Endoscopic Ultrasound to Identify the Actual Cause of Idiopathic Acute Pancreatitis: A Systematic Review.

Idiopathic acute pancreatitis (IAP) presents a diagnostic challenge and refers to cases where the cause of acute pancreatitis remains uncertain despite a comprehensive diagnostic evaluation. Endoscopic ultrasound (EUS) has emerged as a valuable tool in the diagnostic workup of IAP. This review explores the pivotal role of EUS in detecting the actual cause of IAP and assessing its accuracy, timing, safety, and future technological improvement. In this review, we investigate the role of EUS in identifying the actual cause of IAP by examining the available literature. We aim to assess possible existing evidence regarding EUS accuracy, timing, and safety and explore potential trends of future technological improvements in EUS for diagnostic purposes. Following PRISMA guidelines, 60 pertinent studies were selected and analysed. EUS emerges as a crucial diagnostic tool, particularly when conventional imaging fails. It can offer intricate visualization of the pancreas, biliary system, and adjacent structures. Microlithiasis, biliary sludge, chronic pancreatitis, and small pancreatic tumors seem to be much more accurately identified with EUS in the setting of IAP. The optimal timing for EUS is post-resolution of the acute phase of the disease. With a low rate of complications, EUS poses minimal safety concerns. EUS-guided interventions, including fine-needle aspiration, collection drainage, and biopsies, aid in the cytological analysis. With high diagnostic accuracy, safety, and therapeutic potential, EUS is able to improve patient outcomes when managing IAP. Further refinement of EUS techniques and cost-effectiveness assessment of EUS-guided approaches need to be explored in multicentre prospective studies. This review underscores EUS as a transformative tool in unraveling IAP's enigma and advancing diagnostic and therapeutic strategies.

Diagnostic Accuracy of Endoscopic Ultrasonography in Selecting Patients for Endoscopic Submucosal Dissection for Early Gastrointestinal Neoplasms.

Tumor invasion depth and lymph node metastasis determine the prognosis of gastrointestinal (GI) neoplasms. GI neoplasms limited to mucosa (m1 or m2) and superficial submucosa (sm1) can be treated effectively with minimally invasive endoscopic therapy, while the deep invasion of the submucosa (sm2 or sm3) is associated with lymph node metastasis, and surgical resection is required. Correct staging is therefore crucial for preoperative evaluation and planning. Endoscopic ultrasonography (EUS) can be used to detect the depth of invasion due to its close proximity to the lesion. The diagnostic accuracy of EUS, when compared to conventional endoscopic staging, is debated as it can under- or overstage the lesion. We aim in this study to determine if EUS can accurately differentiate mucosal from submucosal GI neoplasms to select patients with early GI lesions for endoscopic submucosal dissection (ESD) or surgery. From March 2014 to February 2022, 293 patients with early superficial GI neoplasms were admitted to our endoscopic unit for EUS staging. To evaluate the accuracy of EUS, we compared the preoperative EUS findings with the definitive histopathologic findings on the resected specimen. Overall, 242 of 293 lesions were correctly staged by EUS (82.59%). In the evaluation of submucosal invasion or deeper, EUS understaged 38 of 293 (12.96%) and overstaged 13 of 293 (4.43%) lesions. EUS has excellent accuracy in staging superficial GI neoplasms; its use is highly recommended before ESD since it can also detect lymph node metastases around the lesions, thus changing the indication from ESD to surgery.

Safety of Endoscopic Snare Ampullectomy for Adenomatous Ampullary Lesions: Focus on Pancreatic Stent Placement to Prevent Pancreatitis.

