Low Colorectal Cancer Risk After Resection of High-Risk Pedunculated Polyps.

BACKGROUND: Post-fecal immunochemical test (FIT) colonoscopy represents a setting with an enriched prevalence of advanced adenomas. Due to an expected higher risk of colorectal cancer (CRC), postpolypectomy surveillance is recommended, generating a substantially increased load on endoscopy services. The aim of our study was to investigate postpolypectomy CRC risk in a screening population of FIT+ subjects after resection of low-risk adenomas (LRAs) or high-risk adenomas (HRAs). METHODS: We retrieved data from a cohort of patients undergoing postpolypectomy surveillance within a FIT-based CRC screening program in Italy between 2002 and 2017 and followed-up to December 2021. Main outcomes were postpolypectomy CRC incidence and mortality risks according to type of adenoma (LRA/HRA) removed at colonoscopy as well as morphology, size, dysplasia, and location of the index lesion. We adopted as comparators FIT+/colonoscopy-negative and FIT- patients. The absolute risk was calculated as the number of incident CRCs per 100,000 person-years of follow-up. We used Cox multivariable regression models to identify associations between CRC risks and patient- and polyp-related variables. RESULTS: Overall, we included 87,248 post-FIT+ colonoscopies (133 endoscopists). Of these, 42,899 (49.2%) were negative, 21,650 (24.8%) had an LRA, and 22,709 (26.0%) an HRA. After a median follow-up of 7.25 years, a total of 635 CRCs were observed. For patients with LRAs, CRC incidence (hazard ratio [HR], 1.18; 95% confidence interval [CI], 0.92-1.53) was not increased compared with the FIT+/colonoscopy-negative group, while for HRAs a significant increase in CRC incidence (HR, 1.53; 95% CI, 1.14-2.04) was found. The presence of 1 or more risk factors among proximal location, nonpedunculated morphology, and high-grade dysplasia explained most of this excess CRC risk in the HRA group (HR, 1.85; 95% CI, 1.36-2.52). Patients with only distal pedunculated polyps without high-grade dysplasia, representing 39.2% of HRA, did not have increased risk compared with the FIT- group (HR, 0.87; 95% CI, 0.59-1.28). CONCLUSIONS: CRC incidence is significantly higher in patients with HRAs diagnosed at colonoscopy. However, such excess risk does not appear to apply to patients with only distal pedunculated polyps without high-grade dysplasia, an observation that could potentially reduce the burden of surveillance in FIT programs.

Adenoma Detection Rate and Colorectal Cancer Risk in Fecal Immunochemical Test Screening Programs : An Observational Cohort Study.

BACKGROUND: Colorectal cancer (CRC) screening programs based on fecal immunochemical tests (FITs) represent the standard of care for population-based interventions. Their benefit depends on the identification of neoplasia at colonoscopy after FIT positivity. Colonoscopy quality measured by adenoma detection rate (ADR) may affect screening program effectiveness. OBJECTIVE: To examine the association between ADR and postcolonoscopy CRC (PCCRC) risk in a FIT-based screening program. DESIGN: Retrospective population-based cohort study. SETTING: Fecal immunochemical test-based CRC screening program between 2003 and 2021 in northeastern Italy. PATIENTS: All patients with a positive FIT result who had a colonoscopy were included. MEASUREMENTS: The regional cancer registry supplied information on any PCCRC diagnosed between 6 months and 10 years after colonoscopy. Endoscopists' ADR was categorized into 5 groups (20% to 39.9%, 40% to 44.9%, 45% to 49.9%, 50% to 54.9%, and 55% to 70%). To examine the association of ADR with PCCRC incidence risk, Cox regression models were fitted to estimate hazard ratios (HRs) and 95% CIs. RESULTS: Of the 110 109 initial colonoscopies, 49 626 colonoscopies done by 113 endoscopists between 2012 and 2017 were included. After 328 778 person-years follow-up, 277 cases of PCCRC were diagnosed. Mean ADR was 48.3% (range, 23% and 70%). Incidence rates of PCCRC from lowest to highest ADR group were 13.13, 10.61, 7.60, 6.01, and 5.78 per 10 000 person-years. There was a significant inverse association between ADR and PCCRC incidence risk, with a 2.35-fold risk increase (95% CI, 1.63 to 3.38) in the lowest group compared with the highest. The adjusted HR for PCCRC associated with 1% increase in ADR was 0.96 (CI, 0.95 to 0.98). LIMITATION: Adenoma detection rate is partly determined by FIT positivity cutoff; exact values may vary in different settings. CONCLUSION: In a FIT-based screening program, ADR is inversely associated with PCCRC incidence risk, mandating appropriate colonoscopy quality monitoring in this setting. Increasing endoscopists' ADR may significantly reduce PCCRC risk. PRIMARY FUNDING SOURCE: None.

