Single-operator cholangioscopy unveiling a pinehole post-cholecystectomy biliary strictures.

77-year-old female with history of cholecystectomy was admitted at emergency department with fever and myalgia, without other complaints. Physical examination revealed fever, and laboratory tests indicated cholestasis (total bilirubin: 1.5xULN, glutamyltransferase: 20xULN, alkaline phosphatase: 5xULN). Computed Tomography revealed common bile duct (CBD) dilation (9mm), with suspected choledocholithiasis. Given the diagnosis of acute cholangitis, antibiotics were started and ERCP was performed. ERCP revealed a short CBD stenosis (< 2mm length), close to surgical clip, with upstream dilation of the CBD; an 8mm stone in the distal CBD was observed and successfully removed. As guidewire advancement failed after multiple attempts, a SpyGlass DS cholangioscopy was performed showing a fibrotic pinehole stenosis. Guidewire was passed through the stenosis under direct visualization, and an 80-mmx10mm fully covered metal stent deployed.

Factors Influencing Performance of Cholangioscopy-Guided Lithotripsy Including Available Different Technologies: A Prospective Multicenter Study with 94 Patients.

BACKGROUND: Peroral cholangioscopy (POC)-guided lithotripsy is an effective treatment for difficult biliary stones. A clear definition of factors associated with the efficacy of POC-guided lithotripsy in one session and the performance of electrohydraulic lithotripsy (EHL) and laser lithotripsy (LL) have not clearly emerged. METHODS: This was a non-randomized prospective multicenter study of all consecutive patients who underwent POC lithotripsy (using EHL and/or LL) for difficult biliary stones. The primary endpoint of the study was the number of sessions needed to achieve complete ductal clearance and the factors associated with this outcome. Secondary endpoints included the evaluated efficacies of LL and EHL. RESULTS: Ninety-four patients underwent 113 procedures of EHL or LL. Complete ductal clearance was obtained in 93/94 patients (98.94%). In total, 80/94 patients (85.11%) achieved stone clearance in a single session. In the multivariate analysis, stone size was independently associated with the need for multiple sessions to achieve complete ductal clearance (odds ratio = 1.146, 95% confidence interval: 1.055-1.244; p = 0.001). Using ROC curves and the Youden index, 22 mm was found to be the optimal cutoff for stone size (95% confidence interval: 15.71-28.28; p < 0.001). The majority of the patients (62.8%) underwent LL in the first session. Six patients failed the first session with EHL after using two probes and therefore were crossed over to LL, obtaining ductal clearance in a single additional session with a single LL fiber. EHL was significantly associated with a larger number of probes (2.0 vs. 1.02) to achieve ductal clearance (p < 0.01). The mean procedural time was significantly longer for EHL than for LL [72.1 (SD 16.3 min) versus 51.1 (SD 10.5 min)] (p < 0.01). CONCLUSIONS: POC is highly effective for difficult biliary stones. Most patients achieved complete ductal clearance in one session, which was significantly more likely for stones < 22 mm. EHL was significantly associated with the need for more probes and a longer procedural time to achieve ductal clearance.

Needle knife fistulotomy in flat and diverticular papillae: Is it time for redemption?

BACKGROUND: European Society of Gastrointestinal Endoscopy (ESGE) recommends needle-knife fistulotomy (NKF) as the preferred precut technique in cases when standard cannulation techniques fail. Despite scarce scientific evidence, flat and diverticular papillae are thought not to be ideal for NKF, as they are associated with poor outcomes. The present study aimed to determine the outcomes of the use of NKF in relation to flat and intradiverticular papillae. METHODS: This prospective multicenter study enrolled consecutive patients, evidencing naïve flat (group A, n = 49) or diverticular papilla (group B, n = 28), who underwent NKF after failure of standard cannulation techniques. Diverticular morphology was subdivided into intradiverticular (group B1, n = 14) and diverticular border papillae (group B2, n = 14), using a previously validated endoscopic classification of the major papilla. The success of biliary cannulation at initial endoscopic retrograde cholangiopancreatography (ERCP), overall biliary cannulation, overall cannulation time, and the rate of adverse events were assessed in the study. RESULTS: The initial cannulation rates were 93.9%, 64.3% and 71.4% for group A, B1, and B2, respectively (P = 0.005); overall cannulation rates after a second ERCP were 98.0%, 92.9% and 85.7%, respectively (P = 0.134). Adverse events occurred in 11.7% of patients, with post-ERCP pancreatitis (PEP) being the most common adverse event (10.4%). Although there was a trend towards a higher incidence of PEP in flat papillae, univariate and multivariate analyses did not show any significant relationship between pancreatitis and trainee involvement, papillary morphology, nor overall cannulation time. CONCLUSIONS: Although flat papillae are associated with high success rates of biliary cannulation using NKF, the rate of PEP is not negligible. NKF is feasible in diverticular papillae, but it is associated with a modest success rate in the initial ERCP.

