Artificial Intelligence in endoscopy: A future poll.

Artificial Intelligence [AI] has been a trendy topic in recent years, with many developed medical applications. In gastrointestinal endoscopy, AI systems include computer-assisted detection [CADe] for lesion detection as bleedings and polyps and computer-assisted diagnosis [CADx] for optical biopsy and lesion characterization. The technology behind these systems is based on a computer algorithm that is trained for a specific function. This function could be to recognize or characterize target lesions such as colonic polyps. Moreover, AI systems can offer technical assistance to improve endoscopic performance as scope insertion guidance. Currently, we believe that such technologies still lack legal and regulatory validations as a large sector of doctors and patients have concerns. However, there is no doubt that these technologies will bring significant improvement in the endoscopic management of patients as well as save money and time.

Training in basic gastrointestinal endoscopic procedures: a European Society of Gastrointestinal Endoscopy (ESGE) and European Society of Gastroenterology and Endoscopy Nurses and Associates (ESGENA) Position Statement.

This ESGE Position Statement provides structured and evidence-based guidance on the essential requirements and processes involved in training in basic gastrointestinal (GI) endoscopic procedures. The document outlines definitions; competencies required, and means to their assessment and maintenance; the structure and requirements of training programs; patient safety and medicolegal issues. 1: ESGE and ESGENA define basic endoscopic procedures as those procedures that are commonly indicated, generally accessible, and expected to be mastered (technically and cognitively) by the end of any core training program in gastrointestinal endoscopy. 2: ESGE and ESGENA consider the following as basic endoscopic procedures: diagnostic upper and lower GI endoscopy, as well as a limited range of interventions such as: tissue acquisition via cold biopsy forceps, polypectomy for lesions ≤ 10 mm, hemostasis techniques, enteral feeding tube placement, foreign body retrieval, dilation of simple esophageal strictures, and India ink tattooing of lesion location. 3: ESGE and ESGENA recommend that training in GI endoscopy should be subject to stringent formal requirements that ensure all ESGE key performance indicators (KPIs) are met. 4: Training in basic endoscopic procedures is a complex process and includes the development and acquisition of cognitive, technical/motor, and integrative skills. Therefore, ESGE and ESGENA recommend the use of validated tools to track the development of skills and assess competence. 5: ESGE and ESGENA recommend incorporating a multimodal approach to evaluating competence in basic GI endoscopic procedures, including procedural thresholds and the measurement and documentation of established ESGE KPIs. 7: ESGE and ESGENA recommend the continuous monitoring of ESGE KPIs during GI endoscopy training to ensure the trainee's maintenance of competence. 9: ESGE and ESGENA recommend that GI endoscopy training units fulfil the ESGE KPIs for endoscopy units and, furthermore, be capable of providing the dedicated personnel, infrastructure, and sufficient case volume required for successful training within a structured training program. 10: ESGE and ESGENA recommend that trainers in basic GI endoscopic procedures should be endoscopists with formal educational training in the teaching of endoscopy, which allows them to successfully and safely teach trainees.

'Potentially curative therapies' for hepatocellular carcinoma: how many patients can actually be cured?

BACKGROUND: Treatment of hepatocellular carcinoma (HCC) is predicated on early diagnosis such that 'curative therapies' can be successfully applied. The term 'curative' is, however, poorly quantitated. We aimed to complement our previous work by developing a statistical model to predict cure after ablation and to use this analysis to compare the true curative potential of the various 'curative' therapies. METHODS: We accessed data from 1571 HCC patients treated in 5 centres receiving radiofrequency (RFA) or microwave (MWA) ablation and used flexible parametric modelling to determine the curative fraction. The results of this analysis were then combined with our previous estimations to provide a simple calculator applicable to all patients undergoing potentially curative therapies. RESULTS: The cure fraction was 18.3% rising to about 40% in patients with good liver function and very small tumours. CONCLUSION: Cure for HCC treated with ablation occurs in the order of 20% to 30%, similar to that achievable by resection but much inferior to transplantation where the analogous figure is >70%. We provide a 'calculator' that permits clinicians to estimate the chance of cure for any individual patient, based on readily available clinical features.