Influence of Frailty in Patients Undergoing Endoscopic Retrograde Cholangiopancreatography for Biliary Stone Disease: A Nationwide Study.

BACKGROUND AND AIMS: Pancreaticobiliary diseases are common in the elderly. To this end, frailty represents a state of vulnerability that should be considered when assessing the risks and benefits of therapeutic endoscopic procedures. We aim to determine the rate of readmissions and clinical outcomes using the validated Hospital Frailty Risk Score in patients undergoing endoscopic retrograde cholangiopancreatography (ERCP). METHODS: Using the National Readmissions Database, we identified patients with an admission diagnosis of cholangitis with obstructive stone from 2016 to 2019. Patients were determined to be of low frailty risk with a score of < 5, while patients of medium to high frailty risk had a score of > 5. RESULTS: During the study period, 5751 patients were identified with acute cholangitis with obstructing stone. Mean age of index admissions was 69.4 years and 51.8% were female. From the total cohort, 5119 (89.2%) patients underwent therapeutic ERCP, 38.0% (n = 1947) of whom were regarded as frail (risk score > 5). Following ERCP, frail patients had a less but statistically insignificant readmission rate compared to non-frail patients (2.76% vs 4.05%, p = 0.450). However, compared to non-frail patients, frail patients experienced higher post-ERCP complications (6.20% vs 14.63%, p < 0.001). Frail patients were more likely to have longer lengths of stay, higher hospital cost, and mortality risk. CONCLUSION: ERCP is not a risk factor for readmission among frail patients. However, frail patients are at higher risk for procedure-related complications, healthcare utilization, and mortality.

Comparative efficacy of different methods for difficult biliary cannulation in ERCP: systematic review and network meta-analysis.

BACKGROUND AND AIMS: Several methods with variable efficacy have been proposed for difficult biliary cannulation in ERCP. We assessed the comparative efficacy of different strategies for difficult biliary cannulation through a network meta-analysis combining direct and indirect treatment comparisons. METHODS: We identified 17 randomized controlled trials (2015 patients) that compared the efficacy of different adjunctive methods for difficult biliary cannulation (needle-knife techniques, pancreatic guidewire-assisted technique, pancreatic-assisted technique, and transpancreatic sphincterotomy) either with each other or with persistence with the standard cannulation techniques. The success rate of biliary cannulation and the incidence of post-ERCP pancreatitis (PEP) were the outcomes of interest. We performed pairwise and network meta-analysis for all treatments and used Grading of Recommendations Assessment, Development and Evaluation criteria to appraise quality of evidence. RESULTS: Low-quality evidence supported the use of transpancreatic sphincterotomy over persistence with standard cannulation techniques (risk ratio [RR], 1.29; 95% confidence interval [CI], 1.05-1.59) and over any other adjunctive intervention (RR, 1.21 [95% CI, 1.01-1.44] vs pancreatic guidewire-assisted technique, RR, 1.19 [95% CI, 1.01-1.43] vs early needle-knife techniques, RR, 1.47 [95% CI, 1.03-2.10] vs pancreatic stent-assisted technique) for increasing the success rate of biliary cannulation. No other significant results were observed in any other comparisons. Based on the network model, transpancreatic sphincterotomy (P-score, .97) followed by early needle-knife techniques (P-score, .62) were ranked highest in terms of increasing the success rate of biliary cannulation. Early needle-knife techniques outperformed persistence with standard cannulation techniques in terms of decreasing PEP rate (RR, .61; 95% CI, .37-1.00), whereas both early needle-knife techniques and transpancreatic sphincterotomy led to lower PEP rates as compared with pancreatic guidewire-assisted technique (RR, .49 [95% CI, .23-.99] and .53 [95% CI, .30-.92], respectively). CONCLUSIONS: Transpancreatic sphincterotomy increases the success rate of biliary cannulation as compared with persistence with the standard cannulation techniques. Early needle-knife techniques and transpancreatic sphincterotomy are superior to other interventions in decreasing PEP rates and should be considered in patients with difficult cannulation.

