COLD SNARE POLYPECTOMY: A SAFE PROCEDURE FOR REMOVING SMALL NON-PEDUNCULATED COLORECTAL LESIONS.

BACKGROUND: Polypectomy is an important treatment option for preventing colorectal cancer. Incomplete polyp resection (IPR) is re-cognized as a risk factor for interval cancer. OBJECTIVE: The primary objective was to evaluate the complete polyp resection (CPR) rate for cold snare polypectomy (CSP) in small non-pedunculated polyps and, secondarily, specimen retrieval and complication rates. METHODS: We prospectively evaluated 479 polyps <10 mm removed by CSP in 276 patients by an inexperienced endoscopist. RESULTS: A total of 476 polyps (99.4%) were resected en bloc. A negative margin (classified as CPR) was observed in 435 polyps (90.8%). An unclear or positive margin (classified as IPR) was observed in 43 cases (9.0%) and 1 case (0.2%), respectively, for an overall IPR rate of 9.2% (44/479). The IPR rate was 12.2% in the first half of cases and 5.9% in the second half (P=0.02). Dividing into tertiles, the IPR rate was 15.0% in the first tertile, 6.9% in the second tertile, and 5.7% in the third tertile (P=0.01). Dividing into quartiles, the IPR rate was 15.8% in the first quartile and 5.9% in the fourth quartile (P=0.03). The IPR rate was 6.3% for type 0-IIa lesions and 14.1% for type 0-Is lesions (P=0.01). For serrated and adenomatous lesions, the IPR rate was 9.2%. Specimen retrieval failed in 3.6% of cases. Immediate bleeding (>30 s) occurred in 1 case (0.2%), treated with argon plasma coagulation. No delayed bleeding or perforation occurred. CONCLUSION: CSP is a safe technique that provides good results for the resection of small non-pedunculated polyps, with a short learning curve.

Polipectomia a frio: um procedimento seguro para remover pequenas lesões colorretais não pediculadas / Cold snare polypectomy: a safe procedure for removing small non-pedunculated colorectal lesions

ABSTRACT Background: Polypectomy is an important treatment option for preventing colorectal cancer. Incomplete polyp resection (IPR) is re­cognized as a risk factor for interval cancer. Objective: The primary objective was to evaluate the complete polyp resection (CPR) rate for cold snare polypectomy (CSP) in small non-pedunculated polyps and, secondarily, specimen retrieval and complication rates. Methods: We prospectively evaluated 479 polyps <10 mm removed by CSP in 276 patients by an inexperienced endoscopist. Results: A total of 476 polyps (99.4%) were resected en bloc. A negative margin (classified as CPR) was observed in 435 polyps (90.8%). An unclear or positive margin (classified as IPR) was observed in 43 cases (9.0%) and 1 case (0.2%), respectively, for an overall IPR rate of 9.2% (44/479). The IPR rate was 12.2% in the first half of cases and 5.9% in the second half (P=0.02). Dividing into tertiles, the IPR rate was 15.0% in the first tertile, 6.9% in the second tertile, and 5.7% in the third tertile (P=0.01). Dividing into quartiles, the IPR rate was 15.8% in the first quartile and 5.9% in the fourth quartile (P=0.03). The IPR rate was 6.3% for type 0-IIa lesions and 14.1% for type 0-Is lesions (P=0.01). For serrated and adenomatous lesions, the IPR rate was 9.2%. Specimen retrieval failed in 3.6% of cases. Immediate bleeding (>30 s) occurred in 1 case (0.2%), treated with argon plasma coagulation. No delayed bleeding or perforation occurred. Conclusion: CSP is a safe technique that provides good results for the resection of small non-pedunculated polyps, with a short learning curve.

