TOP 100 and detection of colorectal lesions in colon capsule endoscopy: more than meets the eye.

Colon capsule endoscopy (CCE) is a well-known method for the detection of colorectal lesions. Nevertheless, there are no studies reporting the accuracy of TOP 100, a CCE software tool, for the automatic detection of colorectal lesions in CCE. We aimed to evaluate the performance of TOP 100 in detecting colorectal lesions in patients submitted to CCE for incomplete colonoscopy compared with classic reading. A retrospective cohort study including adult patients submitted to CCE (PillCam COLON 2; Medtronic) for incomplete colonoscopy. Blinded for each other's evaluation, one experienced reader analyzed the TOP 100 images and the other performed classic reading to identify colorectal lesions. Detection of colorectal lesions, namely polyps, angioectasia, blood, diverticula, erosions/ulcers, neoplasia, and subepithelial lesions was assessed and TOP 100 performance was evaluated compared with the gold standard (classic reading). A total of 188 CCEs were included. Prevalence of colorectal lesions, polyps, angioectasia, blood, diverticula, erosions/ulcers, neoplasia, and subepithelial lesions were 77.7, 54.3, 8.5, 1.6, 50.0, 0.5, 0.5, and 1.1%, respectively. TOP 100 had a sensitivity of 92.5%, specificity of 69.1%, negative predictive value of 72.5%, positive predictive value of 91.2%, and accuracy of 87.2% for detecting colorectal lesions. TOP 100 had a sensitivity of 89.2%, specificity of 84.9%, negative predictive value of 86.9%, positive predictive value of 87.5%, and accuracy of 87.2% in detecting polyps. All colorectal lesions other than polyps were identified with 100% accuracy by TOP 100. TOP 100 has been shown to be a simple and useful tool in assisting the reader in the prompt identification of colorectal lesions in CCE.

BEST-J Score: Validation of a Predicting Model for Delayed Bleeding After Gastric Endoscopic Submucosal Dissection on a European Sample.

BACKGROUND: Delayed bleeding (DB) is a possible adverse event following gastric endoscopic submucosal dissection (ESD). The BEST-J score was created as a risk prediction model for DB following gastric ESD, but is yet to be validated in Western populations. AIMS: We aimed to validate the BEST-J score on a European sample and to perform a subgroup analysis according to histological classification. METHODS: Retrospective study of all consecutive patients undergoing gastric ESD on a European Endoscopic Unit. DB was defined as hemorrhage with clinical symptoms and confirmed by emergency endoscopy from the time of completion to 28 days after ESD. BEST-J score was calculated in each patient and confronted with the outcome (DB). RESULTS: Final sample included 161 patients. From these, 10 (6.2%) presented DB following ESD, with a median time to bleeding of 7 days (IQR 6.8). BEST-J score presented an excellent accuracy predicting DB in our sample, with an AUC = 0.907 (95%CI 0.801-1.000; p < 0.001). Subgroup analysis by histological classification proved that the discriminative power was still excellent for each grade: low-grade dysplasia-AUC = 0.970 (p < 0.001); high-grade dysplasia-AUC = 0.874 (p < 0.001); early gastric cancer-AUC = 0.881 (p < 0.001). The optimal cut-off value to predict DB was a BEST-J score ≥ 3, which matches the cut-off value for high-risk of bleeding in the original investigation. CONCLUSIONS: The BEST-J score still presents excellent accuracy in risk stratification for post-ESD bleeding in European individuals. Thus, this score may help to guide which patients benefit the most from prophylactic therapies following gastric ESD in this setting.

Gastric dysplasia in random biopsies: the influence of Helicobacter pylori infection and alcohol consumption in the presence of a lesion.

BACKGROUND: Gastric dysplasia in the absence of an endoscopically defined lesion is rare, usually either a false positive diagnosis or a previously unidentified precancerous lesion during esophagogastroduodenoscopy (EGD). AIMS: Evaluate factors associated with the presence of an endoscopically visible lesion during follow-up in patients with histologic diagnosis of gastric dysplasia in random biopsies. METHODS: Retrospective cohort study including patients referred to our institution for gastric dysplasia in random biopsies during Index EGD. Endoscopic evaluation was performed with a high-definition endoscope using narrow band imaging (HD EGD-0). If no lesion was detected, endoscopic surveillance (HD EGD-FU) was conducted within 6 months for high grade dysplasia (HGD) or 12 months for low grade (LGD) or indefinite for dysplasia (IFD). RESULTS: From a total sample of 96 patients, 5 (5.2%) presented with an endoscopically visible lesion during HD EGD-0, while 10 lesions (10.4%) were identified during HD EGD-FU. Patients with Helicobacter pylori infection at Index EDG and with regular alcohol consumption (≥25 g/day) were 8 and 4 times more likely to have an endoscopically visible lesion on HD EGD-FU (p = 0.012 and p = 0.047). In binary logistic regression, both factors were independent predictors of the presence of gastric lesion on HD EGD-FU (OR 9.284, p = 0.009 and OR 5.025, p = 0.033). CONCLUSIONS: The presence of an endoscopically visible lesion after the histologic diagnosis of gastric dysplasia in random biopsies was more frequent during HD EGD-FU. H. pylori infection at Index EGD and regular alcohol consumption were significant predictors of the presence of gastric lesion on HD EGD-FU.

