobre su manejo conservador con cirugía de intervalo, lo cual evita un gran número de intervenciones innecesarias con morbimortalidad, comparables a los pacientes sometidos a cirugía en forma urgente. Conclusiones: La apendicetomía continúa siendo el estándar de oro del manejo de la apendicitis aguda; sin embargo, han surgido alternativas de manejo diferentes al criterio quirúrgico tradicional, las cuales han demostrado ser útiles y permiten disminuir la cirugía innecesaria, sin incremento de la morbimortalidad.

Objective: To analyze and compare the results obtained with the diverse surgical techniques currently in use and the conservative management of appendicitis. Setting: Institute of Medical Biological Research and School of Medicine of the University of Veracruz, Mexico. Design: Review of the literature. Material and methods: We performed a bibliographical review of the main scientific articles published in the last 6 years, as well as of the databases contained in the EBSCOhost, Cochrane and UpToDate electronic libraries. We analyze and present critical literature on the management of complicated and non-complicated appendicitis by means of conventional surgery, laparoscopic surgery, NOTES® surgery, one-port surgery, medical handling and/or conservative management, published between 1996 and 2012. Results: Conventional appendicectomy has been for many years the gold standard for its management. In 1982, the laparoscopic approach was introduced and has shown to be as safe and efficient as conventional surgery; later on, in 2004, the natural orifice transluminal endoscopic surgery (NOTES®) was introduced, and surgery through only one port was introduced in 2007. Recently, reports on the conservative management with interval surgery have been published, which avoids a large number of unnecessary intervention with morbidity and mortality comparable to that of patients subjected to emergency surgery. Conclusions: Appendicectomy remains the gold standard for the management of acute appendicitis; however, alternatives have arisen for a different management to that of the traditional surgical criterion, which have demonstrated to be useful and have allowed diminishing unnecessary surgeries, without increasing morbidity and mortality.