BACKGROUND: Ampullary tumors, although relatively uncommon, are increasingly diagnosed due to ongoing progress in imaging technology and the diagnostic accuracy of endoscopic ultrasound and magnetic resonance cholangiopancreatography. Endoscopic ampullectomy (EA) has become the preferred treatment option over surgery due to its lower morbidity for benign ampullary adenomas. This study aims to evaluate the efficacy, safety, and outcome of EA in 30 patients with benign-appearing ampullary lesions with particular emphasis on the accuracy of preampullectomy histology and technical details of the pancreatic duct drainage to prevent postprocedural pancreatitis. MATERIALS AND METHODS: Data from a cohort of 30 patients who underwent EA were retrospectively analyzed. Histologic characteristics of the ampullomas, accuracy of histology of pre-EA biopsy specimen, safety of the procedure, recurrence rate, as well as the clinical outcome of all patients, are analyzed and discussed. RESULTS: Endoscopic resection was successful as a definitive treatment in 25 patients (83.3%). Five patients required additional surgery. In 8 patients, a definitive histologic specimen revealed an adenocarcinoma (3 in situ and 5 invasive). The diagnostic accuracy obtained by preresection biopsy specimen was low (0.70). Pancreatic duct stent placement after snare resection was unsuccessful in 9 patients, and 3 of them developed pancreatitis after EA. CONCLUSIONS: EA appears to be a relatively safe alternative to surgery as the first therapeutic option for selected patients with benign-appearing ampullary adenomas. A correct preoperative evaluation by endoscopic ultrasound and magnetic resonance cholangiopancreatography can help to define the anatomy of the pancreatic duct to improve the success rate of pancreatic stent placement which seems to offer a protective role in the prevention of postprocedural pancreatitis.

Infection Control Practices and Outcomes of Endoscopy Units in the Lombardy Region of Italy: A Survey From the Italian Society of Digestive Endoscopy During COVID-19 Spread.

GOALS: The present survey from the Italian Society of Digestive Endoscopy (SIED-Società Italiana di Endoscopia Digestiva) was aimed at reporting infection control practice and outcomes at Digestive Endoscopy Units in a high-incidence area. BACKGROUND: Lombardy was the Italian region with the highest coronavirus disease-2019 (COVID-19) prevalence, at the end of March 2020 accounting for 20% of all worldwide deaths. Joint Gastro-Intestinal societies released recommendations for Endoscopy Units to reduce the risk of the contagion. However, there are few data from high-prevalence areas on adherence to these recommendations and on their efficacy. METHODS: A survey was designed by the Lombardy section of SIED to analyze (a) changes in activity and organization, (b) adherence to recommendations, (c) rate of health care professionals' (HCP) infection during the COVID-19 outbreak. RESULTS: In total, 35/61 invited centers (57.4%) participated; most modified activities were according to recommendations and had filtering face piece 2/filtering face piece 3 and water-repellent gowns available, but few had negative-pressure rooms or provided telephonic follow-up; 15% of HCPs called in sick and 6% had confirmed COVID-19. There was a trend (P=0.07) toward different confirmed COVID-19 rates among endoscopists (7.9%), nurses (6.6%), intermediate-care technicians (3.4%), and administrative personnel (2.2%). There was no correlation between the rate of sick HCPs and COVID-19 incidence in the provinces and personal protective equipment availability and use, whereas an inverse correlation with hospital volume was found. CONCLUSIONS: Adherence to recommendations was rather good, though a minority were able to follow all recommendations. Confirmed COVID-19 seemed higher among endoscopists and nurses, suggesting that activities in the endoscopy rooms are at considerable viral spread risk.

Endoscopic submucosal dissection versus endoscopic mucosal resection for type 0-II superficial gastric lesions larger than 20 mm.

BACKGROUND: Endoscopic mucosal resection (EMR) and endoscopic submucosal dissection (ESD) are increasingly used for the treatment of superficial gastrointestinal neoplasia. However, the limits and the indications for each technique are still debated. Our retrospective study aimed to compare these techniques in patients with gastric flat lesions larger than 20 mm without the non-lifting sign. METHODS: Between January 2013 and July 2016, a total of 36 patients with early gastric flat lesions larger than 20 mm and without the non-lifting sign were resected by ESD and were followed up by endoscopy. As a control group, 40 EMR cases from our database were matched. En bloc and curative resection were compared between the two groups according to histological assessment, tumor size, recurrence, complication rate, and procedure time. A Kaplan-Meier comparison was performed for both groups with a log-rank test to compare the survival curves; the chi-square test was employed for other parameters. RESULTS: En bloc resection rate and curative resection rate were significantly higher in the ESD group than in the EMR group. Procedure time was significantly longer in the ESD group. No significant differences were found in the recurrence and complication rates, although the former were higher in the EMR group and the latter in the ESD group. Survival curves were similar for both groups. CONCLUSIONS: Our retrospective analysis seems to confirm a clear advantage for ESD over EMR in removing early superficial gastric neoplasm. Although ESD has expanded the endoscopic resectability of endoscopic gastric lesions, EMR may still be considered one of the therapeutic options for flat gastric lesions without the non-lifting sign.