Participation in clinical trials increases the detection of pre-malignant lesions during colonoscopy.

BACKGROUND: colorectal adenoma detection has been associated with the effectiveness of cancer prevention. Clinical trials have been designed to determine the role of several interventions to increase the detection of pre-malignant lesions. We hypothesized that colonoscopy in the setting of clinical trials has a higher pre-malignant lesion detection rate. METHODS: a cross-sectional study was performed that compared the detection of pre-malignant lesions in 147 randomly sampled non-research colonoscopies and 294 from the control group of two prospective trials. Outpatients aged 40-79 years, with no personal history of colorectal cancer (CRC) were included. RESULTS: baseline characteristics were similar between the two groups. The pre-malignant lesion detection rate in the trial vs control group was 65.6 % vs 44.2 % (OR 2.411; 95 % CI: 1.608-3.614; p < 0.001), the polyp detection rate was 73.8 % vs 59.9 % (OR 1.889; 95 % CI: 1.242-2.876; p = 0.003), the adenoma detection rate was 62.6 % vs 44.2 % (OR 2.110; 95 % CI: 1.411-3.155; p < 0.001) and the sessile serrated lesion detection rate was 17 % vs 4.1 % (OR 4.816; 95 % CI: 2.014-11.515; p < 0.001). The mean number of pre-malignant and sessile serrated lesions was 1.70 vs 1.06 (p = 0.002) and 0.32 vs 0.06 (p = 0.001) lesions per colonoscopy, respectively. There was no significant change in any of the study outcomes according to the multivariate analysis with each single potential confounder. CONCLUSIONS: patients involved in colonoscopy trials may benefit from higher quality examinations, as shown by the higher detection rates. Institutions should consider supporting clinical research in colonoscopy as a simple means to improve colonoscopy quality and colorectal cancer prevention.

Outcomes of single-endoscopist-performed needle-knife fistulotomy for selective biliary access in 842 consecutive patients: learning curve and changes over a 14-year period in a retrospective study.

BACKGROUND AND AIMS: Needle-knife fistulotomy (NKF) has emerged as the preferred precut technique. From a late strategy, NKF has shifted to an early rescue technique and has been used recently as a primary method for biliary access. It is unknown how these changes have affected NKF outcomes. We analyzed the outcomes of NKF over time in a large cohort of patients. METHODS: Multicenter retrospective cohort study of 842 patients who underwent NKF for biliary access between 2006 and 2019. Patients were divided into four study periods according to a late or early cannulation strategy and to the use of post-ERCP pancreatitis prophylaxis (Period 1-Period 4). We assessed outcomes of NKF, learning curves and shifts over time. RESULTS: Bile duct access was obtained in 88.0% of the patients. The initial cannulation rate increased significantly from 77.5% in P1 to 92.0% in P4 (p < .001). An endoscopist can obtain 80% success rate after performing 100 NKF procedures (95% CI: 0.79-0.86) and a 95% success rate after 830 procedures (95% CI: 0.92-0.98). Adverse events and pancreatitis were observed in 6.5% and 4.9% of patients respectively. The rate of pancreatitis was not significantly different during the 4 periods (p = .190). A decline in the pancreatitis rate was observed from 2006 until 2016 (no trainees) and then an increase until 2019 (trainees involved). The presence of trainees increased the rate of pancreatitis in the last period by 9.9%. CONCLUSIONS: The success of NKF has increased significantly over the years, initially in a rapid manner and then more slowly. It is associated with a low rate of complications, which tend to decrease with experience. The involvement of trainees is associated with an increased rate of pancreatitis.

