Diagnosis of non-Hodgkin's lymphoma due to a tiny polyp in the cecum.

Endoscopic findings in primary or secondary intestinal lymphoma are non-specific, which can lead to finding a polyp, an ulcer or a completely normal mucosa. As a matter of fact, this makes having a high clinical suspicion with only the endoscopic technique, quite difficult. Due to this reason, we believe that either taking random biopsies or biopsies from visible lesions of affected sections in another imaging tests, should be indicated in order to increase the diagnostic capacity of the endoscopic technique.

Serological levels of IGF-1 and IGFBP-3 in patients with Barrett's esophagus and esophageal adenocarcinoma: Longitudinal study. / Niveles séricos de IGF-1 e IGFBP-3 en pacientes con esófago de Barrett y adenocarcinoma de esófago. Estudio longitudinal.

BACKGROUND: Barrett's esophagus (BE) is an entity with a known histological progression to malignancy. The insulin-like growth factor (IGF) system is involved in the carcinogenesis through obesity-related mechanisms that include IGF and it has been associated with several types of cancer. OBJECTIVES: To evaluate the serological levels of IGF-1 and IGFBP-3 in patients with BE and esophageal adenocarcinoma. PATIENTS AND METHODS: Prospective study of patients with BE and esophageal adenocarcinoma who underwent upper endoscopy between September 2012 and December 2015. A baseline determination of IGF-1 and IGFBP-3 was performed. We included a control group of patients without BE. RESULTS: One hundred sixteen patients were included: 36 controls, 62 with BE (42 without dysplasia and 20 with dysplasia) and 18 with adenocarcinoma. IGF-1 and IGF-1/IGFBP-3 molar ratio showed a progression to high levels in BE and adenocarcinoma than in controls (IGF-1: 135.55±66.07ng/ml, 148.33±81.5ng/ml, 108.19±46.69ng/ml, respectively; P=.049) (molar ratio: 0.23±0.91, 0.29±0.11, 0.19±0.06, respectively; P=.001), without differences between the histological types of BE. Fifty-four out of the 65 patients with BE were followed up (median of 58.50 months, range 12-113) and 11 of them (20.4%) presented progression to low-grade dysplasia (n=8) or high-grade dysplasia/adenocarcinoma (n=3), without differences in the IGF system compared with patients without progression. CONCLUSIONS: Patients with BE and esophageal adenocarcinoma have changes in the IGF system although the serological levels of IGF-1 and IGFBP-3 do not correlate with histological progression of BE.

Cold loop polypectomy perforation of a tiny colon polyp.

We report the case of a 61-year-old woman having corticoid treatment with corticosteroids for polyarthralgia, who underwent a post-polypectomy surveillance colonoscopy, identifying a 5-mm diameter, flat-elevated polyp in the proximal transverse colon (Paris 0-IIa).

Antibiotic Prophylaxis Is Not Required for Endoscopic Ultrasonography-Guided Fine-Needle Aspiration of Pancreatic Cystic Lesions, Based on a Randomized Trial.

BACKGROUND & AIMS: Guidelines recommend routine antibiotic prophylaxis for patients undergoing endoscopic ultrasonography-guided fine needle aspiration (EUS-FNA) of pancreatic cysts, but there is conflicting evidence for its necessity. We investigated whether performing the procedure without antimicrobial prophylaxis increases the incidence of infection. METHODS: We performed a multicenter, randomized, noninferiority trial to compare prophylaxis with ciprofloxacin vs placebo in patients with a pancreatic cyst requiring EUS-FNA at multiple centers in Spain. From September 2014 to June 2018, patients were randomly assigned to groups that received the prophylaxis with ciprofloxacin (n = 112) or saline solution (n = 114, placebo). We recorded patients' demographic data, lesion characteristics, and procedure data and followed patients for 21 days. A total of 205 patients completed the trial (90.7%), receiving ciprofloxacin or the control, with no statistically significant differences in demographics, baseline data, or procedure characteristics between groups. The primary outcome was FNA-related infection. Secondary outcomes were incidence of fever, procedure complications, and medication-related adverse events. RESULTS: The only case of FNA-related infection (0.44%) occurred in a patient in the placebo group (0.87%); this patient developed acute pancreatitis and bacteremia after the procedure. Prevention of infection was not inferior in the control group; the difference between proportions was 0.87% (95% confidence interval, -0.84% to 2.59%). There were no differences between groups in fever (2 patients in each group: 1.78% vs 1.76%; P = 1.00) or other adverse events. CONCLUSIONS: In a randomized trial of patients undergoing EUS-FNA for pancreatic cyst evaluation, we found the risk of infection to be low. The incidence of infections did not differ significantly with vs without ciprofloxacin prophylaxis. (ClinicalTrials.gov, Number: NCT02261896).

