Evaluating the Efficacy of Resect-and-Discard and Resect-and-Retrieve Strategies for Diminutive Colonic Polyps.

BACKGROUND AND OBJECTIVES: Diminutive polyps present a unique challenge in colorectal cancer (CRC) prevention strategies. This study aims to assess the characteristics and variables of diminutive polyps in a Romanian cohort, intending to develop a combined resect-and-retrieve or resect-and-discard strategy that reduces the need for an optical diagnosis. MATERIALS AND METHODS: A prospective cohort study was conducted at two endoscopy centers in Romania from July to December 2021. Adult patients undergoing colonoscopies where polyps were identified and resected were included. Endoscopic procedures employed advanced diagnostic features, including blue-light imaging (BLI) and narrow-band imaging (NBI). Logistic regression analysis was utilized to determine factors impacting the probability of adenomatous polyps with high-grade dysplasia (HGD). RESULTS: A total of 427 patients were included, with a mean age of 59.42 years (±11.19), predominantly male (60.2%). The most common indication for a colonoscopy was lower gastrointestinal symptoms (42.6%), followed by screening (28.8%). Adequate bowel preparation was achieved in 87.8% of cases. The logistic regression analysis revealed significant predictors of HGD in adenomatous polyps: age (OR = 1.05, 95% CI: 1.01-1.08, p = 0.01) and polyp size (>5 mm vs. ≤5 mm, OR = 4.4, 95% CI: 1.94-10.06, p < 0.001). Polyps classified as Paris IIa, Ip, and Isp were significantly more likely to harbor HGD compared to the reference group (Is), with odds ratios of 6.05, 3.68, and 2.7, respectively. CONCLUSIONS: The study elucidates significant associations between the presence of HGD in adenomatous polyps and factors such as age, polyp size, and Paris classification. These findings support the feasibility of a tailored approach in the resect-and-discard and resect-and-retrieve strategies for diminutive polyps, potentially optimizing CRC prevention and intervention practices. Further research is warranted to validate these strategies in broader clinical settings.

Just five more minutes, mom: why video games could make you a better endoscopist.

BACKGROUND: Gaming is a growing industry, having met an exponential growth amid the pandemic context. Video games improve the allocation and speed of attention and provide better spatial orientation in visual processing. These same qualities are sought after in GI endoscopists. This study aimed to investigate whether individuals with a gaming history have superior fine motor and visual skills on a virtual reality (VR) endoscopy simulator and if gaming consoles could be added as a proficiency tool in acquiring endoscopic skills. METHODS: Firstly, subjects' baseline psychomotor skills and hand-eye coordination were tested using a VR simulator. Secondly, subjects were assigned to either group C and asked to refrain from any gaming for 14 days, or group T, who were asked to play on a console for 14 days. All subjects were then retested. RESULTS: 81 students were included in the study. Baseline VR simulator testing showed better scores in those with a higher number of previous gaming hours (0 h-1598, 0 to 30 h-1970, 30 to 50 h-2150, 50 to 100 h-2395, > 100 h-2519; p < 0.05), with males outperforming females (p < 0.01). After spending an average of 19 h gaming, all parameters showed noteworthy improvement for those in group T (p < 0.01). No improvement was seen in group C. CONCLUSIONS: Subjects who engage in console gaming have superior psychomotor skills and perform better on VR simulators. Approximately 20 h of console gaming can improve one's simulator skills. With consoles being accessible, entertaining, and cheap, they could be used as an additional training platform for GI endoscopy residents.

Pulmonary complications of portal hypertension: The overlooked decompensation.

The systemic nature of cirrhosis and portal hypertension has long been recognized, and the amount of data characterizing the interplay between each system is becoming ever so complex. Lung involvement was among the first described associated entities in cirrhosis, with reports dating back to the late nineteenth century. However, it appears that throughout the years, interest in the pulmonary complications of portal hypertension has generally faded, especially in contrast to other decompensating events, as expertise in this field has primarily been concentrated in highly experienced tertiary care facilities and liver transplantation centers. Despite affecting up to 10%-15% of patients with advanced liver disease and having a proven prognostic impact, hepato-pulmonary syndrome, porto-pulmonary hypertension, and hepatic hydrothorax are frequently misdiagnosed, mistreated, or misinterpreted. This lack of precision might adversely impact patient care, referral to expert centers, and, ultimately, liver disease-related mortality and successful transplantation odds. The present minireview aims to increase awareness of the pulmonary complications of chronic liver disease by providing a brief overview of each of the three entities. The paper focuses on the essential theoretical aspects, addressing the most critical knowledge gaps on the one hand and, on the other hand, critically discussing one key issue for each complication.