RESUMO Contexto: A polipectomia é uma importante opção terapêutica na prevenção do câncer colorretal (CCR). A ressecção incompleta do pólipo (RIP) é reconhecida como fator de risco para o câncer de intervalo. Objetivo: O principal objetivo foi avaliar o índice de ressecção completa da polipectomia a frio (PF) em pequenos pólipos não pediculados e, secundariamente, a recuperação do espécime e índice de complicações. Métodos: Avaliamos prospectivamente 479 pólipos <10 mm removidos por PF em 276 pacientes, por um endoscopista sem experiência com este método. Resultados: Foram ressecados em bloco 476 pólipos (99,4%). Tivemos margem negativa, considerada ressecção completa do pólipo (RCP), em 435 (90,8%) casos. Margem indefinida ou positiva (classificada como RIP) foi observada em 43 (9,0%) casos e em 1 (0,2%) caso, respectivamente, com um índice global de RIP de 9,2% (44/479). O índice de RIP foi de 12,5% na primeira metade dos casos e 5,9% na última metade (P=0,02). Dividindo em tercis, o índice de RIP foi de 15,0% no primeiro terço, 6,9% no segundo terço e 5,7% no terceiro quarto, P=0,01. Dividindo em quartis, o índice de RIP foi de 15,8% no primeiro quarto, enquanto o último quarto foi de 5,9%, P=0,03. O índice de RIP foi de 6,3% para lesões tipo 0-IIa e de 14,1% para lesões tipo 0-Is, P=0,01. O índice de RIP foi de 9,2% para lesões serrilhadas e adenomatosas. Houve falha na recuperação dos espécimes em 3,6% dos casos. Sangramento imediato (>30 s) ocorreu em um caso (0,2%), controlado com plasma de argônio. Sem sangramento tardio e perfuração. Conclusão: PF é uma técnica segura que apresenta bons resultados para a ressecção de pequenas lesões não pediculadas, com uma curta curva aprendizado.

Antral plexiform fibromyxoma: case report of a rare mesenchymal neoplasm

Plexiform fibromyxoma (PF) is a rare mesenchymal neoplasm of the stomach usually arising in the gastric antrum, and its main differential diagnosis is gastrointestinal stromal tumor. Most common symptoms are hematemesis, anemia. Immunohistochemically, positivity for smooth muscle actin (SMA) and vimentin suggests the diagnosis of PF. We report the case of a 56-year-old female patient with a 30- day history of nausea at presentation 4 years ago. Gastroscopy at that time revealed a subepithelial lesion (SEL) in the gastric antrum, measuring approximately 20 mm in diameter, with leakage of serous fluid after biopsy. Histopathology showed only an inflammatory process. Follow-up gastroscopies were performed 24, 36, and 48 months later, with surveillance biopsy at each follow-up. The last gastroscopies showed changes in lesion appearance, reduction in size, and absence of fluid leakage. Histopathology showed bland spindle cell proliferation, with a vaguely plexiform/multinodular pattern, in a fibromyxoid stroma with an arborizing capillary network without mitoses. The tumor cells were positive for SMA and negative for DOG1, CD117, CD34, S100, desmin, EMA, CD10, calponin, and beta-catenin. The choice of treatment and follow-up depends on the SEL features, but because no cases of malignancy or metastatic disease have previously been reported, the patient chose a conservative approach.

El fibromixoma plexiforme (FP) es una rara neoplasia mesenquimatosa del estómago que generalmente surge en el antro gástrico. Su principal diagnóstico diferencial es el tumor del estroma gastrointestinal. Los síntomas más comunes de los FP son hematemesis y anemia. Inmunohistoquímicamente, la positividad para actina del músculo liso (SMA) y vimentina sugieren el diagnóstico de FP. Presentamos el caso de una paciente de 56 años de edad que inicia su enfermedad hace 4 años con náuseas de 30 días de evolución. La primera gastroscopia reveló una lesión subepitelial (SEL) en el antro gástrico, de aproximadamente 20 mm de diámetro, con fuga de líquido seroso después de la biopsia. La histopatología mostró sólo un proceso inflamatorio. Se realizaron gastroscopias de seguimiento a los 24, 36 y 48 meses con biopsia de vigilancia en cada seguimiento. Las gastroscopias siguientes mostraron cambios en la apariencia de la lesión, reducción de tamaño y ausencia de fuga de líquido. La última histopatología mostró una proliferación blanda de células fusiformes, con un patrón vagamente plexiforme/multinodular, en un estroma fibromixoide con una red de capilares arborizantes sin mitosis. Las células tumorales fueron positivas para SMA y negativas para DOG1, CD117, CD34, S100, desmina, EMA, CD10, calponina y beta-catenina. La elección del tratamiento y el seguimiento depende de las características del SEL, sin embargo, por ser una enfermedad que no presentaba rasgos de enfermedad maligna o metastásica, el paciente eligió un mantener un enfoque conservador.

Performance of artificial intelligence in the characterization of colorectal lesions.