Reducing the environmental footprint of gastrointestinal endoscopy: European Society of Gastrointestinal Endoscopy (ESGE) and European Society of Gastroenterology and Endoscopy Nurses and Associates (ESGENA) Position Statement.

Climate change and the destruction of ecosystems by human activities are among the greatest challenges of the 21st century and require urgent action. Health care activities significantly contribute to the emission of greenhouse gases and waste production, with gastrointestinal (GI) endoscopy being one of the largest contributors. This Position Statement aims to raise awareness of the ecological footprint of GI endoscopy and provides guidance to reduce its environmental impact. The European Society of Gastrointestinal Endoscopy (ESGE) and the European Society of Gastroenterology and Endoscopy Nurses and Associates (ESGENA) outline suggestions and recommendations for health care providers, patients, governments, and industry. MAIN STATEMENTS 1: GI endoscopy is a resource-intensive activity with a significant yet poorly assessed environmental impact. 2: ESGE-ESGENA recommend adopting immediate actions to reduce the environmental impact of GI endoscopy. 3: ESGE-ESGENA recommend adherence to guidelines and implementation of audit strategies on the appropriateness of GI endoscopy to avoid the environmental impact of unnecessary procedures. 4: ESGE-ESGENA recommend the embedding of reduce, reuse, and recycle programs in the GI endoscopy unit. 5: ESGE-ESGENA suggest that there is an urgent need to reassess and reduce the environmental and economic impact of single-use GI endoscopic devices. 6: ESGE-ESGENA suggest against routine use of single-use GI endoscopes. However, their use could be considered in highly selected patients on a case-by-case basis. 7: ESGE-ESGENA recommend inclusion of sustainability in the training curricula of GI endoscopy and as a quality domain. 8: ESGE-ESGENA recommend conducting high quality research to quantify and minimize the environmental impact of GI endoscopy. 9: ESGE-ESGENA recommend that GI endoscopy companies assess, disclose, and audit the environmental impact of their value chain. 10:  ESGE-ESGENA recommend that GI endoscopy should become a net-zero greenhouse gas emissions practice by 2050.

Migration rate using fully covered metal stent in anastomotic strictures after liver transplantation: Results from the BASALT study group.

