Interventions to improve the performance of upper GI endoscopy quality indicators.

The promotion of quality and best practices in gastroenterology and endoscopy is an ongoing effort. For upper GI endoscopy, quality indicators derived from clinical studies and expert consensus have been long established but remain variably obtained. To date, data on interventions aimed to improve these indicators are scarce. We systematically reviewed the literature to identify interventions and measures demonstrated to improve the performance of previously established upper endoscopy quality indicators. We also identified evidence gaps and opportunities for improvement in this area.

Peroral endoscopic myotomy for management of cricopharyngeal bars (CP-POEM): a retrospective evaluation.

BACKGROUND: Cricopharyngeal bars (CPBs) are a unique etiology of oropharyngeal dysphagia. Symptomatic patients are managed with endoscopic dilation or surgical myotomy. Cricopharyngeal peroral endoscopic myotomy (CP-POEM) is an emerging technique for the management of dysphagia due to CPBs. This study evaluated technical success, clinical success, adverse events, and long-term recurrence following CP-POEM. METHODS: Consecutive patients who underwent POEM for management of CPBs between May 2015 and December 2020 at four tertiary care centers were included. Primary outcome was clinical success (defined as improvement of dysphagia score to ≤ 1). Secondary outcomes were technical success, rate and severity of adverse events, procedure duration, and symptom recurrence. RESULTS: 27 patients (mean age 69 years; 10 female) underwent CP-POEM during the study period. The most common presenting symptoms at the time of index procedure were dysphagia (26; 96.3 %) and regurgitation (20; 74.1 %). Clinical and technical success were achieved in all patients. Mild/moderate adverse events occurred in two patients (7.4 %). CP-POEM significantly reduced the median dysphagia score. CONCLUSIONS: CP-POEM was a safe and effective treatment for symptomatic CPBs. Although symptom recurrence was low, long-term outcome data are needed. CP-POEM should be considered as a management option for symptomatic CPBs at centers with POEM expertise.

Clinical and technical outcomes of patients undergoing endoscopic ultrasound-guided gastroenterostomy using 20-mm vs. 15-mm lumen-apposing metal stents.

BACKGROUND: Most studies on endoscopic ultrasound (EUS)-guided gastroenterostomy (EUS-GE) for palliation of malignant gastric outlet obstruction (GOO) utilized a 15-mm lumen-apposing metal stent (LAMS). More recently, a 20-mm LAMS has become available. This study aimed to compare rates of technical and clinical success and adverse events (AEs) in patients undergoing EUS-GE using a 20-mm vs. 15-mm LAMS. METHODS: Patients who underwent EUS-GE with 15-mm or 20-mm LAMS for malignant GOO during the period from January 2018 to October 2020 were included. The primary outcome was clinical success, defined as an increase in the gastric outlet obstruction score (GOOS) by at least 1 point during follow-up. Secondary outcomes were technical success, maximum tolerated diet, re-intervention rate, and rate/severity of AEs. RESULTS: 267 patients (mean age 67 years, 43 % women) with malignant GOO from 19 centers underwent EUS-GE. Clinical success rates were similar for the 15-mm and 20-mm stents (89.2 % [95 %CI 84.2 %-94.2 %] vs. 84.1 % [77.4%-90.6 %], respectively). However, a significantly higher proportion of patients in the 20-mm group tolerated a soft solid/complete diet at the end of follow-up (91.2 % [84.4 %-95.7 %] vs. 81.2 % [73.9 %-87.2 %], P = 0.04). Overall, AEs occurred in 33 patients (12.4 % [8.4 %-16.3 %]), with similar rates for 15-mm and 20-mm stents (12.8 % [7.5 %-18.2 %] vs. 11.8 % [6 %-17.6 %]), including incidence of severe/fatal AEs (2 % [0.4 %-5.8 %] vs. 3.4 % [0.9 %-8.4 %]). CONCLUSIONS: The 20-mm and 15-mm LAMS show similar safety and efficacy for patients undergoing EUS-GE for malignant GOO. The 20-mm LAMS allows a more advanced diet and is, thus preferred for EUS-GE.