Review of computational methods for the detection and classification of polyps in colonoscopy imaging. / Revisión de métodos computacionales de detección y clasificación de pólipos en imagen de colonoscopia.

Computer-aided diagnosis (CAD) is a tool with great potential to help endoscopists in the tasks of detecting and histologically classifying colorectal polyps. In recent years, different technologies have been described and their potential utility has been increasingly evidenced, which has generated great expectations among scientific societies. However, most of these works are retrospective and use images of different quality and characteristics which are analysed off line. This review aims to familiarise gastroenterologists with computational methods and the particularities of endoscopic imaging, which have an impact on image processing analysis. Finally, the publicly available image databases, needed to compare and confirm the results obtained with different methods, are presented.

Advanced endoscopy technologies to improve the detection and characterisation of colorrectal polyps. / Tecnologías de endoscopia avanzada para mejorar la detección y caracterización de los pólipos colorrectales.

Colorectal cancer is a major health problem. An improvement to its survival has been demonstrated by performing colonoscopy screenings and removing its precursor lesions: polyps. However, colonoscopy is not infallible and multiple strategies have been proposed aimed at improving the quality thereof. This report describes the endoscopic systems available to improve the detection and characterization of polyps, the different classifications for histological prediction and the current indications of advanced endoscopic diagnostic techniques.

Diagnostic yield of endoscopic ultrasound with fine-needle aspiration in pancreatic cystic lesions. / Rendimiento diagnóstico de la punción mediante ultrasonografía endoscópica de las lesiones quísticas del páncreas.

INTRODUCTION: Despite advances in imaging techniques, in many cases they are insufficient to establish the diagnosis of pancreatic cystic lesions (PCL). There are few publications in our setting that evaluate the combination of several methods obtained by endoscopic ultrasound-guided fine needle aspiration (EUS-FNA). The aim of the study was to evaluate the overall utility of EUS-FNA in the diagnosis of PCL. MATERIAL AND METHODS: Retrospective study based on a database updated prospectively of a cohort of patients referred for EUS-FNA due to PCL detected in an imaging test. The sensitivity, specificity and diagnostic yield of carcinoembryonic antigen (CEA), cytology and viscosity were studied to detect mucinous lesions. RESULTS: From November 2013 to April 2018, 122 EUS were performed for PCL. EUS-FNA was performed in 94/122 (77%) and 21/122 (17.2%) patients were operated on. We included 33/122 patients who had diagnostic confirmation by histology, imaging (serous cyst with typical pattern) or clinical evolution. The study of the ROC curve determined the cutoff point ≥419 ng/ml to differentiate mucinous/non-mucinous cystic lesions. The diagnostic yield of CEA was 87.5% (21/24), cytology 81.8% (27/33) and viscosity 84.4% (27/32). The three parameters in combination obtained the best result (30/33, 90.9%). CONCLUSION: The combination of CEA analysis, cytology and viscosity of pancreatic fluid obtained by EUS-FNA increases the performance in the diagnosis of mucinous pancreatic cystic lesions, with it being greater than 90%.

Computer-aided prediction of polyp histology on white light colonoscopy using surface pattern analysis.