Predicting residual neoplasia after a non-curative gastric ESD: validation and modification of the eCura system in the Western setting: the W-eCura score.

OBJECTIVE: To evaluate the risk factors for lymph node metastasis (LNM) after a non-curative (NC) gastric endoscopic submucosal dissection (ESD) and to validate and eventually refine the eCura scoring system in the Western setting. Also, to assess the rate and risk factors for parietal residual disease. DESIGN: Retrospective multicentre multinational study of prospectively collected registries from 19 Western centres. Patients who had been submitted to surgery or had at least one follow-up endoscopy were included. The eCura system was applied to assess its accuracy in the Western setting, and a modified version was created according to the results (W-eCura score). The discriminative capacities of the eCura and W-eCura scores to predict LNM were assessed and compared. RESULTS: A total of 314 NC gastric ESDs were analysed (72% high-risk resection (HRR); 28% local-risk resection). Among HRR patients submitted to surgery, 25% had parietal disease and 15% had LNM in the surgical specimen. The risk of LNM was significantly different across the eCura groups (areas under the receiver operating characteristic curve (AUC-ROC) of 0.900 (95% CI 0.852 to 0.949)). The AUC-ROC of the W-eCura for LNM (0.916, 95% CI 0.870 to 0.961; p=0.012) was significantly higher compared with the original eCura. Positive vertical margin, lymphatic invasion and younger age were associated with a higher risk of parietal residual lesion in the surgical specimen. CONCLUSION: The eCura scoring system may be applied in Western countries to stratify the risk of LNM after a gastric HRR. A new score is proposed that may further decrease the number of unnecessary surgeries.

Decision-To-Scope Score: A novel tool with excellent accuracy in predicting foreign bodies in the esophagus.

INTRODUCTION: Foreign body (FB) ingestion is a common indication for urgent esophagogastroduodenoscopy (EGD). Nevertheless, most pass spontaneously through the gastrointestinal (GI) tract. Differently from GI bleeding, there is no validated score aiming to identify "low-risk" patients in suspected FB ingestion. We aimed to create a score able to discriminate patients who are candidates to emergent EGD in this scenario. METHODS: Retrospective study of consecutive patients admitted for suspected FB in the upper GI tract between 2016 and 2021. The evaluated outcome was endoscopic confirmation of FB in the esophagus. Variables significantly associated with the outcome on multivariate analysis were computed into a score predicting endoscopic confirmation. RESULTS: We included 228 patients. From these, 97 (42.5%) had a confirmed FB in EGD. Time since ingestion <6 h (OR = 4.0; P = 0.042), absence of any meal after FB ingestion (OR = 7.1; P = 0.005), dysphagia (OR = 11.8; P < 0.001), odynophagia (OR = 4.6; P = 0.004), and drooling (OR = 15.1; P < 0.001) were independent predictors of confirmed FB. These variables were used to compute a FB predicting score-the Decision-To-Scope (DTS) Score: time since ingestion <6 h (+1 point), absence of meals (+2 points), dysphagia (+3 points), odynophagia (+1 point), and drooling (+4 points). DTS-Score had excellent accuracy to predict the outcome (AUC = 0.953; 95%CI = 0.928-0.977; P < 0.001). The optimal cutoff to identify low-risk patients was a score ≤5 (sensitivity 85.0% and specificity 94.7%). CONCLUSIONS: More than half of the suspected FB were not confirmed by EGD. The DTS-Score presented excellent accuracy at stratifying patients' risk and may contribute to the decision to perform emergent EGD in suspected FB ingestion.

A "new" option in Helicobacter pylori eradication: High-dose amoxicillin dual therapy outperforms bismuth quadruple therapy in a high dual resistance setting.