Influence of a novel classification of the papilla of Vater on the outcome of needle-knife fistulotomy for biliary cannulation.

BACKGROUND: Existing proposed classification systems for the Papilla of Vater (PV) suboptimally account for all relevant, encountered PV appearances, are too complex or have not been assessed for intra- or interobserver variability. We proposed a novel endoscopic classification system for PV, determined its inter- and intraobserver rates and used the classification system to assess whether the success and complications of needle-knife fistulotomy (NKF) are influenced by the morphology of the PV. METHODS: The classification system was developed by expert endoscopists. To evaluate the inter- and intraobserver agreement, an online questionnaire was sent to 20 endoscopists from several countries (10 experts and 10 nonexperts) that included 50 images of papillae of Vater divided among various categories. Four weeks later, a second survey, with the images from the first questionnaire randomly reordered, was sent to the same endoscopists. The inter- and intraobserver agreements among the experts and nonexperts was calculated. Using the proposed classification system, all 361 consecutive patients who underwent NKF for biliary access to a naïve papilla were prospectively enrolled in the study. RESULTS: The novel classification system comprises 7 categories: type I, flat type, lacking an oral protrusion; type IIA, prominent tubular nonpleated type, with an oral protrusion and < 1 transverse fold over the oral protrusion; type IIB, prominent tubular pleated type, with an oral protrusion and > 2 transverse folds over the oral protrusion; type IIC: prominent bulging type, with an enlarged and bulging oral protrusion; type IIIA, diverticular-intradiverticular type, with a papillary orifice inside the diverticulum; type IIIB: diverticular-diverticular border type, with a papillary orifice less than 2 cm from the diverticular border; type IV: unclassified papilla, with no morphology classified in the other categories. The interobserver agreement between experts was substantial (K = 0.611, 95% CI 0.498-0.709) and was higher than that between nonexperts (K = 0.516; 95% CI 0.410-0.636). The intraobserver agreement was substantial among both experts (K = 0,651; 95% CI 0.586-0.715) and nonexperts (K = 0.646, 95% CI 0.615-0.677). In a multivariate model, type IIIA and IIIB were the only independent risk factors for difficult rescue NKF biliary cannulation (P = 0.003 and P = 0.019, respectively), and type I and type IIB were the only independent risk factors for a prolonged cannulation time using NKF (P < 0.001 and P = 0.005, respectively). CONCLUSIONS: The novel endoscopic classification system for PV is highly reproducible among experienced ERCPists according to the substantial level of agreement between experts. However, nonexperts require further training in its use. Using the novel classification system, we identified different types of papillae significantly associated with a lower efficacy of NKF and a prolonged time to obtain successful biliary cannulation using NKF.

A non-randomized study in consecutive patients with postcholecystectomy refractory biliary leaks who were managed endoscopically with the use of multiple plastic stents or fully covered self-expandable metal stents (with videos).

BACKGROUND: Endoscopic management of postcholecystectomy biliary leaks is widely accepted as the treatment of choice. However, refractory biliary leaks after a combination of biliary sphincterotomy and the placement of a large-bore (10F) plastic stent can occur, and the optimal rescue endotherapy for this situation is unclear. OBJECTIVE: To compare the clinical effectiveness of the use of a fully covered self-expandable metal stent (FCSEMS) with the placement of multiple plastic stents (MPS) for the treatment of postcholecystectomy refractory biliary leaks. DESIGN: Prospective study. SETTING: Two tertiary-care referral academic centers and one general district hospital. PATIENTS: Forty consecutive patients with refractory biliary leaks who underwent endoscopic management. INTERVENTIONS: Temporary placement of MPS (n = 20) or FCSEMSs (n = 20). MAIN OUTCOME MEASUREMENTS: Clinical outcomes of endotherapy as well as the technical success, adverse events, need for reinterventions, and prognostic factors for clinical success. RESULTS: Endotherapy was possible in all patients. After endotherapy, closure of the leak was accomplished in 13 patients (65%) who received MPS and in 20 patients (100%) who received FCSEMSs (P = .004). The Kaplan-Meier (log-rank) leak-free survival analysis showed a statistically significant difference between the 2 patient populations (χ(2) [1] = 8.30; P < .01) in favor of the FCSEMS group. Use of <3 plastic stents (P = .024), a plastic stent diameter <20F (P = .006), and a high-grade biliary leak (P = .015) were shown to be significant predictors of treatment failure with MPS. The 7 patients in whom placement of MPS failed were retreated with FCSEMSs, resulting in closure of the leaks in all cases. LIMITATIONS: Non-randomized design. CONCLUSION: In our series, the results of the temporary placement of FCSEMSs for postcholecystectomy refractory biliary leaks were superior to those from the use of MPS. A randomized study is needed to confirm our results before further recommendations.