BACKGROUND: This study aimed to evaluate a new computational histology prediction system based on colorectal polyp textural surface patterns using high definition white light images. METHODS: Textural elements (textons) were characterized according to their contrast with respect to the surface, shape, and number of bifurcations, assuming that dysplastic polyps are associated with highly contrasted, large tubular patterns with some degree of bifurcation. Computer-aided diagnosis (CAD) was compared with pathological diagnosis and the diagnosis made by endoscopists using Kudo and Narrow-Band Imaging International Colorectal Endoscopic classifications. RESULTS: Images of 225 polyps were evaluated (142 dysplastic and 83 nondysplastic). The CAD system correctly classified 205 polyps (91.1 %): 131/142 dysplastic (92.3 %) and 74/83 (89.2 %) nondysplastic. For the subgroup of 100 diminutive polyps (≤ 5 mm), CAD correctly classified 87 polyps (87.0 %): 43/50 (86.0 %) dysplastic and 44/50 (88.0 %) nondysplastic. There were no statistically significant differences in polyp histology prediction between the CAD system and endoscopist assessment. CONCLUSION: A computer vision system based on the characterization of the polyp surface in white light accurately predicted colorectal polyp histology.

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.

Basic training in digestive endoscopy for resident physicians in gastroenterology. Recommendations by the Sociedad Española de Endoscopia Digestiva (SEED).

Digestive endoscopy is the most effective tool available for the diagnosis of multiple gastrointestinal (GI) tract conditions, and it represents a key aspect in the training of gastroenterology residents according to the Spanish MIR (médico interno residente) program. The Sociedad Española de Endoscopia Digestiva (SEED), aware of all the technical advances that have emerged during the past few years, deems it necessary to define a program of the skills specialists-in-training in gastroenterology should acquire during their residency. This paper describes the goals of endoscopy training, the techniques that should be mastered, and the diagnostic and therapeutic skills this specialty requires. Finally, a model is suggested for the assessment of competence.

Cervical arthrodesis penetrated into the esophagus detected by gastroscopy.

We present the case of a 76-year-old male who underwent arthrodesis due to a C7 fracture, which was complicated by an esophageal perforation and required primary surgical closure.

Endoscopic ultrasonography can avoid unnecessary laparotomies in patients with pancreatic adenocarcinoma and undetected peritoneal carcinomatosis.

BACKGROUND/OBJECTIVE: To assess the relationship between the presence of ascites detected by endoscopic ultrasonography (EUS) and peritoneal carcinomatosis (PC) in patients with pancreatic adenocarcinoma. METHODS: Consecutive patients who underwent a EUS for preoperative staging of a pancreatic adenocarcinoma between 1998 and 2014 were retrospectively reviewed. The diagnosis of PC was confirmed by histopathology or peritoneal fluid cytology. The main outcome of the study was the relationship of ascites at EUS and PC in patients with pancreatic cancer. Secondarily, to evaluate the relationship between this finding and survival as well as the development of PC during follow-up. RESULTS: A total of 136 patients were included: 30 patients with local unresectable tumor or metastatic disease and 106 potentially-resectable candidates based on CT staging. EUS showed ascites in 27 (20%) patients, of whom 8 (29.6%) had PC. The sensitivity, specificity, PPV, NPV and accuracy of ascites by EUS in the detection of PC in this group of patients were 67%, 85%, 30%, 96% and 83%, respectively. Ascites detected by EUS was the only independent predictive factor of PC with an OR of 11 (CI 95%: 3-40). The detection of ascites by EUS was associated with a shorter survival (median survival time 7,3 months; range 0-60 vs 14.2 months; range 0-140) (p = 0.018) and earlier development of PC during follow-up (median 3.2 months, range 1.4-18.1 vs 12.7 months, range 5.4-54.8; p = 0.003). CONCLUSION: The finding of ascites at EUS in patients with pancreatic adenocarcinoma is highly associated with PC and a poor outcome.