Endotherapy for bile leaks from isolated ducts after hepatic resection: A long awaited challenge.

BACKGROUND: Bile leakage is a common complication after hepatic resection [1-4] (Donadon et al., 2016; Dechene et al., 2014; Zimmitti et al., 2013; Yabe et al., 2016). Endotherapy is the treatment of choice for this complication except for bile leaks originating from isolated ducts; a condition resembling the post laparoscopic cholecystectomy Strasberg type C lesions [5-9] (Lillemo et al., 2000; Gupta and Chandra, 2011; Park et al., 2005; Colovic, 2009; Mutignani et al., 2002). In such cases, surgical repair is complex, often of uncertain result and with a high morbidity and mortality [1] (Donadon et al., 2016). On the other hand, percutaneous interventions (i.e. plugging the isolated duct with glue) are technically difficult and risky [7,8] (Park et al., 2005; Colovic, 2009). Endoscopy, thus far, was not considered amongst treatment options. That is because the isolated duct cannot be opacified during cholangiography and is not accessible with the usual endoscopic methods [5,6] (Lillemo et al., 2000; Gupta and Chandra, 2011). METHODS: Considering the pathophysiology of this type of bile leaks, it is possible to change the pressure gradient endoscopically in order to direct bile flow from the isolated duct towards the duodenal lumen, thus creating an internal biliary fistula to restore bile flow. In order to achieve this goal, we have to perforate the biliary tree into the abdomen. The key element of endoscopic treatment is to create a direct connection between the abdominal cavity and the duodenal lumen by-passing the residual biliary tree with a new technique fully explained in the paper. Our case series (from 2011 to 2016) consists of 13 patients (eight male, five female, mean age 58 years) with fistulas from isolated ducts after various types of hepatic resection. RESULTS: We performed sphincterotomy and placed a biliary stent with the proximal edge inside the intra-abdominal bile collection in 11 patients (eight biliary fully-covered self-expandable metal stents; three plastic stents). In the remaining two patients we successfully cannulated the involved isolated biliary duct and we placed a bridging stent (one fully covered self-expandable metal stent; one plastic stent). Technical and clinical success (considered as fistula healing) was achieved in all 13 patients (mean fistula healing time was four days). Biliary stents were removed three to six months after atrophy of the involved duct in nine cases. In two patients the stent is still in situ. Two patients died with stent in situ due to advanced cancer at 8 and 42 months respectively. Mean follow up was 18 months (range: 8-42 months). CONCLUSIONS: The described endoscopic treatment is innovative, safe and effective. It is applicable in tertiary level endoscopic centers and requires considerable expertise. This minimally invasive procedure can increase the rate of fistula healing and will eventually reduce the need for more aggressive and risky surgical procedures.

Pulmonary Malformations: Predictors of Neonatal Respiratory Distress and Early Surgery.

OBJECTIVES: The objective of our study is to retrospectively analyze a single-centre series of antenatally detected pulmonary malformations (PM) and to evaluate their postnatal outcome. MATERIALS AND METHODS: We retrospectively reviewed all prenatally diagnosed PM patients referred to our Centre in the period between January 1999 and December 2014. All cases were diagnosed by one of our Maternal-Fetal Specialists by US examination. Congenital pulmonary airway malformation (CPAM) volume ratio (CVR), development of fetal complications, need for fetal therapy, need for neonatal resuscitation and timing of surgery were analyzed. RESULTS: A total of 70 fetuses were diagnosed with a PM in the period of study. An initial CVR higher than 1.6 was found in 16/70 patients (22.8%); 14/16 developed fetal complications (p less than .0001). Fifty-six fetuses (80%) did not develop any complications during pregnancy. To all complicated cases a prenatal treatment was offered, carried out in 12 (1 termination, 1 refusal). Survival rate was 100%. Sixty-three fetuses (90%) were asymptomatic at birth and did not require any neonatal resuscitation. Six patients submitted to fetal therapy and one untreated presented with neonatal respiratory distress, required mechanical ventilation at birth and early surgery in the neonatal period (7/70, 10%). CONCLUSION: CVR > 1.6 and the presence of fetal complications can be considered as predictors of respiratory distress at birth and of the need for early surgery. Nevertheless, the vast majority of PM are asymptomatic at birth and only a small group of fetuses require prenatal and postnatal treatment and support.