Zenker's peroral endoscopic myotomy, or flexible or rigid septotomy for Zenker's diverticulum: a multicenter retrospective comparison.

BACKGROUND: Treatment of Zenker's diverticulum has evolved from open surgery to endoscopic techniques, including flexible and rigid endoscopic septotomy, and more recently, peroral endoscopic myotomy (Z-POEM). This study compared the effectiveness of flexible and rigid endoscopic septotomy with that of Z-POEM. METHODS: Consecutive patients who underwent endoscopic septotomy (flexible/rigid) or Z-POEM for Zenker's diverticulum between 1/2016 and 9/2019 were included. Primary outcomes were clinical success (decrease in Dakkak and Bennett dysphagia score to ≤ 1), clinical failure, and clinical recurrence. Secondary outcomes included technical success and rate/severity of adverse events. RESULTS: 245 patients (110 females, mean age 72.63 years, standard deviation [SD] 12.37 years) from 12 centers were included. Z-POEM was the most common management modality (n = 119), followed by flexible (n = 86) and rigid (n = 40) endoscopic septotomy. Clinical success was 92.7 % for Z-POEM, 89.2 % for rigid septotomy, and 86.7 % for flexible septotomy (P = 0.26). Symptoms recurred in 24 patients (15 Z-POEM during a mean follow-up of 282.04 [SD 300.48] days, 6 flexible, 3 rigid [P = 0.47]). Adverse events occurred in 30.0 % rigid septotomy patients, 16.8 % Z-POEM patients, and 2.3 % flexible septotomy patients (P < 0.05). CONCLUSIONS: There was no difference in outcomes between the three treatment approaches for symptomatic Zenker's diverticulum. Rigid endoscopic septotomy was associated with the highest rate of complications, while flexible endoscopic septotomy appeared to be the safest. Recurrence following Z-POEM was similar to flexible and rigid endoscopic septotomy. Prospective studies with long-term follow-up are required.

Direct Endoscopic Necrosectomy With and Without Hydrogen Peroxide for Walled-off Pancreatic Necrosis: A Multicenter Comparative Study.

INTRODUCTION: Endoscopic necrosectomy has emerged as the preferred treatment modality for walled-off pancreatic necrosis. This study was designed to evaluate the safety and efficacy of direct endoscopic necrosectomy with and without hydrogen peroxide (H2O2) lavage. METHODS: Retrospective chart reviews were performed for all patients undergoing endoscopic transmural management of walled-off pancreatic necrosis at 9 major medical centers from November 2011 to August 2018. Clinical success was defined as the resolution of the collection by imaging within 6 months, without requiring non-endoscopic procedures or surgery. RESULTS: Of 293 patients, 204 met the inclusion criteria. Technical and clinical success rates were 100% (204/204) and 81% (166/189), respectively. For patients, 122 (59.8%) patients had at least one H2O2 necrosectomy (H2O2 group) and 82 (40.2%) patients had standard endoscopic necrosectomy. Clinical success was higher in the H2O2 group: 106/113 (93.8%) vs 60/76 (78.9%), P = 0.002. On a multivariate analysis, the use of H2O2 was associated with higher clinical success rate (odds ratio 3.30, P = 0.033) and earlier resolution (odds ratio 2.27, P < 0.001). During a mean follow-up of 274 days, 27 complications occurred. Comparing procedures performed with and without H2O2 (n = 250 vs 183), there was no difference in post-procedure bleeding (7 vs 9, P = 0.25), perforation (2 vs 3, P = 0.66), infection (1 vs 2, P = 0.58), or overall complication rate (n = 13 [5.2%] vs 14 [7.7%], P = 0.30). DISCUSSION: H2O2-assisted endoscopic necrosectomy had a higher clinical success rate and a shorter time to resolution with equivalent complication rates relative to standard necrosectomy.See the visual abstract at http://links.lww.com/AJG/B714.(Equation is included in full-text article.).

Enhanced NiO Dispersion on a High Surface Area Pillared Heterostructure Covered by Niobium Leads to Optimal Behaviour in the Oxidative Dehydrogenation of Ethane.