BACKGROUND: Currently, bismuth quadruple therapy (BQT) is indicated as a first-line treatment for Helicobacter pylori eradication in areas with high dual metronidazole and clarithromycin resistance, with its use being limited by its low tolerability and significant cost. A novel regimen with high-dose amoxicillin dual therapy (HDADT) has emerged as an alternative. The aim of this study was to compare the results of these two treatments on HP eradication. MATERIALS AND METHODS: Prospective randomized study including 100 consecutive patients undergoing H. pylori eradication. Each patient was randomized (in a 1:1 ratio) to one group of treatment: BQT (bismuth 140 mg + metronidazole 125 mg + tetracycline 125 mg, four times a day, for 10 days) or HDADT (amoxicillin 1000 mg alternating with amoxicillin 500 mg, four times a day, for 14 days), both associated with esomeprazole 40 mg twice a day. The primary aim was to compare treatments' efficacies. Secondary aims were to assess symptoms persistence and tolerability. RESULTS: A total of 100 patients were included, 54% women, with a mean age of 55 ± 14 years. From these, five were lost to follow-up. Effective eradication proven by negative stool antigen test was significantly higher in patients randomized to HDADT when compared to BQT for both intention-to-treat (ITT) (96.2% vs. 81.4%; p = .022) and per-protocol (PP) (95.9% vs. 81%; p = .025) analysis. These differences were even more pronounced when only considering second line treatment (100% vs. 62.5%; p = .028). Side effects did not differ significantly between BQT and HDADT groups for both ITT (7.0% vs. 2.0%; p = .254) and PP (4.8% vs. 0%; p = .210) analysis. CONCLUSIONS: When compared to BQT, treatment with HDADT presented higher and near 100% efficacy in eradicating H. pylori, without differences in reported side effects or compliance. This treatment represents an important alternative for populations with increasing incidences of resistance to the currently recommended antibiotic regimens.

Real-life patency of plastic biliary stents in the pandemic era: is stent removal after 6 months safe and effective?

BACKGROUND: The SARS-CoV-2 pandemic conditioned the optimal timing of some endoscopic procedures. ESGE guidelines recommend replacement or removal of the plastic biliary stents within 3-6 months to reduce the risk of complications. Our aim was to analyse the outcomes of patients who had delayed plastic biliary stent removal following endoscopic retrograde cholangiopancreatography (ERCP) in the pandemic era. METHODS: Retrospective study including consecutive ERCPs with plastic biliary stent placement between January 2019 and December 2021. Delayed removal was defined as presence of biliary stent >6 months after ERCP. The evaluated outcomes were stent migration, stent dysfunction, obstructive jaundice, cholangitis, acute pancreatitis, hospitalization, and biliary pathology-related mortality. RESULTS: One-hundred and twenty ERCPs were included, 56.7% male patients, with a mean age of 69.4 ± 15.7 years. Indications for plastic biliary stent insertion were choledocholithiasis (72.5%), benign biliary stricture (20.0%), and post-cholecystectomy fistula (7.5%). Delayed stent removal occurred in 32.5% of the cases. The median time to stent removal was 3.5 ± 1.3 months for early removal and 8.6 ± 3.1 months for delayed removal. Patients who had delayed stent removal did not have a significantly higher frequency of stent migration (20.5 vs 11.1%, p = 0.17), stent dysfunction (17.9 vs 13.6%, p = 0.53), hospitalization (17.9 vs 14.8%, p = 0.66), obstructive jaundice (2.6 vs 0.0%, p = 0.33), cholangitis (10.3 vs 13.6%, p = 0.77), acute pancreatitis (0.0 vs 1.2%, p = 1.0), or biliary pathology-related mortality (2.6 vs 1.2%, p = 0.55). CONCLUSIONS: Delayed plastic biliary stent removal does not seem to have a negative impact on patients' outcomes. In the current pandemic situation, while scheduled endoscopic procedures may have to be postponed, elective removal of plastic biliary stents can be safely deferred.

Gastrostomy Button Diameter and Length Variations after Percutaneous Endoscopic Gastrostomy: One Size Does Not Fit All.

BACKGROUND: Percutaneous endoscopic gastrostomy (PEG) is a useful option for long-term enteral nutrition. Low-profile gastrostomy tubes ("buttons") may afterward be placed in the stomach through the abdominal wall following maturation of the preexisting ostomy. Regular verification is essential since inadequate sizing is associated with accidental exteriorization or food leakage. We aimed to evaluate gastrostomy buttons diameter or length variations on the first year after their placement and possible factors associated with these variations. METHODS: We analyzed consecutive PEGs between 2016 and 2018. A minimum follow-up of 12 after gastrostomy button placement was required. Diameter or length variations were assessed in a specialized PEG appointment during the follow-up period. RESULTS: Final sample included 94 patients, from which 65 (69.1%) were women, and 29 (30.9%) were men, with a mean age of 76.9 ± 13.3 years. Measurements variations occurred in 44 (46.8%) patients. Diameter variation was significantly more frequent in patients living in a nursing home (OR = 5.43; 95% CI = 1.32-22.27; p = 0.019), patients with previous PEG tube dislodgement (OR = 3.84; 95% CI = 1.21-12.20; p = 0.023), and male patients (OR = 3.50; 95% CI = 1.06-11.49, p = 0.039). Length variation occurred more frequently in patients with a weight change during the follow-up period greater than 5 kg (OR = 3.71; 95% CI = 1.14-12.05; p = 0.029). CONCLUSIONS: A significant proportion of patients with gastrostomy buttons required a change in their measurements, especially if male, living in nursing homes, having significant weight changes, or accidental tube exteriorization. This emphasizes the importance of having a specialized PEG appointment to regularly assure the best fitted button for each patient and ultimately guarantee an adequate nutritional intake.