2-Litre polyethylene glycol-citrate-simethicone plus bisacodyl versus 4-litre polyethylene glycol as preparation for colonoscopy in chronic constipation.

BACKGROUND: Chronic constipation is a risk factor of inadequate bowel preparation for colonoscopy; however, no large clinical trials have been performed in this subgroup of patients. AIMS: To compare bowel cleansing efficacy, tolerability and acceptability of 2-L polyethylene-glycol-citrate-simethicone (PEG-CS) plus 2-day bisacodyl (reinforced regimen) vs. 4-L PEG in patients with chronic constipation undergoing colonoscopy. METHODS: Randomized, observer-blind, parallel group study. Adult outpatients undergoing colonoscopy were randomly allocated to 2-L PEG-CS/bisacodyl or 4-L PEG, taken as split regimens before colonoscopy. Quality of bowel preparation was assessed by the Ottawa Bowel Cleansing Scale (OBCS). The amount of foam/bubble interfering with colonic visualization was also measured. RESULTS: 400 patients were enrolled. There was no significant difference in successful cleansing (OBCS score ≤6): 80.2% in the 2-L PEG-CS/bisacodyl vs. 81.4% in the 4-L PEG group. Significantly more patients taking 2L PEG-CS/bisacodyl showed no or minimal foam/bubbles in all colonic segments (80% vs. 63%; p<0.001). 2-L PEG-CS/bisacodyl was significantly more acceptable for ease of administration (p<0.001), willingness to repeat (p<0.001) and showed better compliance (p=0.002). CONCLUSION: Split 2-L PEG-CS plus bisacodyl was not superior to split 4-L PEG for colonoscopy bowel cleansing in patients with chronic constipation; however, it performed better than the standard regimen in terms of colonic mucosa visualization, patient acceptance and compliance.

Colon Cleansing for Colonoscopy in Patients with Ulcerative Colitis: Efficacy and Acceptability of a 2-L PEG Plus Bisacodyl Versus 4-L PEG.

BACKGROUND: Low-volume preparations are gaining attention for higher acceptability but have been never evaluated in IBD. We compare the efficacy, safety, and tolerability of a 2-L PEG with a 4-L PEG solution in patients with ulcerative colitis. METHODS: This is a multicenter, randomized, single-blind study. Adult outpatients with ulcerative colitis undergoing colonoscopy received either 2-L PEG plus bisacodyl or 4-L PEG. Bowel cleansing was assessed using the Ottawa Scale and rated as adequate if the score was ≤2 in each colon segment. Patient acceptance, satisfaction, and related symptoms were recorded. RESULTS: Preparation was adequate in 80% of the 211 patients without any differences between groups. Mean Ottawa scores for whole and right colon were similar in the 2 groups. As concern tolerability, 83% patients in 2-L PEG arm and 44.8% in 4-L PEG arm reported no or mild discomfort (P < 0.0001) and 94.3% and 61.9% expressed their willingness to repeat the preparation (P < 0.001). Palatability was better with 2-L PEG, whereas related symptoms occurred more frequently with 4-L PEG. Regardless of preparation, split dosage was associated with better cleansing. Further predictors of poor cleansing were moderate/severe discomfort during preparation and more than 6 hours between end of preparation and colonoscopy. Extension and severity of colitis did not influence quality of preparation. CONCLUSIONS: Low-volume PEG is not inferior to 4-L PEG for bowel cleansing in ulcerative colitis, but it is better tolerated and accepted. The time interval from solution intake and colonoscopy is the most important factor affecting quality of cleansing in ulcerative colitis.