A Nb-containing siliceous porous clay heterostructure (PCH) with Nb contents from 0 to 30 wt %) was prepared from a bentonite and used as support in the preparation of supported NiO catalysts with NiO loading from 15 to 80 wt %. Supports and NiO-containing catalysts were characterised by several physicochemical techniques and tested in the oxidative dehydrogenation (ODH) of ethane. The characterisation studies on Nb-containing supports showed the presence of well-anchored Nb5+ species without the formation of Nb2 O5 crystals. High dispersion of nickel oxide with low crystallinity was observed for the Nb-containing PCH supports. In addition, when NiO is supported on these Nb-containing porous clays, it is more effective in the ODH of ethane (ethylene selectivity of ca. 90 %) than NiO supported on the corresponding Nb-free siliceous PCH or on Nb2 O5 (ethylene selectivities of ca. 30 and 60 %, respectively). Factors such as the NiO-Nb5+ interaction, the NiO particle size and the properties of surface Nin+ species were shown to determine the catalytic performance.

Endoscopic ultrasound-guided drainage of pancreatic walled-off necrosis using 20-mm versus 15-mm lumen-apposing metal stents: an international, multicenter, case-matched study.

BACKGROUNDS: Endoscopic ultrasound (EUS)-guided placement of lumen-apposing metal stents (LAMSs) has gained popularity for the treatment of pancreatic walled-off necrosis (WON). We compared the 20-mm and 15-mm LAMSs for the treatment of symptomatic WON in terms of clinical success and adverse events. METHODS: We conducted a retrospective, case-matched study of 306 adults at 22 tertiary centers from 04/2014 to 10/2018. A total of 102 patients with symptomatic WON who underwent drainage with 20-mm LAMS (cases) and 204 patients who underwent drainage with 15-mm LAMS (controls) were matched by age, sex, and drainage approach. Conditional logistic regression analysis was performed to compare clinical success (resolution of WON on follow-up imaging without reintervention) and adverse events (according to American Society for Gastrointestinal Endoscopy criteria). RESULTS: Clinical success was achieved in 92.2 % of patients with 20-mm LAMS and 91.7 % of patients with 15-mm LAMS (odds ratio 0.92; P = 0.91). Patients with 20-mm LAMS underwent fewer direct endoscopic necrosectomy (DEN) sessions (mean 1.3 vs. 2.1; P < 0.001), despite having larger WON collections (transverse axis 118.2 vs. 101.9 mm, P = 0.003; anteroposterior axis 95.9 vs. 80.1 mm, P = 0.01). There was no difference in overall adverse events (21.6 % vs. 15.2 %; P = 0.72) and bleeding events (4.9 % vs. 3.4 %; P = 0.54) between the 20-mm and 15-mm LAMS groups, respectively. CONCLUSIONS: The 20-mm LAMS showed comparable clinical success and safety profile to the 15-mm LAMS, with the need for fewer DEN sessions for WON resolution.

Lumen-apposing covered self-expandable metal stents for short benign gastrointestinal strictures: a multicenter study.

Background and study aim Use of the fully covered self-expandable metal stent (SEMS) for benign luminal gastrointestinal (GI) stricture (BLGS) has been limited by the migration rate. The role of the lumen-apposing metal stent (LAMS) for BLGS is not well defined. We assessed the safety, feasibility, and efficacy of LAMS for the treatment of BLGS. Patients and methods This was an observational, open-label, retrospective, single-arm, multicenter consecutive case series of patients undergoing LAMS placement for BLGS. Technical success was defined as successful placement of the LAMS. Short- and long-term clinical success rates were defined as symptom improvement/resolution with indwelling stent and after stent removal, respectively. All adverse events and additional interventions were recorded. Results A total of 30 patients (mean age 51.6 years; 63.3 % women) underwent LAMS placement for GI strictures (83.9 % anastomotic). Median stricture diameter and length were 4.5 mm (range 2 - 10 mm) and 8 mm (range 5 - 10 mm), respectively. Technical success was achieved in 29 patients (96.7 %), with an adverse event rate of 13.3 %. The stent migration rate was 8.0 % (2/25) on follow-up endoscopy. Short-term clinical success was achieved in 90.0 % (27/30) at a median of 60 days (interquartile range [IQR] 40 - 90 days). Most patients (19/23; 82.6 %) experienced sustained symptom improvement/resolution without the need for additional interventions at a median follow-up of 100 days (IQR 60 - 139 days) after LAMS removal. Conclusion This multicenter study demonstrated that LAMS placement represents a safe, feasible, and effective therapeutic option for patients with BLGS and is associated with a low stent migration rate. Our initial findings suggest that future prospective comparative studies are needed on the use of LAMS, endoscopic dilation, and conventional SEMS. .