Small Bowel CLEansing Assessment and Report (SB-CLEAR): Standardizing bowel preparation report in capsule endoscopy.

BACKGROUND AND AIM: Small-bowel (SB) cleansing is crucial to assess the reliability of capsule endoscopy (CE) findings. However, the presence of multiple grading systems is hampering their use in clinical practice. In 2020, Colon CLeansing Assessment and Report (CC-CLEAR) was created and validated. We sought to develop and validate a new score for the evaluation of the SB cleansing, adapted from CC-CLEAR, aiming to standardize CE reporting regarding the quality of preparation. METHODS: The new grading score, SB CLeansing Assessment and Report (SB-CLEAR), divided the SB into three tertiles, each being scored depending on the percentage of visualized mucosa (0, < 50%; 1, 50%-75%; 2, > 75%; 3, > 90%). The overall classification was a sum of each segment score, graded between excellent, good, and inadequate (0-5). Any segment scoring ≤1 resulted in inadequate overall classification. CE videos were prospectively evaluated by two experienced CE readers blinded to each other. RESULTS: We included 52 CEs, 41(78.8%) female, with a mean age of 57.9 ± 17.9 years. Inter-observer agreement was very strong for each tertile (first: r = 0.863; second: r = 0.865; third: r = 0.861; P < 0.001), which resulted in overall excellent correlation when considering the quality of preparation in all tertiles (r = 0.940; P < 0.001). By applying final classifications of "inadequate," "good," and "excellent," correlation between observers was also very strong (r = 0.875; P < 0.001). CONCLUSIONS: SB-CLEAR is an innovative and reproducible grading score for evaluation of SB preparation quality in CE, with overall excellent inter-observer agreement. Along with CC-CLEAR, this may become a valuable tool to uniformize reporting of bowel preparation quality in CE.

Stepping it up: Physical activity is associated with a lower incidence of prolonged gastric transit time in capsule endoscopy.

BACKGROUND AND AIM: Physical activity has been proposed as a potential factor influencing capsule endoscopy (CE) gastric transit time (GTT). However, there is no reported factual evidence confirming this association. We aimed to prospectively assess the effect of physical activity in the first hour of CE in the occurrence of prolonged GTT. METHODS: This is a prospective study including consecutive patients undergoing CE. For each patient, a step counter was attached to the CE register. The number of steps during the first hour of the procedure was registered. The main outcome was prolonged GTT (CE remaining in the stomach for > 1 h). Outcomes were adjusted for possible confounders by multivariate analysis. RESULTS: We included 100 patients, 60% undergoing small bowel CE and 40% colon CE. The mean number of steps in the first hour was significantly lower in patients with prolonged GTT (2009 ± 1578 steps) comparatively with those without prolonged GTT (3597 ± 1889 steps) (P < 0.001). On multivariate analysis including significant confounders, steps in the first hour were an independent predictor of prolonged GTT (P = 0.018). Single-handedly, the number of steps taken in the first hour had a good acuity for predicting prolonged GTT (area under the curve = 0.74; P < 0.001), with an optimal cut-off of 2000 steps (sensitivity 81.3% and specificity 70%). CONCLUSIONS: Physical activity during the first hour of CE significantly decreased the occurrence of prolonged GTT. These findings pave the way for further definition of clear instructions to give to patients undergoing CE.

Humoral Immunogenicity After Vaccination Against SARS-CoV-2 Infection in Inflammatory Bowel Disease Patients Under Immunosuppressive Therapy: Should We Prioritize an Additional Booster Injection?

BACKGROUND: Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection may lead to the development of the novel coronavirus disease (coronavirus disease 2019 [COVID-19]). Scarce data are available regarding safety and efficacy of SARS-CoV-2 vaccination in inflammatory bowel disease (IBD) patients, which may present differences between subgroups. Lower humoral immunological response could require additional booster injections. METHODS: This is a prospective study including adult patients with IBD after complete vaccination against SARS-CoV-2 infection with BioNTech vaccine. Patients with previous SARS-CoV-2 infection were excluded. A control group with healthy individuals matched for age and sex was also analyzed. Blood samples were collected 30 days after complete vaccination to quantify immunoglobulin G (IgG) antibody titers against SARS-CoV-2 in both groups. RESULTS: The final sample included 81 IBD and 32 non-IBD patients, 55 (48.7%) of them women, with a mean age of 40.2 ±â€…13.0 years. From IBD patients, 58 (71.6%) had Crohn's disease and 23 (28.4%) had ulcerative colitis. IBD patients had significantly lower median anti-SARS-CoV-2 IgG levels when compared with the control group (6479 [interquartile range (IQR) 1830-11883, 10 053] AU/mL vs 13 061 [IQR 2826-21427, 15 539] AU/mL; P = .003). Regarding IBD medication, significant lower levels of SARS-CoV-2 IgG antibodies when compared with control subjects were observed in patients treated with thiopurines (5423 [IQR 3109-13369, 10 260] AU/mL; P = .011), methotrexate (834 [IQR 507-3467, 4155] AU/mL; P = .002), anti-tumor necrosis factor α agents (5065 [IQR 1033-11669, 10 636] AU/mL; P = .001), and corticosteroids (548 AU/mL; P = .001). The incidence of SARS-CoV-2 infection after vaccination was also significantly higher in patients treated with these agents. CONCLUSIONS: IBD patients treated with immunomodulators, anti-tumor necrosis factor α agents and corticosteroids presented significantly lower anti-SARS-CoV-2 IgG levels following complete vaccination when compared with healthy control subjects. These findings support the benefit of additional booster injections in this population.