Development, Validity, and Reliability of the Perceived Telemedicine Importance, Disadvantages, and Barriers (PTIDB) Questionnaire for Egyptian Healthcare Professionals.

BACKGROUND: This study aimed to develop and investigate the psychometric properties of the Perceived Telemedicine Importance, Disadvantages, and Barriers (PTIDB) questionnaire for healthcare professionals (HCPs) in Egypt. This study was conducted in three phases: (1) development of the questionnaire, (2) preliminary testing of the questionnaire, and (3) investigation of its validity and reliability using a large survey. METHODS: A cross-sectional survey was conducted over two months. A convenience sample of 691 HCPs and clerks from 22 governorates accessed the online survey. The construct validity was assessed using exploratory factor analysis (EFA), confirmatory factor analysis (CFA), and internal reliability. RESULTS: The initial Eigenvalues showed that all 19 items of the questionnaire explained 56.0% of the variance in three factors. For Factor 1 (importance), eight items were loaded on one factor, with factor loading ranging from 0.61 to 0.78. For Factor 2 (disadvantages), seven items were loaded on one factor with factor loading ranging from 0.60 to 0.79. For Factor 3 (barriers), four items were loaded on one factor, with factor loading ranging from 0.60 to 0.86. The CFA showed that All loadings ranged from 0.4 to 1.0, with CFI = 0.93 and RMSEA = 0.061. All the factors had satisfactory reliability; 0.87 for ''Importance'', 0.82 for ''Disadvantages'', and 0.79 for ''Barriers''. CONCLUSION: The PTIDB questionnaire has an acceptable level of validity and internal consistency, at a readability level of 12th grade. The retest reliability, however, still needs to be tested.

Quality indicators for colonoscopy in Egypt: A prospective multicenter study.

BACKGROUND AND STUDY AIMS: Despite its wide availability, we do not have sufficient data aboutthe quality of colonoscopy in Egypt. In this study, we proposed 13 indicators to assess the quality of colonoscopy procedures in the included study centers aiming to attain a representative image of the quality of CS in Egypt. PATIENTS AND METHODS: A multicenter prospective study was conducted between July and December 2020, which included all patients who underwent colonoscopy in the participating centers. The following were the proposed quality indicators: indications for colonoscopy, preprocedure clinical assessment, obtaining written informed consent, adequate colon preparation, sedation, cecal intubation rate (CIR), withdrawal time, adenoma detection rate (ADR), complication rate, photographic documentation, automated sterilization, regular infection control check, and well-equipped postprocedure recovery room. RESULT: A total of 1,006 colonoscopy procedures were performed during the study duration in the included centers. Our analysis showed the following four indicators that were fulfilled in all centers: appropriate indications for colonoscopy, preprocedure assessment, written informed consent, and automated sterilization. However, photographic documentation and postprocedure follow-up room were fulfilled only in 57 %. Furthermore, 71 % of the centers performed regular infection control checks. Adequate colon preparation was achieved in 61 % of the procedures, 81 % of the procedures were performed under sedation, 95.4 % CIR, 11-min mean withdrawal time, 15 % ADR, and 0.1 % overall complication rate. Statistically significant factors affecting CIR were age > 40 years, high-definition endoscope, previous colon intervention, and rectal bleeding, whereas those affecting ADR were age > 40 years, the use of image enhancement, previous colon intervention, rectal bleeding, the use of water pump, and a withdrawal time of > 9 min. CONCLUSION: Our study revealed the bright aspects of colonoscopy practice in Egypt, including high CIRs and low complication rates; conversely, ADR, bowel cleansing quality, and infection control measures should be improved.

Healthcare Providers' Perspective about the Use of Telemedicine in Egypt: A National Survey.