Rebalancing of mitochondrial homeostasis through an NAD+-SIRT1 pathway preserves intestinal barrier function in severe malnutrition.

BACKGROUND: The intestine of children with severe malnutrition (SM) shows structural and functional changes that are linked to increased infection and mortality. SM dysregulates the tryptophan-kynurenine pathway, which may impact processes such as SIRT1- and mTORC1-mediated autophagy and mitochondrial homeostasis. Using a mouse and organoid model of SM, we studied the repercussions of these dysregulations on malnutrition enteropathy and the protective capacity of maintaining autophagy activity and mitochondrial health. METHODS: SM was induced through feeding male weanling C57BL/6 mice a low protein diet (LPD) for 14-days. Mice were either treated with the NAD+-precursor, nicotinamide; an mTORC1-inhibitor, rapamycin; a SIRT1-activator, resveratrol; or SIRT1-inhibitor, EX-527. Malnutrition enteropathy was induced in enteric organoids through amino-acid deprivation. Features of and pathways to malnutrition enteropathy were examined, including paracellular permeability, nutrient absorption, and autophagic, mitochondrial, and reactive-oxygen-species (ROS) abnormalities. FINDINGS: LPD-feeding and ensuing low-tryptophan availability led to villus atrophy, nutrient malabsorption, and intestinal barrier dysfunction. In LPD-fed mice, nicotinamide-supplementation was linked to SIRT1-mediated activation of mitophagy, which reduced damaged mitochondria, and improved intestinal barrier function. Inhibition of mTORC1 reduced intestinal barrier dysfunction and nutrient malabsorption. Findings were validated and extended using an organoid model, demonstrating that resolution of mitochondrial ROS resolved barrier dysfunction. INTERPRETATION: Malnutrition enteropathy arises from a dysregulation of the SIRT1 and mTORC1 pathways, leading to disrupted autophagy, mitochondrial homeostasis, and ROS. Whether nicotinamide-supplementation in children with SM could ameliorate malnutrition enteropathy should be explored in clinical trials. FUNDING: This work was supported by the Bill and Melinda Gates Foundation, the Sickkids Research Institute, the Canadian Institutes of Health Research, and the University Medical Center Groningen.

Endoscopic Ultrasound-Guided Liver Biopsy.

Endoscopic ultrasound-guided liver biopsy (EUS-LB) has emerged as a safe and effective alternative to percutaneous and trans-jugular approaches for hepatic tissue acquisition. It has shown superior diagnostic yield for the targeted approach of focal lesions, less sampling variability, improved patient comfort, and safety profile. These advantages have contributed to the increased use of EUS-LB as a technique for obtaining liver tissue. In this review, we provide an update on the recent evidence of EUS-LB for the evaluation of liver disease.

V-Porphyrins Encapsulated or Supported on Siliceous Materials: Synthesis, Characterization, and Photoelectrochemical Properties.