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.

Quality indicators for esophagogastroduodenoscopy: A comparative study of outcomes after an improvement programme in a tertiary hospital. / Indicadores de calidad en la esofagogastroduodenoscopia: estudio comparativo de los resultados tras un programa de mejora en un hospital terciario.

INTRODUCTION: There is an opportunity for improvement in the recording and measuring of quality indicators. However, no previous experiences exist in our field in terms of their compliance in esophagogastroduodenoscopy (EGD). OBJECTIVE: To analyse compliance with EGD quality criteria and evaluate improvement after conducting a training programme. PATIENTS AND METHODS: Comparative study of 2 cohorts: one retrospective (control group) and one prospective (intervention group), before and after a training programme consisting of an information session and the report writing improvement programme. The quality indicators proposed by the American Society for Gastrointestinal Endoscopy and the American College of Gastroenterology were used. RESULTS: A total of 1,200 EGDs were included in a sequential manner (600 in each group). Following the training programme, a significant improvement was observed in the following indicators: documented indication (93 vs. 99.8%; P<0.01), documented full examinations (94.7 vs. 97.3%; P<0.01), correct performance (63.7 vs. 87.9%; P<0.01), appropriate biopsies according to protocols (57.9 vs. 83.8%; P<0.01), photo-documentation of described lesions (84.1 vs. 94.9%; P<0.01), photo-documentation per segment (52.9 vs. 70.5%; P<0.01) and correct overall assessment (56,9 vs. 90.5%; P<0.01). Biopsies for coeliac disease, documented indication, full examination and correct performance, if it went ahead, exceeded the recommended standard. CONCLUSION: A very simple training programme improves EGD quality indicators, with the majority reaching the standards recommended by the American Society for Gastrointestinal Endoscopy and the American College of Gastroenterology.

Adverse events of EUS-guided FNA of pancreatic cystic and solid lesions by using the lexicon proposed in an ASGE workshop: a prospective and comparative study.

BACKGROUND AND AIMS: Pancreatic cysts and solid lesions are routinely examined by EUS-guided FNA (EUS-FNA). The aim of this study was to compare the incidence of adverse events (AEs) of this procedure by using the lexicon recommended by the American Society for Gastrointestinal Endoscopy (ASGE). METHODS: This was a prospective and comparative study of patients who underwent EUS-FNA in which a 22-gauge needle was used. In the pancreatic cystic lesions group (group I), complete fluid evacuation in a single needle pass was attempted, and ciprofloxacin was given during the procedure and for 3 days after. In the pancreatic solid lesions group (group II), the number of passes was determined by the on-site evaluation of the sample. AEs were defined and graded according to the lexicon recommended by the ASGE. Patients were followed for 48 hours, 1 week, and 1 month after the procedure. RESULTS: A total of 146 patients were included, 73 in group I and 73 in group II. Potential factors influencing the incidence of AEs (ie, access route for FNA) were similar in both groups. AEs occurred in 5 of 146 patients (3.4%; 95% confidence interval [CI], 1.3%-8%): 4 in group I (5.5%; 95% CI, 1.7%-13.7%) and 1 in group II (1.4%; 95% CI, -0.5% to 8.1%) (P = .03). Severity was mild in 1 of 5 patients (20%) and moderate in 3 of 5 patients (60%). One patient with a solid mass in the head of the pancreas had a duodenal perforation after EUS and died after surgery. All other AEs occurred in the first 48 hours and resolved with medical therapy. There were 3 incidents of transient hypoxia and self-limited abdominal pain in 1 and 2 patients, respectively. No patients were lost to follow-up. CONCLUSION: EUS-FNA of pancreatic cysts has an AEs rate similar to that of solid pancreatic masses, which is small enough to consider this procedure a safe and effective method for managing patients with both types of lesions. AEs occurred early after EUS-FNA, and patients should be closely followed during the first 2 days after the procedure.

Exploring the clinical potential of an automatic colonic polyp detection method based on the creation of energy maps.