Incorporation of telemedicine in general clinical practice is becoming a compelling need nowadays in the context of COVID-19 pandemic and its consequent burdens on the healthcare systems. Though telemedicine appears to be appealing and carries a lot of advantages, yet it is still faced by many challenges and barriers especially in developing countries. Our aim was to explore the impression of healthcare providers about telemedicine and its applicability in clinical practice in Egypt. A cross-sectional study was conducted among healthcare providers from different Egyptian governorates through a web-based survey. The survey gathered information about demographic, socioeconomic features of the enrolled healthcare participants; their knowledge, previous experience, impression about telemedicine, advantages of telemedicine over traditional medical services, barriers that may face telemedicine, and additional services that can be provided by telemedicine were also explored. Our study enrolled 642 healthcare providers from all over Egypt, 43.77% were females, of which 55.5% were physicians, 27.3% were nurses, 6.1% were technicians, 7.6% were administrative clerks, and 3.6% were medical directors. Sixty-four percent of participants reported that they have never used telemedicine. Smartphones were the most commonly used mean in the group who used telemedicine (65%), and smartphone applications were the favorable telemedicine service for about 50% of participants. Participants assumed that the use of telemedicine might not have a negative effect on the doctor-patient relationship but raised some concerns regarding the privacy and security of patients' data. Despite the fact that telemedicine appears to be appealing and widely accepted by healthcare providers, yet still, its implementation is confronted by some obstacles. Precise organizational guidelines need to be developed to clearly figure out the exact role of each healthcare provider to minimize their doubtfulness about telemedicine and to facilitate its adoption.

Acoustic radiation force impulse to measure liver stiffness and predict hepatic decompensation in pregnancy with cirrhosis: A cohort study.

BACKGROUND AND STUDY AIMS: Pregnancy in association with cirrhosis is a rather uncommon and highly risky situation for both mother and child. We aim to study all factors and the utility of liver stiffness (LS) measurement by Acoustic Radiation Force Impulse elastography (ARFI) to predict hepatic decompensation in pregnant cirrhotic patients. PATIENTS AND METHODS: We prospectively recruited 224 pregnant women at the multidisciplinary clinic of liver disease with pregnancy, Cairo University. LS was measured using ARFI (Siemens ACUSON S3000 ultrasound system) during the second trimester and 8-12 weeks post-delivery. The outcome of pregnancy and the incidence of hepatic decompensation were assessed. RESULTS: Our cohort comprised 128 normal pregnancies, 37 patients with pregnancy-related liver disease (Intrahepatic cholestasis (n = 6), preeclampsia (n = 23), and hyperemesis gravidarum (n = 8)) and 59 patients with an established chronic liver disease not related to pregnancy. In all patients, LS significantly decreased after delivery from 1.19 m/s to 0.94 m/s (P < 0.001). In multivariate analysis, LS was an independent predictor for the outcome of pregnancy in all patients (odds ratio (OR) = 5.442 (3.01-6.82), cut-off = 1.21 m/s). Patients with cirrhosis, mean LS was 1.57 ± 0.66 m/s and 26 (44%) patients had hepatic decompensation (hepatocellular jaundice (n = 8), ascites (n = 9) and variceal bleeding (n = 6)). In multivariate analysis; LS, platelets, albumin, and bilirubin were independent predictors of decompensation post-delivery and the OR for LS was 6.141(4.32-7.98). The optimal cut off value of LS to predict decompensation was 1.46 m/s (8.4 kPa) with AUROC of 0.827. CONCLUSION: LS can be used to predict hepatic decompensation after delivery in pregnant women with manifest cirrhosis.

The TM6SF2 variant as a risk factor for hepatocellular carcinoma development in chronic liver disease patients.