BACKGROUND AND STUDY AIM: The traditional endoscopic therapy of anastomotic strictures (AS) after orthotopic liver transplantation (OLT) is multiple ERCPs with the insertion of an increasing number of plastic stents side-by-side. Fully covered self-expanding metal stents (cSEMS) could be a valuable option to decrease the number of procedures needed or non-responders to plastic stents. This study aims to retrospectively analyse the results of AS endoscopic treatment by cSEMS and to identify any factors associated with its success. PATIENTS AND METHODS: Ninety-one patients (mean age 55.9 ± 7.6 SD; 73 males) from nine Italian transplantation centres, had a cSEMS positioned for post-OLT-AS between 2007 and 2017. Forty-nine (54%) patients were treated with cSEMS as a second-line treatment. RESULTS: All the procedures were successfully performed without immediate complications. After ERCP, adverse events occurred in 11% of cases (2 moderate pancreatitis and 8 cholangitis). In 49 patients (54%), cSEMSs migrated. After cSEMS removal, 46 patients (51%) needed further endoscopic (45 patients) or radiological (1 patient) treatments to solve the AS. Lastly, seven patients underwent surgery. Multivariable stepwise logistic regression showed that cSEMS migration was the only factor associated with further treatments (OR 2.6, 95% CI 1.0-6.6; p value 0.03); cSEMS implantation before 12 months from OLT was associated with stent migration (OR 5.2, 95% CI 1.7-16.0; p value 0.004). CONCLUSIONS: cSEMS appears to be a safe tool to treat AS. cSEMS migration is the main limitation to its routinary implantation and needs to be prevented, probably with the use of new generation anti-migration stents.

Covered versus uncovered metal stents for malignant gastric outlet obstruction: a systematic review and meta-analysis.

BACKGROUND AND AIMS: Self-expandable metal stents (SEMSs) are used for palliation of malignant gastric outlet obstruction (GOO). Studies comparing covered SEMSs (C-SEMSs) and uncovered SEMSs (U-SEMSs) have led to inconclusive results. We compared efficacy and safety of C-SEMSs versus U-SEMSs in patients with GOO. METHODS: We searched MEDLINE, EMBASE, and Cochrane Library from 2000 to 2019 to identify available studies comparing C-SEMSs versus U-SEMSs in patients with GOO. Primary outcomes were stent survival and patient survival, whereas secondary outcomes were clinical and technical success, Gastric Outlet Obstruction Score System (GOOSS) score after the procedure, overall adverse events, reintervention rate, dysfunction rate, stent occlusion, and stent migration. RESULTS: Overall, 7 randomized controlled trials and 9 observational studies were identified that included 1741 patients. C-SEMSs were associated with higher stent survival (hazard ratio, .68; 95% confidence interval [CI], .48-.96), whereas patient survival did not statistically significantly differ between C-SEMS and U-SEMS groups (hazard ratio, .96; 95% CI, .75-1.23). Clinical and technical success were not statistically different between groups (odds ratios, 1.1 [95% CI, .76-1.61] and .69 [95% CI, .21-2.3], respectively). There were no differences in terms of overall adverse events, reintervention rate, dysfunction rate, and GOOSS rate ≥2 after SEMS placement. U-SEMSs were associated with a higher rate of occlusion (odds ratio, .34; 95% CI, .21-.53) and C-SEMSs with a higher rate of migration (odds ratio, 4.28; 95% CI, 2.79-6.57). CONCLUSIONS: C-SEMSs were associated with higher stent survival (time between stent deployment and stent dysfunction) compared with U-SEMSs, whereas no differences in terms of patient survival (time between stent deployment and patient's death) emerged. However, U-SEMSs were associated with higher risk of occlusion and C-SEMSs with higher risk of migration. Further studies using new C-SEMSs with an antimigration system are needed.

A cumulative meta-analysis of endoscopic papillary balloon dilation versus endoscopic sphincterotomy for removal of common bile duct stones.