The threat of carbapenem resistance in Eastern Europe in patients with decompensated cirrhosis admitted to intensive care unit.

BACKGROUND: Multidrug-resistant organisms are an increasing concern in patients with decompensated cirrhosis. AIM: We aimed to evaluate the prevalence of infections with carbapenem-resistant Enterobacteriaceae in patients with decompensated cirrhosis. METHODS: Patients with decompensated cirrhosis admitted to ICU were included. The isolated Enterobacteriaceae strains were tested for carbapenemase-producing genes using the Roche LightMix® Modular VIM/IMP/NDM/GES/KPC/OXA48-carbapenemase detection kit. RESULTS: 48 culture-positive infections were registered in 75 patients with acutely decompensated cirrhosis. Thirty patients contracted a second infection. 46% of bacteria isolated at admission and 60% of bacteria responsible for infections identified during ICU-stay were multiresistant. ESBL+ Enterobacteriaceae were predominant at admission, while carbapenem-resistance was dominant in both Enterobacteriaceae and Non-Fermenting-Gram-Negative Bacteria responsible for infections diagnosed during hospitalisation. OXA 48 or KPC type carbapenemases were present in 30% of the analyzed Enterobacteriaceae and in 40% of the phenotypically carbapenem-resistant Klebsiella pneumoniae strains. The length of ICU stay was a risk-factor for a second infection (p=0.04). Previous carbapenem usage was associated with occurence of infections with carbapenem-resistant Gram-negative bacteria during hospitalization (p=0.03). CONCLUSION: The prevalence of infections with carbapenem-resistant Enterobacteriaceae is high in patients with decompensated cirrhosis admitted to ICU. Carbapenemase-producing genes in Enterobacteriaceae in our center are blaOXA-48 and blaKPC.

Novel approaches in search for biomarkers of cholangiocarcinoma.

Cholangiocarcinoma (CCA) arises from the ductular epithelium of the biliary tree, either within the liver (intrahepatic CCA) or more commonly from the extrahepatic bile ducts (extrahepatic CCA). This disease has a poor prognosis and a growing worldwide prevalence. The poor outcomes of CCA are partially explained by the fact that a final diagnosis is challenging, especially the differential diagnosis between hepatocellular carcinoma and intrahepatic CCA, or distal CCA and pancreatic head adenocarcinoma. Most patients present with an advanced disease, unresectable disease, and there is a lack in non-surgical therapeutic modalities. Not least, there is an acute lack of prognostic biomarkers which further complicates disease management. Therefore, there is a dire need to find alternative diagnostic and follow-up pathways that can lead to an accurate result, either singlehandedly or combined with other methods. In the "-omics" era, this goal can be attained by various means, as it has been successfully demonstrated in other primary tumors. Numerous variants can reach a biomarker status ranging from circulating nucleic acids to proteins, metabolites, extracellular vesicles, and ultimately circulating tumor cells. However, given the relatively heterogeneous data, extracting clinical meaning from the inconsequential noise might become a tall task. The current review aims to navigate the nascent waters of the non-invasive approach to CCA and provide an evidence-based input to aid clinical decisions and provide grounds for future research.

Blood Metabolomic Signatures to Identify Bacterial Infection in Patients with Decompensated Cirrhosis.

