New management of hepatolithiasis: Can surgery be avoided? (with video).

BACKGROUND: The presence of hepatolithiasis (HL) is prevalent in eastern countries. It is a clinical entity which is rarely reported in non-surgical series because the standard treatment is the surgical option. Currently, treatment has evolved, with the use of endoscopic techniques being increased and the number of hepatectomies being decreased. SpyGlass™ is a small-calibre endoscopic direct cholangiopancreatoscopy developed to explore and perform procedures in the bile and pancreatic ducts. Single-operator peroral cholangioscopy (POC) is an endoscopic technique useful for treating difficult bile duct stones. AIMS: To assess the usefulness, efficacy, and safety of POC with the SpyGlass™ system in patients with HL. PRIMARY OBJECTIVES: to achieve technical success of the procedure and clinical success of patients with HL. STUDY DESIGN AND PATIENTS: Retrospective, single-centre cohort study of patients with HL from April 2012 to August 2018. SpyGlass™ was chosen in symptomatic patients referred from the surgery unit as the first-line procedure. To perform electrohydraulic lithotripsy (EHL), we used a Northgate Autolith IEHL generator with a 0.66-mm biliary probe. RESULTS: We performed a total of 13 procedures in 7 patients with HL. The mean age was 46 years (range 35-65) and 3/7 of patients were female. We achieved technical success in 5/7 cases (71.4%) and clinical success in 4/7 cases (57%). DISCUSSION: SpyGlass™ is safe and effective in the treatment of HL. With these results, we confirm the need for management of patients with HL in a multidisciplinary team. When the endoscopic approach is the option, this procedure must be performed by experts in advanced endoscopy.

Multiple biliary hamartomatosis: an endoscopic ultrasound clinical case.

A 54-year-old female patient was referred to our outpatient clinic in December 2017 due to unresolved epigastric pain. She underwent cholecystectomyin in October 2012 due to epigastric pain, without evidence of lithiasis or biliary sludge. Subsequently, the patient continued to present epigastric discomfort with episodes of epigastralgia and was admitted in August 2016. There was evidence of elevated transaminases AST 125, ALT 97 and GGT 47, with normal amylase and no specific diagnosis was made on discharge from hospital.

Endoluminal radiofrequency ablation with SpyGlass™ in the management of cholangiocarcinoma.

Most extrahepatic cholangiocarcinomas are unresectable at the time of diagnosis and even in case of a resectable cancer, surgery is not an option for the elderly or patients with comorbidities (1). Current treatment alternatives in these scenarios are very limited. Biliary stenting with self-expanding metal stents (SEMS) is the mainstay palliative treatment for biliary obstruction (2). However, emerging experience with endoscopic RF ablation (RFA) in this setting has been reported in the literature.

Single-operator cholangiopancreatoscopy in pancreatobiliary diseases: clinical experience in a tertiary referral hospital.

BACKGROUND AND AIMS: to assess the usefulness, efficacy and safety of single-operator cholangiopancreatoscopy (SOCP) with the SpyGlass™ system for the management of biliopancreatic diseases. METHODS: a retrospective analysis of patients undergoing SOCP with the SpyGlass™ between September 2008 and April 2016 was performed. Data was obtained from a prospectively-maintained database at a tertiary referral center. The primary study outcomes were technical and complete endoscopic success of the procedure. Two different SpyGlass™ systems were employed; the former is called legacy and the latter, digital system (DS). RESULTS: a total of 107 SOCP procedures in 93 patients performed by a single operator were analyzed. Technical success of the SpyGlass™ examination was achieved in 90/93 (97%) of patients and complete success by resolving the biliopancreatic condition in 82/93 (88%) cases. In indeterminate biliary strictures, a complete success was achieved in 45/52 (85%) of cases. With regard to stone treatment, technical success was achieved in 34/34 (100%) patients and complete success, in 31/34 (91%) cases. Electrohydraulic lithotripsy was applied in 16/34 (47%) of cases. There were a total of 7/93 adverse effects (7.5%). CONCLUSIONS: SOCP is a useful and safe technique for the treatment of biliopancreatic diseases with a low rate of adverse effects. The procedure seems technically demanding and dedication is required.

Gastric polyps: Retrospective analysis of 41,253 upper endoscopies. / Pólipos gástricos: análisis retrospectivo de 41.253 endoscopias digestivas altas.

INTRODUCTION: Gastric polyps are usually asymptomatic lesions incidentally discovered during endoscopy. OBJECTIVE: To study the frequency of different types of gastric polyps in our population and their possible association with other factors. PATIENTS AND METHODS: Retrospective study of gastroscopies performed in a tertiary hospital over a ten-year period. Demographics, medical history, indication for gastroscopy and morphological and histological characteristics of polyps were collected. RESULTS: Gastric polyps were found in 827 out of 41253 (2%) reviewed gastroscopies, corresponding to 709 patients. Mean age was 65.6 years, and 62% were female. 53.9% of patients had multiple polyps. The most common location was the fundus and 83.3% were smaller than 1cm. Histopathology was obtained in 607 patients: hyperplastic polyps were the most common (42.8%), followed by fundic gland polyps (37.7%). Factors independently associated with hyperplastic polyps were age and single polyp, size ≥6mm and location other than fundus. In contrast, fundic gland polyps were associated with reflux and multiple polyps, size <6mm and located in fundus. Adenomas were independently associated with single polyp. CONCLUSIONS: Fundic gland and hyperplastic polyps are the most common in our population and have characteristic features that can guide histological diagnosis. With single polyps it is advisable to take biopsies to rule out adenoma.