BACKGROUND: Endoscopic papillary balloon dilation (EPBD) was introduced to overcome the risk of adverse events associated with endoscopic sphincterotomy in the removal of common bile duct (CBD) stones. We performed a meta-analysis of randomized controlled trials (RCTs) comparing efficacy and safety of EPBD vs. endoscopic sphincterotomy, focusing on stone size, balloon diameter, and balloon dilation time. METHODS: A multiple database search was performed, including MEDLINE, EMBASE and Cochrane Library, from their inception date until October 2017. RCTs comparing the efficacy and safety of EPBD vs. endoscopic sphincterotomy in the removal of CBD stones were included. Cumulative meta-analyses over time, and subgroup analyses according to stone size, and balloon diameter and dilation time were carried out. RESULTS: 25 RCTs met the inclusion criteria. Despite the cumulative meta-analysis showing a trend over time in favor of endoscopic sphincterotomy in studies published up to 2004, the conventional meta-analysis revealed that EPBD was equally efficacious compared with endoscopic sphincterotomy in stone removal at first attempt (odds ratio [OR] 0.95, 95 % confidence interval [CI] 0.65 - 1.38). Endoscopic sphincterotomy was superior to EPBD in terms of overall stone clearance (OR 0.65, 95 %CI 0.43 - 0.99) in studies published since 2002, but no differences emerged in studies using large ( ≥ 10 mm) balloons (OR 1.37, 95 %CI 0.72 - 2.62). No statistically significant difference in pancreatitis occurrence emerged between EPBD and endoscopic sphincterotomy (OR 1.35, 95 %CI 0.90 - 2.03). Pancreatitis was more common with EPBD than with endoscopic sphincterotomy in studies using balloons < 10 mm (OR 1.78, 95 %CI 1.07 - 2.97), whereas no difference emerged in studies using large balloons (OR 0.84, 95 %CI 0.46 - 1.53). EPBD had lower rates of bleeding and cholecystitis. CONCLUSIONS: Our latest data confirm that EPBD is currently inferior to endoscopic sphincterotomy in terms of overall stone clearance. However, EPBD using large balloons (≥ 10 mm) was as effective as endoscopic sphincterotomy, both in stone clearance and the need for endoscopic mechanical lithotripsy, without carrying an increased risk of pancreatitis.

Endoscopic entero-enteral bypass: an effective new approach to the treatment of postsurgical complications of hepaticojejunostomy.

BACKGROUND: Management of biliary adverse events (BAEs) after biliodigestive anastomosis is challenging. We propose a new endoscopic approach to improve BAEs in this clinical setting. METHODS: Patients who had BAEs after a hepaticojejunostomy with Roux-en-Y loop or a Whipple procedure underwent creation of an entero-enteral endoscopic bypass (EEEB) between the duodenal/gastric wall and the biliary jejunal loop under endoscopic ultrasound (EUS) and fluoroscopic guidance using specifically designed fully covered self-expandable metal stents. RESULTS: 32 consecutive patients underwent EEEB, which was successful in all but one patient. One procedural and five long-term mild adverse events occurred. Endoscopic retrograde cholangiography (ERC) through the EEEB successfully treated all types of BAEs in these patients. Disease recurred in two patients who were successfully re-treated through the EEEB. CONCLUSIONS: Our retrospective study showed that in patients with BAEs after biliodigestive anastomosis, EEEB is safe, feasible, and allows a successful long-term treatment of different BAEs in a tertiary referral center with high-level experience in both endoscopic retrograde cholangiopancreatography and EUS.

A multicenter randomized trial comparing the use of touch versus no-touch guidewire technique for deep biliary cannulation: the TNT study.

BACKGROUND AND AIMS: There are 2 techniques described for selective bile duct guidewire cannulation, the touch (T) technique (engaging the papilla with a sphincterotome and then advancing the guidewire) and the no-touch (NT) technique (engaging the papilla only with the guidewire). The aim of this prospective, multicenter randomized study was to compare the outcomes of the 2 guidewire cannulation techniques. METHODS: Three hundred consecutive patients with naïve papillae were enrolled in 2 groups (150 to T group and 150 to NT group). A maximum of 15 biliary cannulation attempts, for no longer than 5 minutes, or a maximum of 5 unintentional cannulations of the pancreatic duct for each group were performed. If biliary cannulation failed, the patient was crossed over to the other technique with the same parameters. The primary outcome was the guidewire cannulation success rate using either the T or NT technique. Secondary outcomes were the number of attempts and cannulation duration, number of pancreatic duct cannulations, and adverse events. RESULTS: The primary cannulation rate was significantly higher in the T group compared with the NT group (88% vs 54%, P < .001), and the cannulation rate was significantly higher using the T technique compared with the NT technique also after crossover (77% vs 17%, P < .001). The mean number of cannulation attempts was 4.6 in the T group versus 5.5 in the NT group (P = .006), and the duration of cannulation before crossover (P < .001) and overall cannulation duration after crossover (P < .001) were significantly lower in the T group. The number of unintended pancreatic duct cannulations was statistically higher using the T technique compared with the NT technique (P = .037). The rates of adverse events did not significantly differ between the 2 groups. CONCLUSIONS: Our results clearly indicated that the T technique is superior to the NT technique for biliary cannulation. (Clinical trial registration number: NCT01954602.).