This is a prospective study quantifying antibody titers against severe acute respiratory syndrome coronavirus 2 after complete vaccination in adult patients with inflammatory bowel disease. Immunomodulators, infliximab, and corticosteroid treatment were associated with lower antibody levels. This could support the benefit of an additional booster injection in this population.

The New FibroScan-AST (FAST) Score: Enhancing Diabetes Mellitus Impact on Metabolic-Associated Fatty Liver Disease.

Background: Metabolic-associated fatty liver disease (MAFLD) is an increasingly prevalent cause of chronic liver disease. In 2020, the FibroScan-AST (FAST) score was internationally validated as a new tool able to identify patients with steatohepatitis who benefit the most from further therapies, based on liver transient elastography (LTE) findings and serum levels of aspartate aminotransferase (AST). We aimed to identify, in MAFLD patients, which metabolic features may predict a higher FAST score. Methods: Retrospective study of consecutive patients with MAFLD submitted to LTE for two consecutive years. Patients without an AST sample collected within 6 months of the LTE were excluded. FAST score was calculated, stratifying the patient's risk as low (<0.35), medium (0.35-0.67), or high (>0.67). Results: The sample included 117 patients, 53.0% of the female gender, with a mean age of 53 years. On multivariate analysis, patients with type 2 diabetes (T2DM) (p < 0.001), dyslipidemia (p = 0.046), and smoking habits (p = 0.037) presented with significantly higher FAST score values. Furthermore, diabetic patients did not only present significantly higher FAST scores but were also more frequently assigned to the high-risk group according to FAST score criteria (OR = 9.2; 95% CI = 1.8-45.5; p = 0.007). Conclusions: Calculating the FAST score, patients with T2DM presented a significantly higher risk of having significant fibrosis and steatohepatitis. Physicians may rely on this validated instrument to more easily identify which patients with T2DM and MAFLD benefit the most from a specialized follow-up.

Introdução: O figado gordo associado a disfuncao metabolica (FGADM) e uma causa crescente de doenca hepatica cronica. Em 2020, o score Fibroscan-AST (FAST) foi validado internacionalmente como uma nova ferramenta capaz de identificar pacientes com esteatohepatite que beneficiam de terapeuticas adicionais, baseado nos achados da elastografia hepatica transitoria (EHT) e niveis sericos de aspartato aminotransferase (AST). Os autores procuraram identificar, em pacientes com FGADM, que fatores metabolicos predizem um score-FAST maior. Métodos: Estudo retrospetivo de pacientes com FGADM submetidos a EHT durante 2 anos consecutivos. Pacientes sem uma amostra de AST colhida nos 6 meses previos a EHT foram excluidos. O score-FAST foi calculado, estratificando o risco do paciente como baixo (<0,35), moderado (0,35-0,67) ou alto (>0,67). Resultados: A amostra incluiu 117 pacientes, 53% do sexo feminino, com uma idade media de 53 anos. Em analise multivariada, pacientes com Diabetes Mellitus tipo 2 (DMT2) (p < 0,001), dislipidemia (p = 0,046) e habitos tabagicos (p = 0,037) apresentaram valores de score-FAST significativamente maiores. Alem disso, os pacientes diabeticos apresentaram nao so valores de score-FAST significativamente maiores, como tambem foram mais frequente classificados como pertencendo ao grupo de alto risco, de acordo com os criterios deste score (OR = 9,2; 95%IC = 1,8­45,5; p = 0,007). Conclusões: Calculando o score-FAST, pacientes com FGADM e DMT2 apresentaram um risco significativamente maior. Esta ferramenta validada podera ser utilizada para selecionar os pacientes com DMT2 e FGADM que poderao beneficiar de seguimento especializado.

Inter/Intra-Observer Agreement in Video-Capsule Endoscopy: Are We Getting It All Wrong? A Systematic Review and Meta-Analysis.