Background: Image-enhanced endoscopy (IEE) has been used in the differentiation between neoplastic and non-neoplastic colorectal lesions through microvasculature analysis. This study aimed to evaluate the computer-aided diagnosis (CADx) mode of the CAD EYE system for the optical diagnosis of colorectal lesions and compare it with the performance of an expert, in addition to evaluating the computer-aided detection (CADe) mode in terms of polyp detection rate (PDR) and adenoma detection rate (ADR). Methods: A prospective study was conducted to evaluate the performance of CAD EYE using blue light imaging (BLI), dichotomizing lesions into hyperplastic and neoplastic, and of an expert based on the Japan Narrow-Band Imaging Expert Team (JNET) classification for the characterization of lesions. After white light imaging (WLI) diagnosis, magnification was used on all lesions, which were removed and examined histologically. Diagnostic criteria were evaluated, and PDR and ADR were calculated. Results: A total of 110 lesions (80 (72.7%) dysplastic lesions and 30 (27.3%) nondysplastic lesions) were evaluated in 52 patients, with a mean lesion size of 4.3 mm. Artificial intelligence (AI) analysis showed 81.8% accuracy, 76.3% sensitivity, 96.7% specificity, 98.5% positive predictive value (PPV), and 60.4% negative predictive value (NPV). The kappa value was 0.61, and the area under the receiver operating characteristic curve (AUC) was 0.87. Expert analysis showed 93.6% accuracy, 92.5% sensitivity, 96.7% specificity, 98.7% PPV, and 82.9% NPV. The kappa value was 0.85, and the AUC was 0.95. Overall, PDR was 67.6% and ADR was 45.9%. Conclusions: The CADx mode showed good accuracy in characterizing colorectal lesions, but the expert assessment was superior in almost all diagnostic criteria. PDR and ADR were high.

Antral plexiform fibromyxoma: case report of a rare mesenchymal neoplasm.

Plexiform fibromyxoma (PF) is a rare mesenchymal neoplasm of the stomach usually arising in the gastric antrum, and its main differential diagnosis is gastrointestinal stromal tumor. Most common symptoms are hematemesis, anemia. Immunohistochemically, positivity for smooth muscle actin (SMA) and vimentin suggests the diagnosis of PF. We report the case of a 56-year-old female patient with a 30-day history of nausea at presentation 4 years ago. Gastroscopy at that time revealed a subepithelial lesion (SEL) in the gastric antrum, measuring approximately 20 mm in diameter, with leakage of serous fluid after biopsy. Histopathology showed only an inflammatory process. Follow-up gastroscopies were performed 24, 36, and 48 months later, with surveillance biopsy at each follow-up. The last gastroscopies showed changes in lesion appearance, reduction in size, and absence of fluid leakage. Histopathology showed bland spindle cell proliferation, with a vaguely plexiform/multinodular pattern, in a fibromyxoid stroma with an arborizing capillary network without mitoses. The tumor cells were positive for SMA and negative for DOG1, CD117, CD34, S100, desmin, EMA, CD10, calponin, and beta-catenin. The choice of treatment and follow-up depends on the SEL features, but because no cases of malignancy or metastatic disease have previously been reported, the patient chose a conservative approach.

Feasibility of endoscopic papillary large balloon dilation to remove difficult stones in patients with nondilated distal bile ducts.

BACKGROUND: Current guidelines recommend not performing papillary large balloon dilation in patients with nondilated distal bile ducts. AIM: To assess the feasibility of balloon dilation to remove difficult stones in patients with nondilated distal bile ducts. METHODS: Data from 1289 endoscopic retrograde cholangiopancreatography (ERCP) procedures were obtained from two prospective studies. While 258 cases had difficult stones (> 1 cm, multiple > 8, impacted, or having a thin distal duct), 191 underwent biliary dilation up to 15 mm after endoscopic sphincterotomy. Cholangiographies of these cases were retrospectively reviewed in order to classify the distal bile duct and both the stone size and number. Primary outcomes were clearance rate at first ERCP and complications. RESULTS: Of the 191 patients (122 women and 69 men; mean age: 60 years) who underwent biliary dilation for difficult stones, 113 (59%) had a nondilated or tapered distal duct. Patients with a dilated distal duct were older than those with nondilated distal ducts (mean 68 and 52 years of age, respectively; P < 0.05), had more stones (median 4 and 2 stones per patient, respectively; P < 0.05), and had less need for additional mechanical lithotripsy (6.4% vs 25%, respectively; P < 0.05). Clearance rate at first ERCP was comparable between patients with a dilated (73/78; 94%) and nondilated distal ducts (103/113; 91%). Procedures were faster in patients with a dilated distal duct (mean 17 vs 24 min, respectively; P < 0.005). Complications were similar in both groups (6.4% vs 7.1%, respectively). CONCLUSION: Large balloon dilation for difficult stones is feasible in patients with a nondilated or even tapered distal duct.

SMALL AS WELL AS LARGE COLORECTAL LESIONS ARE EFFECTIVELY MANAGED BY ENDOSCOPIC MUCOSAL RESECTION TECHNIQUE.