Surface electromyography and magnetic resonance imaging of the masticatory muscles in patients with arthrogenous temporomandibular disorders.

OBJECTIVE: The purpose of this study was to verify the characteristics of surface electromyography (sEMG) of masticatory muscles in patients with temporomandibular disorders (TMDs) with differing pathology. STUDY DESIGN: A total of 24 patients with TMDs were categorized according to the Research Diagnostic Criteria for Temporomandibular Disorders (RDC/TMD); magnetic resonance imaging (MRI) classified the patients as having disk displacement alone (DD) (mean age, 22 years; SD, 5; 3 men, 6 women) or having osteoarthrosis with or without disk displacement (OA) (mean age, 37 years; SD, 10; 4 men, 11 women); sEMG was performed according to a standardized protocol. RESULTS: The MRI score was significantly correlated to the torque coefficient (r = 0.57) and the temporalis (r = 0.85) and masseter (r = 0.46) muscle standardized symmetry. The discriminating ability of participant age and sEMG scores in separating the 2 groups was assessed by receiver operating characteristic analysis. Each of the sEMG scores showed a significant ability in discriminating between osteoarthrosis and disk displacement. CONCLUSIONS: The recording of the masticatory muscle function through sEMG can be a first diagnostic approach to patients with TMDs, reserving MRI assessment to selected cases.

Impact of portal vein thrombosis on the efficacy of endoscopic variceal band ligation.

BACKGROUND: Influence of portal vein thrombosis on efficacy of endoscopic variceal banding in patients with cirrhosis or extrahepatic portal vein obstruction has never been evaluated. Aim of the study was to assess influence of thrombosis on rate and time to eradication in cirrhosis and extrahepatic portal vein obstruction undergoing banding, compared to cirrhotic patients without thrombosis. METHODS: Retrospective analysis of 235 consecutive patients (192 with cirrhosis without thrombosis, 22 cirrhosis and thrombosis and 21 extrahepatic portal vein obstruction) who underwent banding. Banding was performed every 2-3 weeks until eradication; endoscopic follow-up was performed at 1, 3, 6 months, then annually. RESULTS: Eradication was achieved in 233 patients. Median time to eradication in cirrhotic patients with portal vein thrombosis vs. cirrhotic patients without thrombosis was 50.9 days (12-440) vs. 43.4 days (13-489.4); log-rank: 0.04; patients with extrahepatic portal vein obstruction vs. cirrhotic patients without thrombosis 63.9 days (31-321.6) vs. 43.4 days (13.0-489.4); log-rank: 0.008. Thrombosis was shown to be the only risk factor for longer time to eradication. CONCLUSIONS: Portal vein thrombosis per se appears to be the cause of a longer time to achieve eradication of varices but, once eradication is achieved, it does not influence their recurrence.

Does sustained lung inflation at birth improve outcome of preterm infants at risk for respiratory distress syndrome?

BACKGROUND: Sustained lung inflation (SLI) applied at birth has been demonstrated to lead to clearance of lung fluid and achievement of a precocious functional residual capacity in animal studies. OBJECTIVES: To verify if the application of SLI in preterm infants at birth may reduce the need for mechanical ventilation and improve their respiratory outcome. METHODS: We prospectively studied 89 infants with respiratory distress (gestational age (GA) 28.1 ± 2.2 weeks) treated at birth with a SLI (25 cm H(2)O, sustained for 15 s) in addition to AAP recommendations versus a historical control group (n = 119; GA 28.1 ± 2.0 weeks) treated without SLI with the same device (controlled positive end-expiratory pressure of 5 cm H(2)O). RESULTS: The SLI group had less need for (51 vs. 76%, p < 0.0001) and shorter duration of mechanical ventilation (5 ± 11 vs. 11 ± 19 days, p = 0.008), a more frequent occurrence of exclusive nasal continuous airway pressure support (49 vs. 24%, p < 0.0001) and INtubation-SURfactant-Extubation (INSURE) treatment (16 vs. 3%, p = 0.01), less need for surfactant (45 vs. 61%, p = 0.027) and postnatal steroids (10 vs. 25%, p = 0.01), a shorter duration of oxygen therapy (21 ± 27 vs. 31 ± 31 days, p = 0.016), and, finally, a lower occurrence of bronchopulmonary dysplasia in survivors (7 vs. 25%, p = 0.004). Multiple regression analysis showed that 23-27 weeks of GA and birth weight <750 g increased the risk of mechanical ventilation, while a clinical risk index for babies (CRIB) score <3 as well as INSURE strategy and SLI treatment in the delivery room decreased it. CONCLUSIONS: The application of a SLI at birth in preterm infants with respiratory distress may decrease the need for mechanical ventilation without inducing evident adverse effects.