Metalloporphyrin-containing mesoporous materials, named VTPP@SBA, were prepared via a simple anchoring of vanadyl porphyrin (5,10,15,20-Tetraphenyl-21H,23H-porphine vanadium(IV) oxide) through a SBA-15-type mesoporous material. For comparison, vanadyl porphyrin was also impregnated on SiO2 (VTPP/SiO2). The characterization results of catalysts by XRD, FTIR, DR-UV-vis, and EPR confirm the incorporation of vanadyl porphyrin within the mesoporous SBA-15. These catalysts have also been studied using electrochemical and photoelectrochemical methods. Impedance measurements confirmed that supporting the porphyrin in silica improved the electrical conductivity of samples. In fact, when using mesoporous silica, current densities associated with oxidation/reduction processes appreciably increased, implying an enhancement in charge transfer processes and, therefore, in electrochemical performance. All samples presented n-type semiconductivity and provided an interesting photoelectrocatalytic response upon illumination, especially silica-supported porphyrins. This is the first time that V-porphyrin-derived materials have been tested for photoelectrochemical applications, showing good potential for this use.

Discerning the Metal Doping Effect on Surface Redox and Acidic Properties in a MoVTeNbO x for Propa(e)ne Oxidation.

Adding a small quantity of K or Bi to a MoVTeNbO x via impregnation with inorganic solutions modifies its surface acid and redox properties and its catalytic performance in propa(e)ne partial oxidation to acrylic acid (AA) without detriment to its pristine crystalline structure. Bi-doping encourages propane oxydehydrogenation to propene, thus enlarging the net production rate of AA up to 35% more. The easier propane activation/higher AA production over the Bi-doped catalyst is ascribed to its higher content of surface V leading to a larger amount of total V5+ species, the isolation site effect of NbO x species on V, and its higher Lewis acidity. K-doping does not affect propane oxydehydrogenation to propene but mainly acts over propene once formed, also increasing AA to a similar extent as Bi-doping. Although K-doping lowers propene conversion, it is converted more selectively to acrylic acid owing to its reduced Brønsted acidity and the presence of more Mo6+ species, thereby favoring propene transformation via the π-allylic species route producing acrylic acid over that forming acetic acid and CO x via acetone oxidation and that yielding directly CO x .

Tungsten-niobium oxide bronzes: a bulk and surface structural study.

Materials from the WO3-Nb2O5 system, presenting bronze-type crystal structures, display outstanding functional properties for several applications as thermoelectric materials, lithium-ion battery electrodes, or catalysts. In this work, a series of W-Nb-O oxide bronzes have been synthesized by the hydrothermal method (with Nb/(W + Nb) ratios in the range of 0-1). A combination of bulk and surface characterisation techniques has been applied to get further insights into: (i) the effect of thermal treatments on as-prepared materials and (ii) the surface chemical nature of W-Nb-O oxide bronzes. Thermal treatments promote the following structural changes: (i) loss of emerging long-range order and (ii) the elimination of NH4+ and H2O species from the structural channels of the as-synthesized materials. It has been observed that W-Nb-O bronzes with Nb at% of ca. 50% are able to retain a long-range order after heat-treatments, which is attributed to the presence of a Cs0.5[W2.5Nb2.5O14]-type structure. Increasing amounts of Nb5+ in the materials (i) promote a phase transition to pseudocrystalline phases ordered along the c-axis; (ii) stabilize surface W5+ species (elucidated by XPS); and (iii) increase the proportion of surface Lewis acid sites (as determined by the FTIR of adsorbed CO). Results suggest that pseudocrystalline oxides (with a Nb at% ≥ 50%) are closely related to NbO7 pentagonal bipyramid-containing structures. The stabilisation of Lewis acid sites on these pseudocrystalline materials leads to a higher yield of heavy compounds, at the expense of acrolein formation, in the gas-phase dehydration of glycerol.

Effects of redox oscillations on the phosphogypsum waste in an estuarine salt-marsh system.