BACKGROUND: Endoscopic mucosal resection (EMR) is an easy-to-use treatment option for superficial colorectal lesions, including lesions ≥20 mm. OBJECTIVE: To evaluate the effectiveness of EMR. METHODS: We evaluated 430 lesions removed by EMR in 404 patients. The lesions were analyzed according to their morphology, size, location, and histology. Lesions <20 mm were resected en bloc, whereas lesions ≥20 mm were removed by piecemeal EMR (p-EMR). Adverse events and recurrence were assessed. RESULTS: Regarding morphology, 145 (33.7%) were depressed lesions, 157 (36.5%) were polypoid lesions and 128 (29.8%) were laterally spreading lesions, with 361 (84%) lesions <20 mm and 69 (16%) ≥20 mm. Regarding histology, 413 (96%) lesions were classified as neoplastic lesions. Overall, 14 (3.3%) adverse reactions occurred, most commonly in lesions removed by p-EMR (P<0.001) and associated with advanced histology (P=0.008). Recurrence occurred in 14 (5.2%) cases, more commonly in lesions removed by p-EMR (P<0.001). CONCLUSION: EMR is an effective technique for the treatment of superficial colorectal lesions, even of large lesions.

Grandes e pequenas lesões colorretais são efetivamente tratadas pela técnica de mucosectomia / Small as well as large colorectal lesions are effectively managed by endoscopic mucosal resection technique

ABSTRACT Background Endoscopic mucosal resection (EMR) is an easy-to-use treatment option for superficial colorectal lesions, including lesions ≥20 mm. Objective To evaluate the effectiveness of EMR. Methods We evaluated 430 lesions removed by EMR in 404 patients. The lesions were analyzed according to their morphology, size, location, and histology. Lesions <20 mm were resected en bloc, whereas lesions ≥20 mm were removed by piecemeal EMR (p-EMR). Adverse events and recurrence were assessed. Results Regarding morphology, 145 (33.7%) were depressed lesions, 157 (36.5%) were polypoid lesions and 128 (29.8%) were laterally spreading lesions, with 361 (84%) lesions <20 mm and 69 (16%) ≥20 mm. Regarding histology, 413 (96%) lesions were classified as neoplastic lesions. Overall, 14 (3.3%) adverse reactions occurred, most commonly in lesions removed by p-EMR (P<0.001) and associated with advanced histology (P=0.008). Recurrence occurred in 14 (5.2%) cases, more commonly in lesions removed by p-EMR (P<0.001). Conclusion EMR is an effective technique for the treatment of superficial colorectal lesions, even of large lesions.

RESUMO Contexto Ressecção endoscópica da mucosa (REM) é uma opção fácil para o tratamento das lesões superficiais do cólon e reto, inclusive para as lesões ≥20 mm de diâmetro. Objetivo Avaliar a efetividade da REM. Métodos Este estudo prospectivo observacional avaliou 430 lesões ressecadas por REM em 404 pacientes. As lesões foram analisadas de acordo com a morfologia, tamanho, localização e histologia. Lesões <20 mm foram removidas em bloco, enquanto lesões ≥20 mm foram ressecadas em piecemeal REM (p-REM). Eventos adversos e recorrência foram avaliados. Resultados Quanto à morfologia, 145 (33,7%) eram lesões deprimidas, 157 (36,5%) eram lesões polipoides e 128 (29,8%) eram lesões que se espalham lateralmente, com 361 (84%) lesões <20 mm e 69 (16%) ≥20 mm. Em relação à histologia, 413 (96%) foram classificadas como lesões neoplásicas. Globalmente tivemos 14 (3,3%) de reações adversas, mais presente nas lesões ≥20 mm removidas por p-REM (P<0,001) e associadas com histologia avançada (P=0,008). A recorrência ocorreu em 14 (5,2%) casos, sendo mais observada em lesões removidas por p-REM (P<0,001). Conclusão REM é uma técnica efetiva para o tratamento das lesões colorretais superficiais, até mesmo para as grandes lesões.

Effect of Linked-color Imaging on the Detection of Adenomas in Screening Colonoscopies.