Covered vs. uncovered self-expandable metal stents for malignant distal biliary strictures: a systematic review and meta-analysis.

BACKGROUND: Self-expandable metal stents (SEMS) are used for palliation of distal malignant biliary strictures, but the role of covered SEMS is less clear. We performed an up-to-date meta-analysis to compare the performance of covered and uncovered SEMS in patients with unresectable distal malignant biliary strictures. METHODS: A computerized medical search was performed using MEDLINE, EMBASE, and the Cochrane Library between 2000 and December 2016 to identify all randomized trials that compared covered with uncovered SEMS in patients with distal malignant biliary strictures. Primary outcomes were stent failure and patient mortality; secondary outcomes were stent dysfunction and adverse events. Pooled estimates were computed using the random effects model. RESULTS: Overall, 11 RCTs involving 1272 patients were included. The primary outcomes of stent failure and patient mortality did not differ significantly between covered and uncovered SEMS (hazard ratio [HR] 0.68, 95 % confidence interval [CI] 0.40 - 1.17; HR 0.89, 95 %CI 0.76 - 1.05, respectively). However, stent migration and sludge formation were much more common with covered SEMS (odds ratio [OR] 5.11, 95 %CI 1.84 - 14.17; OR 2.46, 95 %CI 1.37 - 4.43). The use of covered SEMS was associated with a lower rate of tumor ingrowth (OR 0.21, 95 %CI 0.09 - 0.50) but a higher rate of tumor overgrowth (OR 2.00, 95 %CI 1.15 - 3.48) compared with uncovered stents. The rates of procedure-related adverse events were similar in both groups. CONCLUSION: There was a risk reduction of about 32 % for both stent failure and patient mortality with covered SEMS but this difference was not significant. Migration and sludge rates were higher with covered SEMS, whereas tumor ingrowth was more likely with uncovered SEMS. The data show no added benefit of covered SEMS; further stent evolution is desirable.

Temporary FC-SEMS for type II ERCP-related perforations: a case series from two referral centers and review of the literature.

BACKGROUND AND AIM: Some case reports have shown that fully covered self-expandable metal stents (FC-SEMS) are effective in cases of Stapfer Type II perforation as rescue treatment. The aim of the study was to assess the efficacy and safety of temporary placement of FC-SEMS as primary treatment for Type II perforations and review the literature regarding the use of FC-SEMS in this setting. PATIENTS AND METHOD: Retrospective analysis of consecutive patients with Type II perforation treated with immediate placement of FC-SEMS. Primary outcomes were need for surgery and mortality rate. Secondary outcomes were complications, technical and clinical success, time to post-operative feeding, length of the hospitalization and time to stent removal. RESULTS: Overall, 18 consecutive patients were enrolled (median age 71.5). All patients were treated with FC-SEMS (6-10 mm, 4-8 cm long). In all patients, there were no need for surgery, and no patient died. Technical and clinical success were achieved both in 100% of cases. The median time to stent removal was 43 (2-105) days. The median hospital stay was of 10 (4-21) days. Median time to post-operative feeding was 4 days (2-15). CONCLUSION: FC-SEMS placement could be a safe and effective treatment in Type II perforations and represent a valuable development and innovation of conservative treatment.