Outcomes of endoscopic management of primary and refractory postcholecystectomy biliary leaks in a multicentre review of 178 patients.

BACKGROUND: Biliary leaks have been treated with endoscopic management using different techniques with conflicting results. Furthermore the appropriate rescue therapy for refractory leaks has not been established. We evaluated the clinical effectiveness of initial endotherapy for postcholecystectomy biliary leaks using an homogenous approach (sphincterotomy + placement of a 10-French plastic stent) in a large series of patients as well as the optimal and efficacy of rescue endotherapy for refractory biliary leaks. METHODS: This was a multicenter, retrospective study of 178 patients who underwent endoscopic management of postcholecystectomy biliary leaks with a combination of biliary sphincterotomy and the placement of a large-bore (10-French) plastic stent. Data were collected to analyze the clinical outcomes and technical success, efficacy of the rescue endotherapy and the need for surgery, adverse events and prognostic factors for clinical success of endotherapy. RESULTS: Following endotherapy, closure of the leak was accomplished in 162/178 patients (91.0%). The multivariate logistic model showed that the type of leak, namely a high-grade biliary leak, was the only independent prognostic factor associated with treatment failure (OR = 26.78; 95% CI = 6.59-108.83; P < 0.01). The remaining 16 patients were treated with multiple plastic stents (MPSs) with a success rate of 62.5% (10 patients). The use of fewer than 3 plastic stents (P = 0.023) and a high-grade biliary leak (P = 0.034) were shown to be significant predictors of treatment failure with MPSs in refractory bile leaks. The 6 patients in whom the placement of MPSs failed were retreated with a fully cover self-expandable metallic stent (FCSEMS), resulting in closure of the leak in all cases. CONCLUSIONS: Endotherapy of biliary leaks with a combination of biliary sphincterotomy and the placement of a large-bore plastic stent is associated with a high rate of success (90%). However in our series there were several failures using MPSs as a strategy for rescue endotherapy suggesting that refractory biliary leaks should be treated with FCSEMS especially in patients with high-grade leaks.

Predictive value of cholangioscopy after endoscopic management of early postcholecystectomy bile duct strictures with an increasing number of plastic stents: a prospective study (with videos).

BACKGROUND: Endotherapy of postcholecystectomy bile duct stricture (PCBS) has been established as an alternative treatment to surgery. Several studies have reported conflicting results regarding the predictors of success or failure of endotherapy. OBJECTIVE: To evaluate the different cholangioscopic appearances of PCBS after endotherapy with an increasing number of plastic stents and the predictive values of these appearances for the outcome. DESIGN: Prospective study with a long-term follow-up. SETTING: Two academic tertiary referral centers. PATIENTS: Twenty consecutive patients with major bile duct injury, with a bile leak, and a PCBS who underwent therapeutic ERCP. INTERVENTIONS: Closure of the leak followed by temporary placement of multiple plastic stents for the treatment of PCBS, followed by cholangioscopy at the end of endotherapy. MAIN OUTCOME MEASUREMENTS: To analyze the predictive value of cholangioscopy, other predictors of stricture recurrence after endotherapy, and long-term clinical success. RESULTS: Closure of the leak was achieved in all patients. The median duration of endotherapy was 12 months (range 7-18 months). After endoscopic stenting, the PCBS was considered to be appropriately dilated in all patients. After endotherapy, 3 different findings were noted on cholangioscopy: (1) no lesion or minor defect (n = 10), (2) minor stricture with a fibrous ring (n = 6), and (3) presence of tissue hyperplasia (n = 4). During follow-up, stricture recurrence developed in 4 of 20 patients. All 4 patients were successfully retreated by an additional period of stenting and remained free of cholestasis after a median follow-up period of 44 months. By Kaplan-Meier (log-rank) and univariate analyses, the cholangioscopic pattern of tissue hyperplasia was significantly associated with stricture recurrence (P < .01). LIMITATIONS: Small sample size. CONCLUSIONS: Endoscopic stenting should be regarded as the primary treatment of choice because of the successful long-term outcome after 1 or more additional periods of treatment. However, the cholangioscopic pattern of tissue hyperplasia at the time of stent removal is a strong predictor of stricture recurrence, and this observation may lead to an additional period of endotherapy or other treatment modalities.