OBJECTIVES: Linked-color imaging (LCI) is a new image-enhancement option that emphasizes mucosal surface contrast, facilitating the differentiation between colorectal lesions and normal mucosa. This study aimed to evaluate the potential of LCI to increase the detection of colorectal adenomas in screening colonoscopies. METHODS: A prospective randomized study was conducted using white-light imaging (WLI), blue-laser imaging (BLI)-bright and LCI. The outcome measures were adenoma detection rate (ADR), mean number of adenomas per patient, and withdrawal time. Lesion characteristics such as size, morphology, location, and histology were also evaluated. RESULTS: A total of 205 patients were randomized, and 251 adenomas were detected. The overall ADR was 62%. The ADR was 52.9% for WLI, 62.1% for BLI-bright, and 71% for LCI, and was significantly higher in the LCI group than in the WLI group (P=0.04). No significant difference was observed between LCI and BLI-bright (P=0.28) or BLI-bright and WLI (P=0.30). The mean number of adenomas per patient was 1.01, 1.03, and 1.62 for WLI, BLI-bright, and LCI, respectively, with a significant difference (P=0.02). Withdrawal time did not differ among the groups. A total of 71 adenomas were detected by WLI, 68 by BLI-bright, and 112 by LCI. There was no difference in the size and morphology of the adenomas detected, nor in the diagnosis of sessile serrated adenomas/polyps. CONCLUSION: LCI significantly increased the detection of adenomas in screening colonoscopies.

Improvement in Muscle Strength and Metabolic Parameters Despite Muscle Mass Loss in the Initial Six Months After Bariatric Surgery.

BACKGROUND: An aggravation in pre-existing sarcopenia or the onset of sarcopenia may occur in the scenario of extensive and fast weight loss in the initial months following bariatric surgery. The accurate identification of sarcopenia criteria and its metabolic repercussions is vital for its correct management. The aim of this study is to evaluate the correlation between the diagnosis criteria for sarcopenia and metabolic repercussions during the first 6 months following bariatric surgery. METHODS: A prospective single-center cohort study was conducted. Convenience sampling was performed among patients with severe obesity undergoing preoperative evaluation for bariatric surgery. Metabolic parameters, nutritional evaluation, and skeletal muscle evaluation were assessed before surgery and 6 months later. RESULTS: A total of 129 patients were selected, 62 participants were included in the final analysis. Mean age was 37.7 years and 88.4% of participants were women. Mean body mass index was 41.8 kg/m2 and 47.8% of patients were sedentary. Sleeve gastrectomy was performed in 41 patients and Roux-en-Y gastric bypass in 21 patients. Significant improvement regarding muscle strength and function after surgery was observed. Sarcopenia criteria were not met by any participant before and after surgery. Blood glucose and ferritin levels remained independently associated with change in muscle strength. CONCLUSIONS: Functional evaluation methods did not reflect the reduction in skeletal muscle mass demonstrated in bioelectrical impedance analysis 6 months after bariatric surgery in comparison to the preoperative baseline. Improvement in muscle strength was followed by improvement in metabolic parameters.

Biliary cannulation with contrast and guide-wire versus exclusive guide-wire: A prospective, randomized, double-blind trial.

BACKGROUND: The use of exclusive guide-wire cannulation (e-GW) instead of contrast injection reduces post-ERCP pancreatitis (PEP) and pre-cutting and increases cannulation rate. Herein, we intend to compare e-GW with the hybrid technique (GW-C and/or contrast injection). METHODS: Prospective single-center randomized comparative study, which included all patients referred to ERCP to our unit. Patients with non-naïve papilla; previous ERCP; direct infundibulotomy, ampullectomy, Billroth II gastrectomy or pancreatic sphincterotomy and patients lost to follow up were excluded. RESULTS: 727 consecutive patients were assessed. Of these, 588 naïve papilla patients were included and randomized to receive e-GW (n = 299) or GW-C (n = 289) for selective biliary cannulation. The mean age was 60.3 years and 60.5% were women. PEP occurred in 15(5%) cases in e-GW group and 9(3.1%) in the GW-C group (p = 0.29). Time to reach deep cannulation was faster in the latter group (75% < 5 min vs. 50.2% < 5 min, p<0.001). > 10 min until cannulation was observed in 21% vs. 10% of the ERCPs (groups e-GW and GW-C, respectively, p < 0.001). Total ERCP time was also shorter in the GW-C group (12 vs. 10 min; p < 0.001). Pre-cut (23.8 vs.11.8%, p < 0.001) and pancreatic sphincterotomy as a pre-cut technique (15.8 vs. 5.6%, p < 0.001) were used more frequently in the e-GW group. CONCLUSIONS: Compared to exclusive G-W- assisted biliary cannulation, the hybrid technique did not significantly reduce the PEP rate, however it promoted faster cannulation and, consequently, reduced the total procedure time and the use of pre-cut techniques.

Endoscopic Biliary Large Balloon Dilation Lithotripsy for Giant and Impacted Stones Removal: A Western Series.