BACKGROUND AND AIMS: Bacterial infections are associated with high mortality rates in patients with decompensated cirrhosis. Early diagnosis with the available diagnostic tools is challenging. Metabolomics is a novel technique with a widespread application in hepatology. The aims of our study were to find new biomarkers for decompensated cirrhosis and for those with overlapping bacterial infections. METHODS: 43 patients with compensated and 54 patients with decompensated cirrhosis were enrolled in the study. In patients with decompensation, a complete infectious workup was performed at admission. Blood and ascitic fluid were collected and stored at -80° C until performing the metabolomic analysis. Statistical analysis was performed using the Metaboanalyst 4.0 software. RESULTS: 36 patients (66%) in the decompensated group were infected. Among them, 15 had multiple infections; thus, finally, 52 infections were diagnosed. The main metabolic pathways affected in patients with decompensated cirrhosis were those related to lipid metabolism, involving acylcarnitines, stearic acid derivatives, and 12/15 HETE-GABA. N-oleoyl ethanolamine was the most promising biomarker for bacterial infection diagnosis. Moreover, prostaglandin E2/D2/H2 and N-oleoyl alanine levels were higher in Gram- positive infections and ceramides (d16:2/18:0), in Gram-negative infections, respectively. L-phenylalanine (m/z=166.09) and lysophosphatidylethanolamine (18:3/0:0) were the two most relevant identified ascitic biomarkers for spontaneous bacterial peritonitis diagnosis. CONCLUSIONS: The lipid and energetic metabolic pathways were the most affected in patients with decompensated cirrhosis and those with overlapping infections.

Correlation between adenoma detection rate and other quality indicators, and its variability depending on factors such as sedation or indication for colonoscopy.

Colorectal cancer (CRC) is an important worldwide public health burden and colonoscopy is the main diagnostic and most importantly, preventive method. For this reason, many countries have implemented national or regional CRC screening programs. High-quality colonoscopy is a prerequisite to effectively detect premalignant lesions, like adenomas. The quality of colonoscopy is assessed using several quality indicators, the main one being adenoma detection rate (ADR). In Romania, despite CRC having the highest incidence of all cancers, there is no national screening program and quality in colonoscopy is not routinely assessed. We therefore wanted to evaluate the actual level of quality in colonoscopy in a region of Romania. Our study was conducted in two private endoscopy clinics over a period of 7 months. 1,440 consecutive colonoscopies performed by five physicians were included in the study. We found that the quality level is above the minimum one recommended by international societies and that the ADR calculation method does not significantly influence its value. Furthermore, ADR correlated well with other quality indicators such as polyp detection rate (PDR) and adenoma per colonoscopy (APC). An interesting finding was that ADR was higher among colonoscopies performed without sedation. Thus, our data encourage endoscopists to adopt a sedation-free colonoscopy in their practice without an impact on the quality of the procedure.

Salinomycin-Based Drug Delivery Systems: Overcoming the Hurdles in Cancer Therapy.

Cancer stem cells (CSCs) are reportedly responsible for the initiation and propagation of cancer. Since CSCs are highly resistant to conventional chemo- and radiotherapy, they are considered the main cause of cancer relapse and metastasis. Salinomycin (Sali), an anticoccidial polyether antibiotic, has emerged as a promising new candidate for cancer therapy, with selective cytotoxicity against CSCs in various malignancies. Nanotechnology provides an efficient means of delivering Sali to tumors in view of reducing collateral damage to healthy tissues and enhancing the therapeutic outcome. This review offers an insight into the most recent advances in cancer therapy using Sali-based nanocarriers.

Endoscopic or percutaneous biliary drainage in hilar cholangiocarcinoma: When and how?

Hilar cholangiocarcinoma (hCCA) is a primary liver tumor associated with a dim prognosis. The role of preoperative and palliative biliary drainage has long been debated. The most common techniques are endoscopic retrograde cholangiopancreatography (ERCP) and percutaneous transhepatic biliary drainage (PTBD); however, recently developed endoscopic ultrasound-assisted methods are gaining more atention. Selecting the best available method in any specific scenario is crucial, yet sometimes challenging. Thus, this review aimed to discuss the available techniques, indications, perks, pitfalls, and timing-related issues in the management of hCCA. In a preoperative setting, PTBD appears to have some advantages: low risk of postprocedural complications (namely cholangitis) and better priming for surgery. For palliative purposes, we propose ERCP/PTBD depending on the experience of the operators, but also on other factors: the level of bilirubin (if very high, rather PTBD), length of the stenosis and the presence of cholangitis (PTBD), ERCP failure, or altered biliary anatomy.