Endoscopic bilio-duodenal bypass: outcomes of primary and revision efficacy of combined metallic stents in malignant duodenal and biliary obstructions.

BACKGROUND: Self-expandable metal stents (SEMSs) can be used for palliation of combined malignant biliary and duodenal obstructions. However, the results of the concomitant stent placement for the duration of the patients' lives, as well as the need for and efficacy of endoscopic revision, are unclear. AIM: This study evaluated the clinical effectiveness of SEMS placement for combined biliary and duodenal obstructions throughout the patients' lives and the need for endoscopic revision. METHODS: This study is a retrospective multicenter study of 50 consecutive patients who underwent simultaneous or sequential SEMS placement for malignant biliary and duodenal obstructions. The data were collected to analyze the sustained relief of obstructive symptoms until the patients' death and the efficacy of endoscopic revision, as well as stent patency, adverse events, survival and prognostic factors for stent patency. RESULTS: Technical and immediate clinical success was achieved in all of the patients. Duodenal stricture occurred before the papilla in 35 patients (70 %), involved the papilla in 11 patients (22 %) and was observed distal to the papilla in four patients (8 %). Initial biliary stenting was performed endoscopically in 42 patients (84 %) and percutaneously in eight patients. After combined stenting, 30 patients (60 %) required no additional intervention until the time of their death. The remaining 20 patients were successfully treated using endoscopic stent reinsertion: nine patients needed biliary revision, three patients needed duodenal restenting and eight patients needed both biliary and duodenal reinsertion. The median duodenal stent patency and median biliary stent patency were 34 and 27 weeks, respectively. The median survival after combined stent placement was 18 weeks. A Cox multivariate analysis showed that duodenal stent obstruction after combined stenting was a risk factor for biliary stent obstruction (hazard ratio 6.85; 95 % confidence interval 1.43-198.98; P = 0.025). CONCLUSIONS: Endoscopic bilio-duodenal bypass is clinically effective, and the majority of the patients need no additional intervention until their death. Endoscopic revision is feasible and has a high success rate.

Endoscopic Retrograde Cholangiopancreatography on Pediatric Patients: Experience of a Portuguese Adult Gastroenterology Department.

Introduction: Experience with endoscopic retrograde cholangiopancreatography (ERCP) in the pediatric population is limited. Few medical centers have experts specifically trained in pediatric therapeutic endoscopy. As a result, patients are generally referred to adult endoscopists with high experience in the procedure. The aim of this study was to characterize the experience of an adult endoscopy unit with ERCP on pediatric patients, with a special focus on very young patients. Methods: We retrospectively analyzed indications, technical success rate, final clinical diagnosis, and complications of ERCPs in children <18 years at our tertiary referral hospital center between January 1994 and June 2022. Results: Sixty-five ERCPs were performed on 57 children with a median age of 13 years (range 1-17 years). Eleven ERCPs were performed on 9 patients up to 5 years old. Indications for ERCP were as follows: biliary obstruction (n = 40), mainly due to choledocholithiasis, lithiasic acute pancreatitis (n = 19), recurrent pancreatitis (n = 3), stent extraction (n = 2), and post-operative biliary fistula (n = 1). The cannulation success rate was 95.1%. Therapeutic interventions were performed in 79% of ERCP. All patients were followed up as inpatients. Complications were recorded in two procedures (3.1%), and no procedure-related mortality occurred. Conclusion: In our experience, ERCP in children can be safely performed with high success rates by advanced adult-trained expert endoscopists at a high-volume center.