BACKGROUND: Endoscopic removal of packed, large, or impacted stones, in which a basket cannot be deployed or is unable to grasp the stone(s), is challenging and inevitably leads to repeated procedures such as stent insertion and extra- or intracorporal lithotripsy. In this study, we describe the results of an alternative stone disintegration technique in a considerable series of patients using an esophageal/pyloric balloon for stone fragmentation or making working space in the bile duct to allow the deployment of the basket, a technique we call endoscopic biliary large balloon lithotripsy. METHODS: We retrieved data from 1,429 endoscopic retrograde cholangiopancreatographies (ERCPs) from 2 prospective trials performed between 2014 and 2019. Patients with difficult bile duct stones, in which a balloon dilator up to 15 mm was used to crush or increase the working space parallel to the stones in the common or hepatic duct, were included in the study. RESULTS: From the 1,429 ERCPs, 299 had difficult stones (>1 cm, impacted or multiple stones). Large balloon lithotripsy was employed in 46 cases after endoscopic papillotomy and endoscopic biliary large balloon dilation with failed attempted balloon or basket stone(s) extraction. Failure to clear the bile duct at first ERCP occurred in 4 cases (91.3% of success). Complications were observed in 5 patients (10.8%; 1 perforation, 1 pancreatitis, and 3 bleedings), who were treated conservatively. CONCLUSIONS: Large balloon lithotripsy, in order to crush the stones or make working room for baskets or balloons in the bile duct, is an effective, safe, and low cost technique for impacted, packed, or giant bile duct stones.

Risk Factors for Success, Complications, and Death after Endoscopic Sphincterotomy for Bile Duct Stones: A 17-Year Experience with 2,137 Cases.

BACKGROUND: Risk factors for post-endoscopic retrograde cholangiopancreatography (ERCP) complications are well-studied. However, risk factors for complications and success after endoscopic sphincterotomy (EST) for duct stones are poorly determined. This study aimed to verify risk factors for mortality, complications, and success after EST. METHODS: A multivariate analysis was carried out in a dataset of ERCPs performed during 17 years. RESULTS: A total of5,226 ERCPs were performed, of which 2,137 were in patients with bile duct stones (1,458 women and 679 men; mean age = 57 years) who underwent EST with attempted stone removal. There were 171 (8%) complications, with pancreatitis in 87 (4.1%), bleeding in 48 (2.2%), other complications in 36 (1.8%), and mortality of 0.6%. Successful stone(s) removal was obtained in 2,028 cases (94.9%). On multivariate analysis, mortality was associated with age >60 years (1 vs. 0.2%), cholangitis (4.3 vs. 0.3%), and EST-related complications (5.8 vs. 0.2%). Complications were associated with unsuccessful stone removal (13.4 vs. 7.5%) and difficult cannulation (13.9 vs. 5.4%). An unsuccessful EST was independently related to difficult cannulation (86.2 vs. 98.7%), precutting (79.4 vs. 96.4%), and complications (86.5 vs. 95.6%). CONCLUSIONS: Risk factors for complications after EST for stones are delayed bile duct cannulation and failed stone retrieval. Mortality is higher in older patients, those who presented with an EST-related complication, or those who presented initially with cholangitis. Difficult cannulation, EST-related complications, and precutting were associated with an unsuccessful procedure. In this series, outpatient EST with attempted stone retrieval was found to be as safe as performing the procedure in hospitalized patients.

Efficacy of endoscopic treatments for acute esophageal variceal bleeding in cirrhotic patients: systematic review and meta-analysis.

Background and aim Guidelines recommend use of ligation and vasoactive drugs as first-line therapy and as grade A evidence for acute variceal bleeding (AVB), although Western studies about this issue are lacking. Methods We performed a systematic review and meta-analysis of randomized controlled trials (RCT) to evaluate the efficacy of endoscopic treatments for AVB in patients with cirrhosis. Trials that included patients with hepatocellular carcinoma, use of portocaval shunts or esophageal resection, balloon tamponade as first bleeding control measure, or that received placebo or elective treatment in one study arm were excluded. Results A total of 8382 publications were searched, of which 36 RCTs with 3593 patients were included. Ligation was associated with a significant improvement in bleeding control (relative risk [RR] 1.08; 95 % confidence interval [CI] 1.02 - 1.15) when compared to sclerotherapy. Sclerotherapy combined with vasoactive drugs showed higher efficacy in active bleeding control compared to sclerotherapy alone (RR 1.17; 95 % CI 1.10 - 1.25). The combination of ligation and vasoactive drugs was not superior to ligation alone in terms of overall rebleeding (RR 2.21; 95 %CI 0.55 - 8.92) and in-hospital mortality (RR 1.97; 95 %CI 0.78 - 4.97). Other treatments did not generate meta-analysis. Conclusions This study showed that ligation is superior to sclerotherapy, although with moderate heterogeneity. The combination of sclerotherapy and vasoactive drugs was more effective than sclerotherapy alone. Although current guidelines recommend combined use of ligation with vasoactive drugs in treatment of esophageal variceal bleeding, this study failed to demonstrate the superiority of this combined treatment.