All that glitters is not gold: a case report of a diffuse peritoneal aspergillosis.

Invasive aspergillosis is a rare disease, more frequently encountered in immunocompromised patients. We report a case of diffuse peritoneal aspergillosis. A 56-year old female with a history of recent renal transplantation was admitted with a suspicion of peritoneal carcinomatosis following a native computed tomography scan. Gray scale abdominal ultrasound showed multiple peritoneal masses. Upon performing contrast-enhanced ultrasound these masses demonstrated peripheral arterial enhancement and slow wash-out during the venous phase. The final histopathological examination confirmed a diagnosis of peritoneal aspergillosis. Gray scale ultrasonography in combination with contrast-enhanced ultrasonography is useful in the evaluation of intraabdominal masses. The procedures are of great value especially in patients with a high risk of contrastinduced nephropathy where contrast-enhanced CT or MRI are contraindicated.

Surface-enhanced Raman scattering for the diagnosis of ulcerative colitis: will it change the rules of the game?

Ulcerative colitis (UC) is a relapsing-remitting inflammatory bowel disease that requires numerous costly invasive investigations which lead to physical and psychological patient discomfort. We need a non-invasive technological approach that would significantly improve its diagnosis. Surface-enhanced Raman scattering (SERS) is a growing technique that can provide a molecular diagnostic fingerprint in just a few minutes, without the need for prior sample preparation. The aim of this pilot in vivo study was to prove that multivariate analysis of SER spectra collected on plasma samples could be employed for non-invasive diagnosis of UC. Plasma samples were collected from healthy subjects (n = 35) and patients with UC (n = 28). SERS spectra were acquired using a 785-nm excitation laser line and a solid plasmonic substrate developed in our laboratory using an original procedure described in the literature. The classification accuracy yielded by SERS was assessed by principal component analysis-linear discriminant analysis (PCA-LDA) and partial least squares discriminant analysis (PLS-DA). PCA-LDA differentiated UC samples from those of healthy subjects with a sensitivity of 86%, a specificity of 92%, and an accuracy of 89%, the AUC being 0.96. The PLS-DA analysis resulted in a sensitivity of 89%, a specificity of 94%, an accuracy of 92%, and an AUC value of 0.92. Several spectral bands were associated with UC: 376-420, 440-513, 686-715, 919-939, 1035-1062, 1083-1093, 1120-1132, 1148-1156, 1191-1211, 1234-1262, 1275-1294, 1382-1405, 1511-1526, and 1693-1702 cm-1. Changes in plasma levels of amino acids, proteins, lipids, and other compounds were noted using SERS in patients with UC. Multivariate analysis of SER spectra collected on a solid plasmonic substrate represents a promising alternative to diagnosing UC, as it is non-invasive, easy to use, and fast.

Effect of Lactobacillus plantarum ACTT 8014 on 5-fluorouracil induced intestinal mucositis in Wistar rats.

Some previous studies reported that probiotics might decrease the severity of chemotherapy-induced mucositis. This study assessed the potential protective effect of Lactobacillus plantarum ATCC 8014 on 5-fluorouracil (5-FU) induced intestinal mucositis in the Wistar rats. The Crl:WI rats were divided into two groups of six animals (F, L) and one group of 5 animals (M). Group L received for 9 days 3.32x109 CFU/ml of Lactobacillus plantarum orally. In the 7th day of the experiment 400 mg of 5-FU was administered intraperitoneally in groups L and F. Group M received only the vehicles. All animals were sacrificed in the 9th day. Eleven histological characteristics of mucositis were quantified from 0 (normal) to 3 (severe) for duodenum, jejunum and colon. Semiquantitative grades measured Toll-like receptor 4 (TLR4) immunopositive cells. The independent groups were analyzed using the Kruskal-Wallis test, Mann-Whitney U test, with a Bonferroni correction for alpha (P≤0.016). In the group F, treated with 5-FU, the most affected areas were the jejunum and the duodenum. The medium score of histological lesions was 27 for jejunum (minimum 25, maximum 32) and 21 for duodenum (minimum 18, maximum 29). Graded microscopic mucosal changes of the jejunum were significantly lower in group L compared with group F (U=0, P=0.009, Mann-Whitney test). The histological changes depicted on the duodenal and colonic mucosa were less severe in group L than in group F, but without reaching the statistical significance (duodenum: U=6, P=0.172, Mann-Whitney test; colon: U=12, P=0.916, Mann-Whitney test). Although the TLR4 immunoexpression was more intense in group L, no significant statistical difference was revealed at duodenum, jejunum or colonic mucosa. Significantly fewer microscopic changes were depicted in L group on the jejunum, suggesting a potential beneficial effect of Lactobacillus plantarum at this level in 5-FU induced mucositis.