Introduction: Hepatocellular carcinoma (HCC) is one of the most prevalent cancers worldwide. A non-synonymous single nucleotide polymorphism (SNP) of the transmembrane 6 superfamily member 2 (TM6SF2) gene is associated with non-alcoholic fatty liver disease. SNPs of the TM6SF2 gene play an important role in the pathogenesis of HCC in alcoholic cirrhosis, but there are limited data regarding other possible etiologies. We aimed to evaluate the role of the rs58542926 polymorphism in the development of HCC in Egyptian chronic liver disease (CLD) patients. Material and methods: A total of 120 participants, including 40 HCC patients, 40 CLD patients, and 40 healthy controls, were selected. Real-time polymerase chain reaction (RT-PCR) was used to detect the TM6SF2 rs58542926 polymorphism. Results: There were no significant differences among the three studied groups regarding age (p = 0.06) and gender (p = 0.75). Frequencies of the CT, TT, CT + TT genotypes and the T allele were significantly higher in HCC patients than in the CLD and control groups (p < 0.001, p = 0.005, and p < 0.001, respectively). CLD patients with the CT genotype had a significantly increased risk of HCC development (OR = 4.67, 95% CI: 1.67-12.90). Patients with the TT genotype had a significantly increased risk of HCC (OR = 9.33, 95% CI: 1.72-50.61). Moreover, the T allele was correlated with an increased risk of HCC (OR = 5.44, 95% CI: 2.09-14.17) compared to the C allele. Conclusions: The TM6SF2 rs58542926 genotype is associated with an increased risk of HCC in the Egyptian population.

Direct modulation of hepatocyte hepcidin signaling by iron.

BACKGROUND: Liver-secreted hepcidin is the systemic master switch of iron homeostasis and decreased levels of hepcidin are considered to cause iron overload not only in hereditary hemochromatosis but also in hemolytic anemia and chronic liver diseases. The regulation of hepcidin is complex and its response to iron is still not completely understood. AIM: To study the direct effect of iron on various established hepcidin signaling pathways in hepatoma cells or primary hepatocytes. METHODS: Hepcidin mRNA expression was studied by quantitative real-time (qRT)-PCR in the presence of various forms of iron including ferric ammonium citrate (FAC) in hepatoma cells (Huh7), murine primary hepatocytes and an established co-culture model of phorbol myristate acetate-differentiated THP-1 monocytes and Huh7 cells. To analyze hepcidin signaling, the response to bone morphogenetic protein 6 (BMP6), interleukin (IL)-6, IL-1ß, hypoxia and lipopolysaccharide (LPS) were studied. Hepcidin and small mothers against decapentaplegic 6 (SMAD6) mRNA levels were assessed by qRT-PCR and the expression of phosphorylated signal transducer and activator of transcription 3 (phospho-STAT3), STAT3, phospho-SMAD1/5/8 and SMAD1 proteins were analyzed by western blot. RESULTS: All iron III forms including FAC efficiently blocked hepcidin mRNA expression at non-toxic dosages in Huh7 cells or primary hepatocytes in a time and dose-dependent manner (P < 0.001; P < 0.05). Hepcidin blockage could be efficiently blunted by iron chelators salicylaldehyde isonicotinoyl hydrazone (SIH) and Desferal (P < 0.001). FAC also inhibited BMP6, hypoxia, IL-1ß and IL-6-mediated hepcidin induction (P < 0.001; P < 0.001; P < 0.05; P < 0.001), and FAC also inhibited LPS-mediated hepatic hepcidin induction in co-culture model (P < 0.001). Moreover, FAC reduced SMAD6 mRNA and p-SMAD1/5/8 protein expression at basal or upon stimulation by BMP6 (P < 0.05; P < 0.01), and FAC also reduced SMAD6 and p-SMAD1/5/8 expression under hypoxia (P < 0.01; P < 0.05). However, FAC has no significant effect on p-STAT3 protein expression at basal or upon stimulation by various stimuli. Notably, in the presence of the BMP/SMAD signaling pathway inhibitor LDN193189 Hydrochloride (LDN), FAC was unable to further decrease hepcidin, SMAD6 and p-SMAD1/5/8 expression compared with LDN alone. CONCLUSION: Iron directly blocks hepatocellular hepcidin signaling through the BMP/SMAD pathway but independent of STAT3. This mechanism may contribute to continued iron overload in many pathophysiological conditions ultimately causing a vicious cycle of continued hepcidin suppression.