Impact of linked-color imaging on colorectal adenoma detection.

BACKGROUND AND AIMS: Linked-color imaging (LCI) is a new technology that emphasizes changes in mucosal color by providing clearer and brighter images, thus allowing red and white areas to be visualized more clearly. We investigated whether LCI increases the detection of colorectal adenomas compared with white-light imaging (WLI) and blue-laser imaging (BLI)-bright. METHODS: Consecutive patients undergoing colonoscopy were randomized (1:1:1) into examination by WLI, BLI-bright, or LCI during withdrawal of the colonoscope. The adenoma detection rate (ADR), mean number of adenomas per patient, and withdrawal time were evaluated. The lesions were evaluated according to size, morphology, location, and histology. RESULTS: A total of 379 patients were randomized, and 412 adenomas were detected. The ADR was 43.2%, 54.0%, and 56.9% for WLI, BLI-bright, and LCI, respectively, and was significantly higher in the LCI group than in the WLI group (P = .03). No significant difference was observed between LCI and BLI-bright (P = .71) or BLI-bright and WLI (P = .09). The mean number of adenomas per patient was 0.82, 1.06, and 1.38 for WLI, BLI-bright, and LCI, respectively, with a significant difference between LCI and WLI (P = .03). Withdrawal time did not differ among the groups. A total of 102 adenomas were detected by WLI, 131 by BLI-bright, and 179 by LCI. LCI provided a higher rate of detection of adenomas ≤5 mm in size than WLI (P = .02), with a borderline significance for a higher detection of sessile serrated adenomas (P = .05). Nonpolypoid adenomas were more commonly located in the right colon segment and polypoid adenomas in the left colon segment, with a significant difference only between BLI-bright (P < .01) and LCI (P = .03). CONCLUSIONS: Our findings show that LCI increases the detection of colorectal adenomas during colonoscopy. (Clinical trial registration number: RBR-9xg6dx.).

The role of linear endosonography for the diagnosis of acute pancreatitis when other methods failed.

BACKGROUND AND STUDY AIMS: Acute pancreatitis has no obvious cause after clinical, laboratory and radiologic investigation in 10%-30% of patients, and the diagnosis of idiopathic pancreatitis is given. This study investigated the role of linear EUS for identification of possible causes for acute pancreatitis when other investigative methods failed. PATIENTS AND METHODS: Between June 2012 and March 2017, 35 patients [25 women; mean age: 51.9 + 17.8 years] with idiopathic acute pancreatitis underwent linear EUS for investigation. All of these cases were contacted for a follow-up telephone interview to compare the EUS findings with the final diagnosis and outcome. RESULTS: Pancreaticobiliary abnormalities were identified in 19 of 35 (54.3%) patients. Ten (28.6%) patients had microlithiasis or biliary sludge. Microlithiasis and choledocholithiasis were identified in 8 (22.8%) and a single (2.8%) patient, respectively. Two patients presented gallbladder biliary sludge, one of them with microlithiasis. Chronic pancreatitis was found on EUS in 6 (17.1%) patients, and pseudotumoral masses confirmed by EUS-FNA as autoimmune pancreatitis were detected in other 3 (8.6%) cases. Linear EUS was normal in 13 (37.1%) patients, and demonstrated findings of recent acute pancreatitis but no other etiological factor in 3 (8.6%) cases. After a mean follow-up of 33.3 months, no case with a normal EUS evaluation presented a new episode of pancreatitis, 1 of 9 cases with microlithiasis presented an episode of recurrent pancreatitis due to choledocolithiasis after cholecystectomy, and 3 of 9 cases with chronic pancreatitis presented recurrent episodes, including the 2 cases of autoimmune pancreatitis. CONCLUSIONS: Linear EUS provides diagnostic information in approximately a half of patients with idiopathic acute pancreatitis. Exclusion of pancreaticobiliary abnormalities on EUS has an important prognostic value for absence of new episodes of acute pancreatitis.

Blue laser imaging: a new image-enhanced endoscopy for the diagnosis of colorectal lesions.