Introdução: Existe pouca experiência na realização de colangiopancreatografia retrógrada endoscópica (CPRE) na população pediátrica. A maioria dos centros carece de especialistas especificamente treinados em endoscopia terapêutica pediátrica, sendo os doentes geralmente referenciados para Gastroenterologistas de adultos com elevada experiência na técnica. O objectivo deste estudo foi caracterizar a experiência de um departamento de Gastrenterologia de adultos em CPRE pediátrica, com destaque particular nos doentes muito novos. Métodos: Foram analisadas retrospectivamente as indicações, sucesso técnico, diagnósticos e complicações das colangiopancreatografias retrógradas endoscópicas (CPREs) realizadas no nosso hospital terciário em crianças <18 anos, entre Janeiro de 1994 e Junho de 2022. Resultados: Foram realizadas 65 CPREs em 57 crianças com idade mediana 13 anos (1­17 anos). Doze procedimentos foram realizados em 9 crianças com idade até 5 anos. As indicações para CPRE foram: obstrução biliar (n = 40), sobretudo devido a coledocolitíase, pancreatite aguda litiásica (n = 19), pancreatite recorrente (n = 3), extracção de prótese (n = 2) e fístula biliar pós cirurgia (n = 1). A taxa de sucesso de canulação foi 95.4%. Foram realizados procedimentos terapêuticos em 80.0% das CPREs. Todos os doentes foram vigiados em regime de internamento, tendo-se registado complicações em dois exames (3.1%). Não existiram mortes relacionadas com a técnica. Discussão/ Conclusão: A CPRE pode ser realizada na população pediátrica com segurança e elevada taxa de sucesso por Gastrenterologistas de adultos com experiência na técnica, num centro com elevado volume de exames.

Short-term stenting using fully covered self-expandable metal stents for treatment of refractory biliary leaks, postsphincterotomy bleeding, and perforations.

BACKGROUND: Fully covered self-expandable metal stents (FCSEMS) have been used as a rescue therapy for several benign biliary tract conditions (BBC). Long-term stent placement commonly occurs, and prolonged FCSEMS placement is associated with the majority of the complications reported. This study evaluated the duration of stenting and the efficacy and safety of temporary FCSEMS placement for three BBCs: refractory biliary leaks, postsphincterotomy bleeding, and perforations. METHODS: This was a retrospective case series with long-term follow-up of 25 patients who underwent FCSEMS placement for BBCs. This study included 17 patients with postcholecystectomy refractory biliary leaks who had previously undergone unsuccessful sphincterotomy and plastic stent placement, 4 patients with difficult-to-control postsphincterotomy bleeding, and 4 patients with a perforation following endoscopic sphincterotomy. Stents were removed according to clinical evidence of problem resolution. The review included stenting duration, safe FCSEMS removal, clinical efficacy, complications, and long-term outcomes. During the follow-up period, ERCP and cholangioscopy procedures were performed to exclude the possibility of bile duct lesion development. RESULTS: Complete resolution of the initial condition was achieved in all patients. Patients with biliary leaks had a median stent duration time of 16 days (range 7-28 days). Patients with bleeding had stents removed after a median time of 6 days (range 3-15 days). Patients with perforations had their stents removed after a median time of 29.5 days (range 21-30 days). There were no complications related to stenting. CONCLUSIONS: Temporary placement of a FCSEMS for 30 days or less is an effective rescue therapy for refractory biliary leaks, difficult-to-control post-endoscopic sphincterotomy bleeding, and perforations. Duration of stenting should be different for each type of condition. Stents can be safely removed, and short-term stenting is associated with the absence of early and late complications.

Candy cane syndrome: A systematic review.