Video-capsule endoscopy (VCE) reading is a time- and energy-consuming task. Agreement on findings between readers (either different or the same) is a crucial point for increasing performance and providing valid reports. The aim of this systematic review with meta-analysis is to provide an evaluation of inter/intra-observer agreement in VCE reading. A systematic literature search in PubMed, Embase and Web of Science was performed throughout September 2022. The degree of observer agreement, expressed with different test statistics, was extracted. As different statistics are not directly comparable, our analyses were stratified by type of test statistics, dividing them in groups of "None/Poor/Minimal", "Moderate/Weak/Fair", "Good/Excellent/Strong" and "Perfect/Almost perfect" to report the proportions of each. In total, 60 studies were included in the analysis, with a total of 579 comparisons. The quality of included studies, assessed with the MINORS score, was sufficient in 52/60 studies. The most common test statistics were the Kappa statistics for categorical outcomes (424 comparisons) and the intra-class correlation coefficient (ICC) for continuous outcomes (73 comparisons). In the overall comparison of inter-observer agreement, only 23% were evaluated as "good" or "perfect"; for intra-observer agreement, this was the case in 36%. Sources of heterogeneity (high, I2 81.8-98.1%) were investigated with meta-regressions, showing a possible role of country, capsule type and year of publication in Kappa inter-observer agreement. VCE reading suffers from substantial heterogeneity and sub-optimal agreement in both inter- and intra-observer evaluation. Artificial-intelligence-based tools and the adoption of a unified terminology may progressively enhance levels of agreement in VCE reading.

The Prediction of Inadequate Colon Capsule Cleansing: A Cohort Selection Guided by CC-CLEAR.

Introduction: In order to optimize the rate of adequate cleansing in colon capsule, it may be important to identify risk factors that can predict a suboptimal colon preparation. Aim: To define predictive factors for inadequate bowel preparation in colon capsule, according to CC-CLEAR (Colon Capsule CLEansing Assessment and Report). Methods: Retrospective, single center, cohort study. Patients' demographics, data, and quality of bowel preparation, according to CC-CLEAR, were collected retrospectively. A univariate analysis tested the association between covariables and the outcome, inadequate cleansing. The statistically significant variables were included in multivariable logistic binary regression, and a receiver operating characteristic curve (ROC) assessment was performed. Results: We included 167 consecutive colon capsules. Sixty-eight percent (n = 114) of patients were female, with a mean age of 64 years. The main indication for colon capsule was previous incomplete colonoscopy, in 158 patients (94.6%). The colon capsules cleansing was graded as good or excellent in 96 patients (57.5%) and as inadequate in 71 (42.5%), according to CC-CLEAR. The variables inadequate previous colon cleansing (OR adjusted 41.72 [95% CI 12.57-138.57], p value < 0.001); chronic laxative (OR adjusted 4.86 [95% CI 1.08-21.79], p value = 0.039); antidepressant (OR adjusted 5.00 [95% CI 1.65-15.16], p value = 0.004), and impaired mobility (OR adjusted 5.54 [95% CI 1.17-26.31], p value = 0.031) were independently associated with the outcome inadequate cleansing, after adjusting for confoundment. The model presented an excellent discriminative power towards the outcome variable (AUC ROC 0.937 [CI 95% 0.899-0.975], p value < 0.001). Conclusion: A previous inadequate colon cleansing, the use of chronic laxative and antidepressant, or impaired mobility are predictors of inadequate colon capsule cleansing, as assessed by the CC-CLEAR. These 4 predictors come together as a model enabling an accurate categorization of the patients at major risk of inadequate bowel preparation for capsule colonoscopy, with an excellent discriminative power and performance, which seems useful for the selection of patients for tailored optimization of the colon cleansing protocol.