BACKGROUND: Image-enhanced endoscopy enables real-time differential diagnosis of colorectal lesions through the observation of microvascular architecture. PURPOSE: To evaluate the efficacy of using blue laser imaging (BLI) for capillary pattern analysis in the differential diagnosis of neoplastic and non-neoplastic lesions. PATIENTS AND METHODS: This prospective study included 920 consecutive superficial lesions diagnosed in 457 patients. The capillary pattern was analysed using BLI-bright magnification on the basis of the Teixeira classification. Histopathology was used as the reference standard. RESULTS: The adenoma detection rate was 42.3%, with a mean of 0.95 adenomas per patient. Neoplastic lesions were predominant (70.3%), of which 33 (5.1%) had advanced histology. Neoplastic progression was significantly increased in patients aged at least 50 years, in lesions at least 10 mm and in lesions located in the right colon (P<0.01). BLI-based capillary pattern analysis showed 95.5% accuracy, 95.7% sensitivity, 95.2% specificity, 97.9% positive predictive value and 90.3% negative predictive value in the diagnosis of neoplastic lesions. For 672 diminutive lesions (≤5 mm), BLI-based capillary pattern analysis showed 95.7% accuracy, 96.6% sensitivity, 93.6% specificity, 97.2% positive predictive value and 92.2% negative predictive value. Analysing only lesions up to 5 mm in the rectum and sigmoid colon, the values were 95.2, 93.9, 96.5, 95.8 and 94.8%, respectively. CONCLUSION: BLI associated with magnification yielded excellent results for the real-time predictive histological diagnosis of colorectal lesions.

Hyoscine butylbromide for colorectal polyp detection: prospective, randomized, placebo-controlled trial.

OBJECTIVES:: The removal of pre-malignant colorectal lesions prevents cancer. Hyoscine has been proposed as a means of improving diagnosis by reducing colonic movements. The aim of this study was to analyze whether this anti-spasmodic enhances the detection of pre-malignant colorectal lesions. METHODS:: In a randomized, double-blinded fashion patients received hyoscine or a saline solution in all consecutive colonoscopies in which the cecum was reached. Lesions were analysed with respect to number, size, location, histology and capillary pattern. RESULTS:: A total of 440 colonoscopies were randomized. The overall polyp detection rate (PDR) and the adenoma detection rate (ADR) were 65.2% and 49.3%, respectively. In the hyoscine group, non-polypoid lesions were detected significantly more often (p=0.01). In the placebo group 281 lesions were diagnosed (202 adenomas) and in the hyoscine group 282 lesions were detected (189 adenomas) (p=0.23). The PDR and ADR were similar between the placebo and hyoscine groups (64% vs 66% and 50% vs 47%, respectively). No differences were observed between the two groups in the advanced-ADR or advanced neoplasia detection rate, as well the mean numbers of polyps, adenomas, advanced adenomas and advanced neoplasias detected per patient. The administration of hyoscine also did not improve the diagnostic accuracy of digital chromoendoscopy. The presence of adenomatous polyps in the right colon was detected significantly more frequently in the hyoscine group (OR 5.41 95% CI 2.7 - 11; p<0.01 vs OR 2.3 95% CI 1.1 - 4.6; p=0.02). CONCLUSION:: The use of hyoscine before beginning the withdrawal of the colonoscope does not seem to enhance the PDR and the ADR.

Hyoscine butylbromide for colorectal polyp detection: prospective, randomized, placebo-controlled trial

OBJECTIVES: The removal of pre-malignant colorectal lesions prevents cancer. Hyoscine has been proposed as a means of improving diagnosis by reducing colonic movements. The aim of this study was to analyze whether this anti-spasmodic enhances the detection of pre-malignant colorectal lesions. METHODS: In a randomized, double-blinded fashion patients received hyoscine or a saline solution in all consecutive colonoscopies in which the cecum was reached. Lesions were analysed with respect to number, size, location, histology and capillary pattern. RESULTS: A total of 440 colonoscopies were randomized. The overall polyp detection rate (PDR) and the adenoma detection rate (ADR) were 65.2% and 49.3%, respectively. In the hyoscine group, non-polypoid lesions were detected significantly more often (p=0.01). In the placebo group 281 lesions were diagnosed (202 adenomas) and in the hyoscine group 282 lesions were detected (189 adenomas) (p=0.23). The PDR and ADR were similar between the placebo and hyoscine groups (64% vs 66% and 50% vs 47%, respectively). No differences were observed between the two groups in the advanced-ADR or advanced neoplasia detection rate, as well the mean numbers of polyps, adenomas, advanced adenomas and advanced neoplasias detected per patient. The administration of hyoscine also did not improve the diagnostic accuracy of digital chromoendoscopy. The presence of adenomatous polyps in the right colon was detected significantly more frequently in the hyoscine group (OR 5.41 95% CI 2.7 - 11; p<0.01 vs OR 2.3 95% CI 1.1 - 4.6; p=0.02). CONCLUSION: The use of hyoscine before beginning the withdrawal of the colonoscope does not seem to enhance the PDR and the ADR.