A Smooth Esophageal Stricture Causing Dysphagia.

Dysphagia in patients with lung cancer is usually due to direct invasion from bronchogenic carcinomas or nodal localizations, while metastases from distant lung neoplasms are considered rare. We report a case of a smooth esophageal narrowing secondary to intramural metastasis from pulmonary adenocarcinoma in a patient with no previous history of neoplasia. Since standard linear echoendoscope could not overpass the malignant stricture, we obtained a histological diagnosis by fine-needle aspiration biopsy using an echobronchoscope (EBUS), due to its lower diameter. The EBUS scope represents a valuable tool to obtain cytological specimens in patients with esophageal strictures.

Comparing intravenous and oral proton pump inhibitor therapy for bleeding peptic ulcers following endoscopic management: a systematic review and meta-analysis.

BACKGROUND AND AIMS: The efficacy of proton pump inhibitors (PPIs) has been demonstrated for bleeding peptic ulcers but the route of administration remains controversial. Several studies have demonstrated that high-dose oral PPIs are as effective as intravenous PPIs in reducing recurrent bleeding. However, current guidelines recommend intravenous PPIs after endoscopic treatment. Previous data based on numbers that were too small to enable a firm conclusion to be reached suggested that oral and intravenous PPIs had equivalent efficacy. We undertook a meta-analysis to compare oral and intravenous PPIs in patients with bleeding peptic ulcers after endoscopic management. METHODS: A literature search was undertaken using MEDLINE, EMBASE and the Cochrane Library, between 1990 and February 2016, to identify all randomized controlled trials (RCTs) that assessed the efficacy of PPIs administered by different routes. Nine RCTs, involving 1036 patients, were analysed. Outcomes were: recurrent bleeding, blood transfusion requirement, duration of hospital stay, a need for repeat endoscopy, surgery and 30-day mortality. RESULTS: There were no differences in the rebleeding rates [odds ratio (OR) 0.93, 95% confidence interval (CI) 0.60, 1.46; P = 0.77], need for surgery (OR 0.77, 95% CI 0.25, 2.40; P = 0.65), need for repeat endoscopy (OR 0.69, 95% CI 0.39, 1.21; P = 0.19), need for blood transfusion [(MD) -0.03, 95% CI -0.26, 0.19; P = 0.76], duration of hospital stay (MD -0.61, 95% CI -1.45, 0.23; P = 0.16) or 30-day mortality (OR 0.89, 95% CI 0.27, 2.43; P = 0.84) according to the route of administration. CONCLUSIONS: Oral PPIs represent better value for money, with clinical efficacy equivalent to intravenous PPIs.

Pancreatic Leaks and Fistulae: An Endoscopy-Oriented Classification.

BACKGROUND: Pancreatic leaks occur as a complication of upper gastrointestinal surgery, acute pancreatitis, or abdominal trauma. Pancreatic fistulas and leaks are primarily managed conservatively. Overall, conservative measures are successful in more than half of cases. Whenever conservative treatment is not efficient, surgery is usually considered the treatment of choice. Nowadays however, endoscopic treatment is being increasingly considered and employed in many cases, as a surgery sparing intervention. AIM: To introduce a classification of pancreatic fistulas according to the location of the leak and ductal anatomy and finally propose the best suited endoscopic method to treat the leak according to current literature. METHODS: We performed an extensive review of the literature on pancreatic fistulae and leaks. RESULTS: In this paper, we review the various types of leaks and propose a novel endoscopic classification of pancreatic fistulas in order to standardize and improve endoscopic treatment. CONCLUSIONS: A proper and precise diagnosis should be made before embarking on endoscopic treatment for pancreatic leaks in order to obtain prime therapeutic results. A multidisciplinary team of interventional endoscopists, pancreatic surgeons, and interventional radiologists is best suited to care for these patients.