Integration of Real-Time Image Fusion in the Robotic-Assisted Treatment of Hepatocellular Carcinoma.

Hepatocellular carcinoma (HCC) is one of the leading causes of cancer-related deaths worldwide, with its mortality rate correlated with the tumor staging; i.e., early detection and treatment are important factors for the survival rate of patients. This paper presents the development of a novel visualization and detection system for HCC, which is a composing module of a robotic system for the targeted treatment of HCC. The system has two modules, one for the tumor visualization that uses image fusion (IF) between computerized tomography (CT) obtained preoperatively and real-time ultrasound (US), and the second module for HCC automatic detection from CT images. Convolutional neural networks (CNN) are used for the tumor segmentation which were trained using 152 contrast-enhanced CT images. Probabilistic maps are shown as well as 3D representation of HCC within the liver tissue. The development of the visualization and detection system represents a milestone in testing the feasibility of a novel robotic system in the targeted treatment of HCC. Further optimizations are planned for the tumor visualization and detection system with the aim of introducing more relevant functions and increase its accuracy.

POEM: Five Years of Experience in a Single East European Center.

BACKGROUND AND AIMS: Achalasia is an esophageal motility disorder with many available therapies. Peroral endoscopic myotomy (POEM) is a therapeutic alternative to surgical myotomy, harboring significant potential short term advantages. Our aim was to analyze a single-series POEM's learning curve, safety and efficiency over short, medium and long-terms in an East European Center. METHODS: This observational, prospective study was carried out in the Regional Institute of Gastroenterology and Hepatology, Cluj-Napoca, Romania. Patients with symptomatic achalasia (Eckardt score>3) and pre-op evaluations consistent with the diagnosis of achalasia were included. All POEMs were performed by a highly skilled endoscopist. All patients were allowed to eat 48 hours after POEM. An esophagography was performed in all patients to exclude any leakage. The patients were asked to return for follow-up at established intervals: 1 month, 6 months, 12 months, and annually thereafter. RESULTS: 136 patients were included with an average duration of symptomatology of 36.75 months. The procedure was technically successful in all patients, while a clinical success rate was achieved in 87.5% (n=119) of patients after one POEM session. The success rate was 92.64% after 6 months, 91.17% after one year, 88.9% after 2 years, and 87.5% after 3 years or more; 12.5% of patients required additional treatment. Eighteen patients (13.23%) presented major early complications. Gastroesophageal reflux disease was encountered in 16 patients immediately after POEM and in 22 patients at subsequent follow-ups. CONCLUSION: POEM is a safe and effective minimally invasive therapeutic option which can substitute surgical myotomy, having a high success rate and a low rate of adverse events in short, medium and long-term.

The potential of metabolic and lipid profiling in inflammatory bowel diseases: A pilot study.