Introdução: Com o intuito de otimizar a taxa de preparações intestinais adequadas em cápsula do cólon, poderá ser importante identificar fatores de risco preditivos de preparações sub-ótimas. Objetivo: Definir fatores preditivos de preparação intestinal inadequada em cápsula do colon, de acordo com a CC-CLEAR (Colon Capsule CLEansing Assessment and Report). Métodos: Estudo de coorte retrospetivo, no qual as variáveis demográficas, clínicas e a qualidade de preparação intestinal, de acordo com a CCCLEAR, foram colhidas retrospetivamente. Uma análise univariada testou a associação entre as covariáveis e a variável outcome ­ preparação intestinal inadequada. As variáveis estatisticamente significativas foram incluídas num modelo de regressão logística binária e performance testada com a realização de curva ROC. Resultados: Incluímos 167 cápsulas do colon consecutivas. Sessenta e oito por cento (n = 114) eram do sexo feminino, com idade média de 64 anos. A principal indicação para cápsula do colon foi uma colonoscopia prévia incompleta, em 158 indivíduos (94.6%). As preparações intestinais em cápsula do colon foram classificadas como boas ou excelentes em 96 indivíduos (57.5%) e como inadequadas em 71 (42.5%), de acordo com a CC-CLEAR. As variáveis preparação cólica prévia inadequada [OR ajustado 41.72 (95% CI 12.57­138.57) valor p < 0.001]; uso crónico de laxante [OR ajustado 4.86 (95% CI 1.08­21.79) valor p = 0.039]; antidepressivo [OR ajustado 5.00 (95% CI 1.65­15.16) valor p = 0.004] e défice de mobilidade [OR ajustado 5.54 (95% CI 1.17­26.31) valor p = 0.031] foram independentemente associadas ao outcome, preparação intestinal inadequada, após o ajuste para o confundimento. O modelo apresentou um excelente poder discriminativo em relação ao outcome [AUC ROC 0.937 (CI95% 0.899­0.975) valor p < 0.001]. Conclusão: Uma preparação cólica prévia inadequada, o uso crónico de laxantes e antidepressivos e um défice de mobilidade são preditores de preparação intestinal inadequada em cápsula do cólon, de acordo com a CC-CLEAR. Estas 4 variáveis formam um modelo que permite a categorização, com excelente acuidade, de indivíduos com risco elevado para preparação intestinal inadequada em cápsula do colon, o que parece ser útil para uma otimização caso a caso do protocolo de preparação intestinal.

Endoscopic submucosal dissection: a country dissemination experience and outcomes.

OBJECTIVE: An increasing use of endoscopic submucosal dissection (ESD) has been reported in Western countries, although some differences in training schemes and outcomes have been described. We aimed to report the training model, implementation, and outcomes of ESD in Portugal. METHODS: All endoscopists trained at our center from our country (n = 9) were invited to a survey regarding: (a) training period; (b) ESD outcomes and (c) implementation of ESD in each respective center. RESULTS: All endoscopists completed the survey. Learning ESD was centered on human ESD assistance in a high-volume center during a median time of 6 months and complemented mainly by hands-on courses (89%). During the surveyed period, a total of 1229 ESD were performed, mostly in gastric locations (74%). Median complete R0 and curative resection rate were 92% (IQR, 81-96.8) and 87% (IQR, 74-93.3), respectively, and median perforation rate was 0.89% (IQR, 0.25-6.22). The main limitations encountered during the implementation of ESD were related to the lack of initial mentoring or insufficient expertise to progress to more difficult lesions. CONCLUSION: Learning ESD through participation in hands-on courses and visiting high-volume centers seems to be adequate to achieve a good competence at the initial stage of ESD, which in fact is in consonance with the European Society of Gastrointestinal Endoscopy recommendations. However, mentoring is essential for technical progression, and this represents the fundamental barrier during the adoption of ESD, which may be overcome by increasing hands-on training in animal or artificial simulators, but preferably with the implementation of a structured training program.

Prognostic scores in post-endoscopic retrograde cholangiopancreatography acute pancreatitis: should we use all, some, or none?

BACKGROUND/AIMS: Acute pancreatitis is the most commonly observed adverse event following endoscopic retrograde cholangiopancreatography (ERCP). Early risk stratification is crucial in the management of these patients, to reduce unfavorable outcomes. Multiple prognostic scores are already used in acute pancreatitis, regardless of its etiology. Scarce data is available for their use specifically on post-ERCP acute pancreatitis (PEP). We aimed to compare the accuracy of different prognostic scores at PEP diagnosis for the prediction of a moderate-to-severe course. METHODS: Cross-sectional study of consecutive ERCPs performed between 2010 and 2020. The final sample included patients with PEP, with the severity graded according to the Atlanta classification. For each patient, different prognostic scores were calculated. Each score's accuracy for the prediction of a moderate-to-severe course was assessed by analysis of receiving-operating-characteristics (ROC) curves. RESULTS: From 2012 ERCPs, 102 (5.1%) were complicated by PEP. From these, 34 (1.7% of all ERCPs) were classified as moderate-to-severe. The scores with the best accuracy in predicting a moderate-to-severe course were the BISAP [ area under curve (AUC) = 0.92], Balthazar (AUC = 0.89) and Glasgow-Imrie (AUC = 0.88) scores, with very good to excellent acuities. APACHE II (AUC = 0.81), Marshall score (AUC = 0.81) and PANC3 score (AUC = 0.76) revealed good accuracies. Ranson's criteria on admission (AUC = 0.70) and HAPS classification (AUC = 0.67) presented less accurate results. Optimal cutoffs for the top scoring classifications were BISAP ≥3 (sensitivity 88.3% and specificity 83.8%), Balthazar ≥2 (sensitivity 84.8% and specificity 85.3%) and Glasgow-Imrie ≥4 (sensitivity 81.0% and specificity 82.6%). CONCLUSION: BISAP, Balthazar and Glasgow-Imrie classifications presented the best results for predicting moderate-to-severe PEP, and represent the most useful prognostic scores for risk stratification in this population.