BACKGROUND AND AIMS: Polyp miss-rate is a drawback of colonoscopy that increases significantly for small polyps. We explored the efficacy of an automatic computer-vision method for polyp detection. METHODS: Our method relies on a model that defines polyp boundaries as valleys of image intensity. Valley information is integrated into energy maps that represent the likelihood of the presence of a polyp. RESULTS: In 24 videos containing polyps from routine colonoscopies, all polyps were detected in at least one frame. The mean of the maximum values on the energy map was higher for frames with polyps than without (P < 0.001). Performance improved in high quality frames (AUC = 0.79 [95 %CI 0.70 - 0.87] vs. 0.75 [95 %CI 0.66 - 0.83]). With 3.75 set as the maximum threshold value, sensitivity and specificity for the detection of polyps were 70.4 % (95 %CI 60.3 % - 80.8 %) and 72.4 % (95 %CI 61.6 % - 84.6 %), respectively. CONCLUSION: Energy maps performed well for colonic polyp detection, indicating their potential applicability in clinical practice.

Endoscopic-assisted laparoscopic resection for gastric subepithelial tumors.

BACKGROUND: Laparoscopic resection is considered the treatment of choice for gastric subepithelial tumors. Occasionally, it is necessary to perform an intraoperative gastroscopy to localize the lesion. There are no data in the literature addressing the factors that can predict when a combined laparoscopic-endoscopic approach will be needed. METHODS: A retrospective cohort study using a prospectively collected database was conducted. From January 2005 to December 2013, all the patients undergoing a laparoscopic gastric resection for subepithelial tumors irresectable by endoscopy were reviewed. Potential predictive factors for the need of an intraoperative endoscopy were analyzed. RESULTS: Thirty-eight consecutive patients (22 men and 16 women) with a mean age of 67 (41-86) years underwent laparoscopic gastric resection for subepithelial tumors. Fourteen (36.8%) patients required intraoperative endoscopic assessment. The only significant factors related to the need of endoscopic assessment during surgery were tumor growth pattern (P = 0.002) and size (P = 0.001). CONCLUSIONS: An accurate description of tumor growth pattern and size by EUS is recommended in the preoperative assessment of gastric subepithelial tumors. Small tumors (≤18 mm) with an intraluminal growth may need a combined endoscopic-assisted laparoscopic management.

Long-term outcome of 'long-term liver transplant survivors'.

There are few studies focusing on long-term complications in liver transplant (LT) recipients. The aim of this study was to define the outcome of LT recipients having survived at least 10 years from LT. Of 323 adult LT done between 1991 and 1997, the 167(52%) alive >10 years post-LT (baseline time) formed the study population. Long-term outcome measures included the following: immunosuppression, metabolic complications [obesity, arterial hypertension (AH), diabetes, dislypidemia], cardiovascular events (CVE), chronic renal dysfunction-CRD, and de novo tumors. Median age at LT was 50 years. Most common indication was postnecrotic cirrhosis (89%), mostly because of HCV (46%). At study-baseline (10 years post-LT), 29% were obese and AH, diabetes, dislypidemia, and CRD were present in 75%, 30%, 42%, and 36%, respectively. In most cases, these complications were already present 1 year post-LT; less than one quarter developed them onward. The 6 year cumulative survival since baseline reached 84% (n = 24 deaths), with most deaths related to recurrent graft diseases (mostly HCV) followed by de novo tumors or CVE. 1, 3, 5 and 10 years cumulative rates of CVE and de novo tumors since baseline were 2%, 5%, 10% and 17%, and 1%, 3%, 6% and 13%, respectively. Chronic renal impairment was independently associated with survival and development of CVE since baseline. The medium-term survival of 'long-term survivors', i.e. patients alive 10 years after LT is good, but metabolic complications and CRD are common and continue to increase afterwards. Cardiovascular events and de novo tumors increase gradually over time and represent a major cause of late mortality.

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.