Nasal continuous positive airway pressure (CPAP) versus bi-level nasal CPAP in preterm babies with respiratory distress syndrome: a randomised control trial.

OBJECTIVE: To evaluate the clinical course, respiratory outcomes and markers of inflammation in preterm infants with moderate respiratory distress syndrome (RDS) assigned from birth to nasal continuous positive airway pressure (NCPAP) or bi-level NCPAP. METHODS: A total of 40 infants with a gestational age (GA) of 28-34 weeks (<35 weeks' GA), affected by moderate RDS, were considered eligible and were randomised to NCPAP (group A; n=20, CPAP level=6 cm H(2)O) or to bi-level NCPAP (group B; n=20, lower CPAP level=4.5 cm H(2)O, higher CPAP level=8 cm H(2)O), provided with variable flow devices. Inflammatory response was the primary outcome; serum cytokines were measured on days 1 and 7 of life. Length of ventilation, oxygen dependency, need for intubation and occurrence of air leaks were considered as secondary outcomes. RESULTS: Infants showed similar characteristics at birth (group A vs group B: GA 30.3+/-2 vs 30.2+/-2 weeks, birth weight 1429+/-545 vs 1411+/-560 g) and showed similar serum cytokine levels at all times. Group A underwent longer respiratory support (6.2+/-2 days vs 3.8+/-1 days, p=0.025), longer O(2) dependency (13.8+/-8 days vs 6.5+/-4 days, p=0.027) and was discharged later (GA at discharge 36.7+/-2.5 weeks vs 35.6+/-1.2 weeks, p=0.02). All infants survived. No bronchopulmonary dysplasia (BPD) or neurological disorders occurred. CONCLUSIONS: Bi-level NCPAP was associated with better respiratory outcomes versus NCPAP, and allowed earlier discharge, inducing the same changes in the cytokine levels. It was found to be well tolerated and safe in the study population.

Lung inflammation in preterm infants with respiratory distress syndrome: effects of ventilation with different tidal volumes.

Ventilation with an inappropriate tidal volume (Vt) triggers lung inflammation, an important predisposing factor of bronchopulmonary dysplasia. It still remains uncertain what the appropriate starting target Vt should be during the acute phase of respiratory distress syndrome (RDS). Our aim was to evaluate lung inflammation in preterm infants undergoing synchronized intermittent positive-pressure ventilation (SIPPV) with two different tidal volumes Vt during the acute phase of RDS. Thirty preterm infants (gestational age, 25-32 weeks) with acute RDS were randomly assigned to be ventilated with Vt = 5 ml/kg (n = 15) or Vt = 3 ml/kg (n = 15). Proinflammatory cytokines (interleukin-6 (IL-6), interleukin-8 (IL-8), and tumor necrosis factor (TNF)-alpha) were determined in the tracheal aspirate on days 1, 3, and 7 of life. IL-8 and TNF-alpha levels collected on day 7 were significantly higher (P < 0.05), and mechanical ventilation lasted longer in the group with Vt = 3 ml/kg (16.8 +/- 4 vs. 9.2 +/- 4 days; P = 0.05). In conclusion, our data show significantly higher lung inflammation in preterm infants ventilated with Vt = 3 ml/kg, suggesting a role for Vt = 5 ml/kg in reducing both inflammatory response during the acute phase of RDS and the length of ventilation. Whether the use of this starting Vt prevents bronchopulmonary dysplasia requires further study.