Predictors for Severity of SARS-CoV-2 Infection Among Healthcare Workers.

BACKGROUND: Healthcare workers (HCWs) are still at higher risk of acquiring severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infections than the general population. Identifying risk factors associated with severe SARS-CoV-2 infections is of paramount importance to protect HCWs and the non-infected patients attending different healthcare facilities. PURPOSE: To recognize the predictors for severity of SARS-CoV2 infection among HCWs working in either COVID-19 or non-COVID-19 healthcare settings. Also, to assess compliance of HCW to standard precautions of infection control and explore the possible risk factors for SARS-CoV-2 infection among HCWs. METHODS: A cross-sectional study was conducted among HCWs with suspected or confirmed SARS-CoV-2 infection, from different Egyptian governorates. They were asked to fill in a web-based self-reporting questionnaire. The questionnaire assessed the demographic and socio-economic characteristics of participants, compliance of HCWs to standard precautions of infection control and COVID-19 presentation. RESULTS: Our study enrolled 204 HCWs (52.3% physicians). Infection of SARS-CoV-2 was confirmed in 61.3% by RT- PCR; 35.8% were admitted to hospital, and of these, 3.9% were admitted to the intensive care unit. While 30.4% had mild disease, 48.5% had moderate disease, 17.2% had severe disease and 3.9% had critical disease. Regression analysis for variables predicting COVID-19 severity among study healthcare workers showed that associated chronic diseases and management at home were the main independent variables predicting severity of their SARS-COV-2 infection, while the variables age, sex, residence, occupation or drug history of immunosuppressives had no role in severity prediction. CONCLUSION: Associated chronic diseases and management at home were the main independent variables predicting severity of SARS-COV-2 infection among HCWs. So, HCWs with chronic diseases should not work in COVID-19 designated hospitals, and there should be a screening strategy for their infection with SARS-COV-2. HCWs must not be negligent in adhering to strict precautions of infection control. HCWs infected with SARS-COV-2 must be managed in hospital not at home.

Knowledge, Applicability, and Barriers of Telemedicine in Egypt: A National Survey.

OBJECTIVES: The study is aimed at evaluating knowledge, attitude, and barriers to telemedicine among the general population in Egypt. METHODS: A questionnaire-based cross-sectional design was carried out among the general Egyptian population. A convenience sampling method was used to approach the eligible participants from University Teaching Hospitals of eight governorates from May to July 2020. RESULTS: A total of 686 participants filled the questionnaire (49.4% were males, mean age 36.7 ± 11.2 years old). Half of the participants stated that they previously used a telemedicine tool, mainly to follow up laboratory results (67.3%). Video or phone calls (39.3%) and mobile applications (23.7%) were the most commonly recognized telemedicine tools by the participants. The included participants exhibited a high level of knowledge and attitude towards telemedicine. On the other hand, 21.9% stated that telemedicine services could jeopardize patient privacy. 32.8% reported that telemedicine service could lead to disclosing medical information to people who are not authorized to do so. Almost half of the participants agreed to strongly agreed that telemedicine service could increase medical errors. 60.80% of the participants said that they are more likely to prefer telemedicine than traditional ways. However, 13.70% stated that telemedicine is more likely to be challenging to use. CONCLUSION: The Egyptian population has high knowledge about the applications of telemedicine. In addition, the vast majority of Egyptians appear to perceive the benefits of telemedicine positively and are willing to use it. However, some barriers that have been found must be taken into consideration to adopt telemedicine successfully, especially for people who are old, are low educated, and live in remote areas. Future studies should address the utility of telemedicine in improving the quality of healthcare and patient's health outcome and quality of life.

Outcomes of curative liver resection for hepatocellular carcinoma in patients with cirrhosis.