BACKGROUND: Candy cane syndrome (CCS) is a condition that occurs following gastrectomy or gastric bypass. CCS remains underrecognized, yet its prevalence is likely to rise due to the obesity epidemic and increased use of bariatric surgery. No previous literature review on this subject has been published. AIM: To collate the current knowledge on CCS. METHODS: A literature search was conducted with PubMed and Google Scholar for studies from May 2007, until March 2023. The bibliographies of the retrieved articles were manually searched for additional relevant articles. RESULTS: Twenty-one articles were identified (135 patients). Abdominal pain, nausea/vomiting, and reflux were the most reported symptoms. Upper gastrointestinal (GI) series and endoscopy were performed for diagnosis. Surgical resection of the blind limb was performed in 13 studies with resolution of symptoms in 73%-100%. In surgical series, 9 complications were reported with no mortality. One study reported the surgical construction of a jejunal pouch with clinical success. Six studies described endoscopic approaches with 100% clinical success and no complications. In one case report, endoscopic dilation did not improve the patient's symptoms. CONCLUSION: CCS remains underrecognized due to lack of knowledge about this condition. The growth of the obesity epidemic worldwide and the increase in bariatric surgery are likely to increase its prevalence. CCS can be prevented if an elongated blind loop is avoided or if a jejunal pouch is constructed after total gastrectomy. Diagnosis should be based on symptoms, endoscopy, and upper GI series. Blind loop resection is curative but complex and associated with significant complications. Endoscopic management using different approaches to divert flow is effective and should be further explored.

Side-Viewing Duodenoscope versus Forward-Viewing Gastroscope for Endoscopic Retrograde Cholangiopancreatography in Billroth II Gastrectomy Patients.

Introduction: Endoscopic retrograde cholangiopancreatography (ERCP) in patients with Billroth II gastrectomy is still a challenging procedure. The optimal approach, namely the type of endoscope and sphincter management, has yet to be defined. Aim: To compare the efficacy and safety of forward-viewing gastroscope and the side-viewing duodenoscope in ERCP of patients with Billroth II gastrectomy. Methods: We conducted a retrospective, single-center cohort study of consecutive patients with Billroth II gastrectomy submitted to ERCP in an expert center for ERCP between 2005 and 2021. The outcomes assessed were: papilla identification, deep biliary cannulation, and adverse events (AEs). Multivariate analysis was performed to evaluate potential associations and predictors of the main outcomes. Results: We included 83 patients with a median age of 73 (IQR 65-81) years. ERCP was performed using side-viewing duodenoscope in 52 and forward-viewing gastroscope in 31 patients. Patients' characteristics were similar in the two groups. The global rate of papilla identification was 66% (n = 55). The rate of deep cannulation was 58% considering all patients and 87% in the subgroup of patients in which the papilla major was identified. Cannulation was performed with standard methods in 65% of cases and with needle-knife fistulotomy in 35%. AEs occurred in 4 patients. There was no difference between duodenoscope and gastroscope in papilla identification (64% [95% CI: 51-77] vs. 71% [55-87]). Although not statistically significant, duodenoscope had a lower deep cannulation rate when considering all patients (52% [15-39] vs. 68% [7-35]) and a higher AEs rate (8% [1-15] vs. 0% [0-1]). In a multivariate analysis, the use of gastroscope significantly increased the deep cannulation rate (OR = 152.62 [2.5-9,283.6]). Conclusion: This study demonstrates that forward-viewing gastroscope is at least as effective and safe as side-viewing duodenoscope for ERCP in patients with Billroth II gastrectomy. Moreover, our study showed that gastroscope is an independent predictor of successful cannulation.

Introdução: Colangiopancreatografia retrógrada endoscópica (CPRE) em doentes submetidos previamente a gastrectomia com reconstrução Billroth II é ainda um exame desafiante. A melhor abordagem, nomeadamente o tipo de endoscópio e a técnica de canulação biliar, ainda não está definida. Objectivo: Comparar a eficácia e segurança do gastroscópio de visão frontal e do duodenoscópio de visão lateral na CPRE de doentes com gastrectomia com reconstrução Billroth II. Métodos: Conduzimos um estudo de coorte retrospectivo e unicêntrico que incluiu consecutivamente doentes com gastrectomia com reconstrução Billroth II submetidos a CPRE num centro de referência para CPRE entre 2005 e 2021. Os outcomes avaliados foram: identificação da papila, canulação biliar profunda e efeitos adversos (EAs). Regressão logística foi realizada para avaliar possíveis associações e preditores dos outcomes. Resultados: Incluímos 83 doentes com uma idade mediana de 73 (IIQ 65­81) anos. A CPRE foi realizada usando duodenoscópio em 52 doentes e usando o gastroscópio de visão frontal em 31 doentes. As características dos doentes foram semelhantes entre os dois grupos. A taxa global de identificação da papila foi de 66% (n = 55). A taxa de canulação profunda foi de 58% considerando todos os doentes e de 87% considerando apenas o subgrupo de doentes nos quais a papila major foi identificada. A canulação foi realizada usando métodos convencionais em 65% e usando fistulotomia com faca em 35% dos doentes. EAs ocorreram em 4 doentes. Não houve diferenças entre duodenoscópio e gastroscópio relativamente à identificação da papila [64% (95% CI: 51­77) vs 71% (55­87)]. Apesar de estatisticamente não significativo, o uso de duodenoscópio teve uma menor taxa de canulação profunda quando considerados todos os doentes [52% (15­39) vs 68% (7­35)] e uma maior taxa de EAs [8% (1­15) vs 0% (0­1)]. Na regressão logística, o uso de gastroscópio significativamente aumentou a taxa de canulação profunda [OR = 152.62 (2.5­9,283.6)]. Conclusão: Este estudo demonstra que o uso de gastroscópio de visão frontal é pelo menos igualmente eficaz e seguro ao duodenoscópio na CPRE de doentes com gastrectomia com reconstrução Billroth II. Para além disso, o nosso estudo demonstrou que o uso de gastroscópio é um predictor independente para canulação.