Multifocal Colonic Ulcerations: An Unusual Presentation of Mucosa-Associated Lymphoid Tissue (MALT) Lymphoma.

Introduction: Mucosa-associated lymphoid tissue (MALT) lymphoma is relatively uncommon and accounts for only 5% of all non-Hodgkin lymphomas. The most common site of extranodal involvement is the gastrointestinal (GI) tract, with most cases affecting the stomach (up to 75% of all GI MALT lymphomas). Colonic disease occurs in only 2.5% of cases, most commonly manifesting as a single polypoid lesion on endoscopic evaluation. Case Presentation: We present the case of a 61-year-old woman whose colonoscopy (after a positive fecal occult blood test as part of colorectal cancer screening) revealed superficially ulcerated pseudo-polypoid lesions in the ascending proximal colon and hepatic flexure; microscopical and immunohistochemical analysis of the tissue sample was compatible with MALT lymphoma. Staging computed tomography showed concomitant nodular pulmonary lesions, the largest being located in the superior left lobe and 34 mm in size. Due to the disseminated state of the disease, systemic treatment with bendamustine and rituximab was initiated. Up to the time of submitting this paper, the patient was still asymptomatic and under chemotherapy treatment. Conclusion: With this case report, we aim to demonstrate the diversity of presentation of MALT lymphoma as well as its less typical locations; gastroenterologists should have an awareness of these and a low suspicion threshold.

Introdução: O linfoma de tecido linfoide associado à mucosa (MALT) é relativamente incomum, representando5% de todos os linfomas não-Hodgkin. O local de envolvimento extra-nodal mais comum é o trato gastrointestinal, com a maioria dos casos a afetar o estômago (até 75% de todos os linfomas de MALT gastrointestinais). O envolvimento primário do cólon ocorre apenas em 2.5% dos doentes, sendo mais comummente observado como lesão polipoide única em avaliação endoscópica. Apresentação de caso: Apresentamos o caso de uma mulher de 61 anos, cuja colonoscopia após pesquisa de sangue oculto nas fezes positiva evidenciou lesões pseudo-polipoides superficialmente erosionadas no cólon ascendente proximal e no ângulo hepático. A análise histológica (microscópica e imunohistoquímica) de ambas as lesões foi concordante e compatível com linfoma de MALT. A tomografia computorizada de estadiamento revelou lesões nodulares pulmonares concomitantes, a maior localizada no lobo superior esquerdo com cerca de 34 mm. Devido ao estado disseminado da doença, a doente foi proposta para terapêutica sistémica com bendamustina e rituximab.À data de submissão deste caso, a doente continuava assintomática e sob tratamento com quimioterapia. Conclusão: Com este caso clínico pretendemos salientar a diversidade de apresentações possíveis no linfoma de MALT, bem como as suas localizações mais atípicas para as quais todos os gastroenterologistas devem estar atentos e com baixo limiar de suspeição.

NSAIDs are not enough - a double blinded randomized controlled trial on the impact of intensive hydration for the prevention of post-endoscopic retrograde cholangiopancreatography pancreatitis.

BACKGROUND: Pancreatitis is the most common complication following endoscopic retrograde cholangiopancreatography (ERCP). In patients receiving NSAID prophylaxis, we aimed to assess whether periprocedural intensive hydration (IH) resulted in a lower incidence of PEP when compared to standard hydration (SH). MATERIAL AND METHODS: Prospective, single-center, double-blinded randomized controlled trial, with inclusion of consecutive patients submitted to inaugural ERCP between January 2015 and December 2018. Patients were randomized on admission, in a 1:1 ratio, to either SH-Ringer's Lactate (RL) at a rate of 1.5 mL/kg/h during and for 8 h following the procedure, or IH-RL at a rate of 3 mL/kg/h during and for 8 h following the procedure, with an additional bolus of 20 mL/kg at the end of the procedure. PEP incidence and severity were assessed according to the Atlanta Guidelines. RESULTS: A total of 155 patients were randomized (83 to IH, 72 to SH). PEP was observed in 8,4% (n = 13) of the patients, and was significantly less frequent in IH patients when compared to SH (3,6% vs 13,9%, P = 0,021; relative risk 0.233 [95% IC, 0.061-0.881]); five patients in the SH group developed moderate to severe PEP, in contrast to 0 patients in the IH group (6.9% vs 0.0%, P = 0,020). CONCLUSIONS: Intensive hydration significantly decreased the risk of post-ERCP pancreatitis by four-fold. Moreover, no cases of moderate or severe pancreatitis were observed in patients submitted to this intervention. Associated with nonsteroidal anti-inflammatory drugs, intensive hydration could constitute a new standard of care for patients undergoing ERCP.