Impact of the European Society of Gastrointestinal Endoscopy 2020 guidelines on the number of scheduled post-polypectomy surveillance colonoscopies: Meeting presentations: Partial results of this research were published in abstract form at ESGE Days 2020.

Background and study aims In contrast with the European Society of Gastrointestinal Endoscopy (ESGE) 2013 and the US Multi-society Task Force (USMSTF) 2020 guidelines, the ESGE 2020 guideline considers patients with three to four adenomas < 10 mm or an adenoma with villous histology as low risk. The aim of this study was to quantify the influence of the application of the new ESGE 2020 guidelines, as opposed to the ESGE 2013 and USMSTF 2020 guidelines, on the number of scheduled colonoscopies, and to describe the main causes for changes in the surveillance intervals. Patients and methods A retrospective evaluation was conducted of a prospectively maintained fecal immunochemical test (FIT)-based regional colorectal cancer screening program database. Surveillance regimens following ESGE 2020, ESGE 2013, and USMSTF 2020 guidelines were compared. Results Overall, 1284 individuals with a positive FIT and undergoing colonoscopy were consecutively included. When applying the ESGE 2020 guidelines, 10.8 % of patients changed to a "no-surveillance" group (relative reduction in colonoscopies of 82.5 %). The main reason for these changes was considering three to four adenomas as low risk. The proportion of patients from the "3-year surveillance" group who moved to the "no-surveillance" group was lower when a sessile serrated lesion (SSL) was present (ESGE 2013, 32.0% vs 16.3 %; USMSTF 2020 17.2 % vs 6.8 %). Analyzing the 41 patients with SSLs who remained unchanged in the "no-surveillance" group, only in 15 (36.6 %) the cause was the presence of an SSL. Conclusions applying the new ESGE 2020 guidelines could reduce by 11 % the proportion of individuals being offered surveillance. SLLs have not a major influence on the change of surveillance intervals.

Evaluation of different bowel preparations for small bowel capsule endoscopy: a prospective, randomized, controlled study.

BACKGROUND AND STUDY AIMS: To obtain an adequate view of the whole small intestine during capsule endoscopy (CE) a clear liquid diet and overnight fasting is recommended. However, intestinal content can hamper vision in spite of these measures. Our aim was to evaluate tolerance and degree of intestinal cleanliness during CE following three types of bowel preparation. PATIENTS AND METHODS: This was a prospective, multicenter, randomized, controlled study. Two-hundred ninety-one patients underwent one of the following preparations: 4 L of clear liquids (CL) (group A; 92 patients); 90 mL of aqueous sodium phosphate (group B; 89 patients); or 4 L of a polyethylene glycol electrolyte solution (group C; 92 patients). The degree of cleanliness of the small bowel was classified by blinded examiners according to four categories (excellent, good, fair or poor). The degree of patient satisfaction, gastric and small bowel transit times, and diagnostic yield were measured. RESULTS: The degree of cleanliness did not differ significantly between the groups (P = 0.496). Interobserver concordance was fair (k = 0.38). No significant differences were detected between the diagnostic yields of the CE (P = 0.601). Gastric transit time was 35.7 ± 3.7 min (group A), 46.1 ± 8.6 min (group B) and 34.6 ± 5.0 min (group C) (P = 0.417). Small-intestinal transit time was 276.9 ± 10.7 min (group A), 249.7 ± 13.1 min (group B) and 245.6 ± 11.6 min (group C) (P = 0.120). CL was the best tolerated preparation. Compliance with the bowel preparation regimen was lowest in group C (P = 0.008). CONCLUSIONS: A clear liquid diet and overnight fasting is sufficient to achieve an adequate level of cleanliness and is better tolerated by patients than other forms of preparation.

Evaluation of the optical criteria for sessile serrated lesions of the colon: A prospective study on a colorectal cancer screening population.

Background and study aims We aimed to describe the presence and combination of Hazewinkel's optical diagnosis (OD) criteria for sessile serrated lesions (SSL), determining which lesion characteristics increase the probability of a correct OD, with a focus on diminutive lesions. Patients and methods This was a prospective study describing the presence of Hazewinkel's OD criteria for SSL in lesions found in consecutive CRC screening colonoscopies. The presence of each OD criterion and their diagnostic combinations in SSL, related to the lesion's NBI International Colorectal Endoscopic (NICE) classification category, size, and location, were described. The presence of two or more optical criteria was considered diagnostic of SSL. The OD was compared to pathology as the gold standard. Results Seventy-nine SSLs (5.6 %) were diagnosed. Cloud-like appearance was the most prevalent OD criterion (35, 44.3 %). OD criteria were more frequently identified in NICE type 1, ≥ 10 mm, and proximal lesions. Only 26 SLLs fulfilled the OD criteria (sensitivity 32.9 %, 95 % CI 29.1 %-36.7 %). The sensitivity for diminutive SSL was 14.7 %, (95 % CI 11.9 %-17.6 %). Eighty-five lesions were optically diagnosed as SSL. However, only in 26 SSL was this the definitive diagnosis (positive predictive value 30.6 %, 95 % CI 26.9 %-34.3 %). Size > 5 mm and proximal location increased the probability of a correct diagnosis. The overall accuracy of the optical criteria was 92.0 % (95 % CI, 89.8 %-94.2 %). Conclusions The Hazewinkel's optical criteria are not reliable for a positive diagnosis of SSL, particularly for diminutive lesions.