Narrow Band Imaging versus White Light for the Detection of Sessile Serrated Colorectal Lesions: A Randomized Clinical Trial.

Background: Colorectal cancer (CRC) is a leading cause of cancer. The detection of pre-malignant lesions by colonoscopy is associated with reduced CRC incidence and mortality. Narrow band imaging has shown promising but conflicting results for the detection of serrated lesions. Methods: We performed a randomized clinical trial to compare the mean detection of serrated lesions and hyperplastic polyps ≥10 mm with NBI or high-definition white light (HD-WL) withdrawal. We also compared all sessile serrated lesions (SSLs), adenoma, and polyp prevalence and rates. Results: Overall, 782 patients were randomized (WL group 392 patients; NBI group 390 patients). The average number of serrated lesions and hyperplastic polyps ≥10 mm detected per colonoscopy (primary endpoint) was similar between the HD-WL and NBI group (0.118 vs. 0.156, p = 0.44). Likewise, the adenoma detection rate (55.2% vs. 53.2%, p = 0.58) and SSL detection rate (6.8% vs. 7.5%, p = 0.502) were not different between the two study groups. Withdrawal time was higher in the NBI group (10.88 vs. 9.47 min, p = 0.004), with a statistically nonsignificant higher total procedure time (20.97 vs. 19.30 min, p = 0.052). Conclusions: The routine utilization of narrow band imaging does not improve the detection of serrated class lesions or any pre-malignant lesion and increases the withdrawal time.

Introdução: O cancro do cólon e reto é a neoplasia mais frequente considerando os dois géneros. . A deteção de lesões pré-malignas por colonoscopia está associada a uma redução da incidência e da mortalidade. Estudos sobre a utilização da luz de banda estreita (NBI) na deteção de lesões serreadas tiveram resultados promissores, mas heterogéneos. Métodos: Realizámos um ensaio clínico randomizado para comparar o número médio de lesões serreadas e lesões hiperplásicas ≥10 mm com NBI ou luz branca de alta-definição (HD-WL). Como resultados secundários comparámos a prevalência e as taxas de deteção de lesões serreadas sésseis, adenomas e todas as lesões. Resultados: Foram randomizados 782 doentes (392 no grupo HD-WL e 390 no grupo NBI). O número médio de lesões serreadas e hiperplásicas ≥10 mm não apresentou diferença estatisticamente significativa entre dois grupos (0.118 vs. 0.156, p = 0.44). A taxa de deteção de adenomas (55.2% vs. 53.2%, p = 0.58) e a taxa de deteção de lesões serreadas sésseis (6.8% vs. 7.5%, p = 0.502) também não foram diferentes. O tempo de retirada foi maior no grupo NBI (10.88 vs. 9.47 min, p = 0.004) e o tempo total de procedimento teve um ligeiro aumento não atingindo significância estatística (20.97 vs. 19.30 min, p = 0.052). Conclusão: A utilização da luz NBI por rotina não aumenta a deteção de lesões serreadas nem de qualquer lesão pré-maligna e aumenta o tempo de retirada na colonoscopia.