Inflammatory bowel diseases (IBDs) are conditions that still pose significant problems. A third of the patients are either misdiagnosed or a proper diagnosis of Crohn's disease (CD) or ulcerative colitis (UC) cannot be made. We need new biomarkers, so that we can offer patients the best treatment and keep the disease in an inactive state for as long as possible. Alterations in metabolic profiles have been incriminated in the pathophysiology of IBD. The aim of the present study was to identify molecules that could serve as biomarkers for a positive diagnosis of IBD as well as to discriminate UC from colonic CD. Twenty-two patients with active colonic IBD (UC = 17, CD = 5) and 24 age- and gender-matched healthy controls were enrolled. Plasma lipid and metabolic profiles were quantified using ultra-high-performance liquid chromatography combined with mass spectrometry. Univariate and multivariate statistical tests were employed. Six lipid species and 7 metabolites were significantly altered in IBD patients compared to healthy controls, with the majority belonging to glycerophospholipid, linoleic acid, and sphingolipid metabolisms. Five lipid species and only 1 metabolite were significantly increased in UC compared to CD. This preliminary study suggests that lipid and metabolic profiling of serum can become diagnostic tools for IBD. In addition, they can be used to differentiate between CD and UC.

Lipidomic signatures of colonic inflammatory bowel diseases: a pilot study.

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Clinical Applications of Raman Spectroscopy in Inflammatory Bowel Diseases. A Review.

BACKGROUND AND AIMS: Inflammatory bowel diseases are still difficult to diagnose and differentiate in some cases despite the serological, imaging, endoscopic and histopathological armamentarium. Raman spectroscopy is a technique that could help with these shortcomings. The aim of this paper is to present the accuracy of Raman spectroscopy in the diagnosis and monitoring of patients with inflammatory bowel diseases. METHODS: We identified the published manuscripts and abstracts up to the 31st of December 2017 by a systematic search of Medline, Embase, Cochrane and other trial registries. RESULTS: Eight publications were found, showing sensitivities and specificities of Raman spectroscopy in diagnosing and differentiating inflammatory bowel diseases ranging from 82 to 99% and 57 to 99%, respectively, and accuracies of up to 95%. CONCLUSION: The technique has so far proven its potential in the positive and differential diagnosis of Crohn's disease or ulcerative colitis, allowing for very rapid results with high sensitivity and specificity.

Flexible endoscopic treatment for Zenker's diverticulum - experience on 31 patients.

BACKGROUND AND AIMS: The aim of this study is to present the experience of our center over the last 8 years in a series of patients with Zenker's diverticulum (ZD), treated using an endoscopic, minimally invasive procedure. METHODS: We retrospectively included 31 patients with a previously established diagnosis of ZD based on endoscopic and oral contrast examinations. Patients' age, comorbidities, size of the diverticulum or previous endoscopic treatment were not considered exclusion criteria. A soft, flexible diverticuloscope to expose the septum and a dual knife for "cutting" the diverticular septum were used. We analyzed the short term efficacy based on symptomatic relief and occurrence of side effects, and long term efficiency at 6 and 12 months by clinical assessment, upper gastrointestinal endoscopy and oral contrast media passage. RESULTS: Patients had a mean age of 67 years (range 42-86); 55% of them were male. All patients reported symptom relief after the procedure. A decrease of more than 70% from the initial size of the diverticulum was noted. There were 3 cases (9.67%) of intraprocedural hemorrhage, endoscopically managed. No serious post-procedural complications and no mortality were reported. The mean procedural time was 21.87 minutes (range 15-25 minutes). Average hospitalization was 2.5 days. Five patients developed recurrence and needed a second session of endoscopic treatment for achieving complete myotomy. CONCLUSIONS: Endoscopic management for ZD was efficient and safe in our series of patients. A short hospitalization period was required.

Peroral Endoscopic Myotomy Versus Heller Myotomy for Achalasia: Pros and Cons.

Achalasia is an esophageal motor disorder that has multiple endoscopic and surgical methods of treatment. However, there is no consensus on optimal therapy in patients suffering from this disorder. This review discusses two therapies with similar but technically different concepts, peroral endoscopic myotomy and Heller surgical myotomy. After a brief introduction to the basic problems of achalasia, technical considerations, intra and postprocedural complications are presented and the advantages and disadvantages of the two procedures are discussed, based on the relevant articles in the literature. Heller surgical myotomy and peroral endoscopic myotomy appear to be similar in performance with similar results in terms of gastroesophageal reflux rates. However, with experience being gained in the field of endoscopic myotomy, this procedure seems more advantageous, with similar success rates to those of the established surgical technique, but offering shorter operating times, shorter hospitalizations and, ultimately, lower costs.