Salt marshes are natural deposits of heavy metals in estuarine systems, where sulphide precipitation associated with redox changes often results in a natural attenuation of contamination. In the present study, we focus on the effects of variable redox conditions imposed to a highly-polluted phosphogypsum stack that is directly piled over the salt marsh soil in the Tinto River estuary (Huelva, Spain). The behaviour of contaminants is evaluated in the phosphogypsum waste and in the marsh basement, separately, in controlled, experimentally-induced oscillating redox conditions. The results revealed that Fe, and to a lesser extent S, control most precipitation/dissolution processes. Ferric iron precipitates in the form of phosphates and oxyhydroxides, while metal sulphide precipitation is insignificant and appears to be prevented by the abundant formation of Fe phosphates. An antagonistic evolution with changing redox conditions was observed for the remaining contaminants such as Zn, As, Cd and U, which remained mobile in solution during most of experimental run. Therefore, these findings revealed that high concentrations of phosphates inhibit the typical processes of immobilisation of pollutants in salt-marshes which highlights the elevated contaminant potential of phosphogypsum wastes on coastal environments.

Ferric sludge derived from the process of water purification as an efficient catalyst and/or support for the removal of volatile organic compounds.

Ferric chloride solutions are used as coagulants or flocculants in water treatment operations for human consumption. This treatment produces large amounts of clay-type solids formed mainly of montmorillonite with iron oxides and humic substances. This ferric sludge can be used as an efficient catalyst for the removal of volatile organic compounds (VOCs) by total oxidation. This waste isolated in the purification process has been activated by calcinations in air, characterized by several physicochemical techniques and employed as a catalyst for the removal by total oxidation of representative VOCs: toluene, propane and mixtures of toluene/propane with or without water. This ferric sludge has shown a catalytic activity one order of magnitude higher than that of a commercial iron oxide. This high activity has been related to the composition of the sludge (as it contains active metal oxides such as oxides of iron and manganese) and to the porous structure (leading to a reasonably high surface area). Moreover, it can be also used as a support for platinum, showing comparable (or even higher) catalytic activity than a similar platinum catalyst supported on conventional γ-alumina. This work presents a double environmental perspective since the material employed as a catalyst is a waste sludge and the catalytic reaction studied deals about the elimination of pollutants.

Endoscopic ultrasound guided gastrojejunostomy.

Endoscopic ultrasound guided gastrojejunostomy (EUS-GJ) has been mostly employed in the treatment of benign and malignant gastric outlet obstruction (GOO). Additionally, EUS-GJ has been used in the treatment of afferent loop syndrome. EUS-GJ has been employed in the treatment of benign and malignant GOO. EUS-GJ has also been used in the treatment of afferent loop syndrome. EUS-GJ involves obtaining access to the jejunum endoscopically and sonographically from the stomach, using a biflanged lumen apposing metal stent (LAMS). This is achieved through a newly formed fistulous tract. Thus creating a gastrojejunal bypass fully endoscopically. Several techniques have been described in preforming EUS-GJ but no method has been shown to be superior. In afferent loop syndrome initial data show high technical and clinical success rates and decreased need for reintervention. With malignant GOO, data available from the limited number of studies conducted demonstrated he superiority of EUS-GJ when compared to standard enteral stenting in terms of decreasing recurrence of GOO and need for reintervention. With benign GOO, EUS-GE offers a solution to the long-term patency and recurrence issue encountered with enteral stenting and endoscopic balloon dilation. EUS-GJ offers a less invasive approach than surgery for the treatment of several etiologies, giving the patients the option to avoid adverse events associated with surgery.

Effects of seawater mixing on the mobility of trace elements in acid phosphogypsum leachates.

This research reports the effects of pH increase on contaminant mobility in phosphogypsum leachates by seawater mixing, as occurs with dumpings on marine environments. Acid leachates from a phosphogypsum stack located in the Estuary of Huelva (Spain) were mixed with seawater to achieve gradually pH7. Concentrations of Al, Fe, Cr, Pb and U in mixed solutions significantly decreased with increasing pH by sorption and/or precipitation processes. Nevertheless, this study provides insight into the high contribution of the phosphogypsum stack to the release of other toxic elements (Co, Ni, Cu, Zn, As, Cd and Sb) to the coastal areas, as 80-100% of their initial concentrations behaved conservatively in mixing solutions with no participation in sorption processes. Stable isotopes ruled out connexion between different phosphogypsum-related wastewaters and unveiled possible weathering inputs of estuarine waters to the stack. The urgency of adopting effective restoration measures in the study area is also stressed.