BACKGROUND: Given the poor synthetic function of cirrhotic liver, successful resection for patients with hepatocellular carcinoma (HCC) necessitates the ability to achieve resections with tumor free margins. AIM: To validate post hepatectomy liver failure score (PHLF), compare it to other established systems and to stratify risks in patients with cirrhosis who underwent curative liver resection for HCC. METHODS: Between December 2010 and January 2017, 120 patients underwent curative resection for HCC in patients with cirrhosis were included, the pre-operative, operative and post-operative factors were recorded to stratify patients' risks of decompensation, survival, and PHLF. RESULTS: The preoperative model for end-stage liver disease (MELD) score [odds ratio (OR) = 2.7, 95%CI: 1.2-5.7, P = 0.013], tumor diameter (OR = 5.4, 95%CI: 2-14.8, P = 0.001) and duration of hospital stay (OR = 2.5, 95%CI: 1.5-4.2, P = 0.001) were significant independent predictors of hepatic decompensation after resection. While the preoperative MELD score [hazard ratio (HR) = 1.37, 95%CI: 1.16-1.62, P < 0.001] and different grades of PHLF (grade A: HR = 2.33, 95%CI: 0.59-9.24; Grade B: HR = 3.15, 95%CI: 1.11-8.95; Grade C: HR = 373.41, 95%CI: 66.23-2105.43; P < 0.001) and HCC recurrence (HR = 11.67, 95%CI: 4.19-32.52, P < 0.001) were significant independent predictors for survival. CONCLUSION: Preoperative MELD score and tumor diameter can independently predict hepatic decompensation. While, preoperative MELD score, different grades of PHLF and HCC recurrence can precisely predict survival.

Refining the Baveno VI elastography criteria for the definition of compensated advanced chronic liver disease.

BACKGROUND: The Baveno VI consensus proposed a dual liver stiffness (LS) by transient elastography threshold of <10 and >15 kPa for excluding and diagnosing compensated advanced chronic liver disease (cACLD) in the absence of other clinical signs. Herein, we aimed to validate these criteria in a real-world multicentre study. METHODS: We included 5,648 patients (mean age 51 ± 13 years, 53% males) from 10 European liver centres who had a liver biopsy and LS measurement within 6 months. We included patients with chronic hepatitis C (n = 2,913, 52%), non-alcoholic fatty liver disease (NAFLD, n = 1,073, 19%), alcohol-related liver disease (ALD, n = 946, 17%) or chronic hepatitis B (n = 716, 13%). cACLD was defined as fibrosis stage ≥F3. RESULTS: Overall, 3,606 (66%) and 987 (18%) patients had LS <10 and >15 kPa, respectively, while cACLD was histologically confirmed in 1,772 (31%) patients. The cut-offs of <10 and >15 kPa showed 75% sensitivity and 96% specificity to exclude and diagnose cACLD, respectively. Examining the ROC curve, a more optimal dual cut-off at <7 and >12 kPa, with 91% sensitivity and 92% specificity for excluding and diagnosing cACLD (AUC 0.87; 95% CI 0.86-0.88; p <0.001) was derived. Specifically, for ALD and NAFLD, a low cut-off of 8 kPa can be used (sensitivity=93%). For the unclassified patients, we derived a risk model based on common patient characteristics with better discrimination than LS alone (AUC 0.74 vs. 0.69; p <0.001). CONCLUSIONS: Instead of the Baveno VI proposed <10 and >15 kPa dual cut-offs, we found that the <8 kPa (or <7 kPa for viral hepatitis) and >12 kPa dual cut-offs have better diagnostic accuracy in cACLD. LAY SUMMARY: The term compensated advanced chronic liver disease (cACLD) was introduced in 2015 to describe the spectrum of advanced fibrosis and cirrhosis in asymptomatic patients. It was also suggested that cACLD could be diagnosed or ruled out based on specific liver stiffness values, which can be non-invasively measured by transient elastography. Herein, we assessed the suggested cut-off values and identified alternative values that offered better overall accuracy for diagnosing or ruling out cACLD.

Barriers for resuming endoscopy service in the context of COVID-19 pandemic: A multicenter survey from Egypt.

BACKGROUND: The current coronavirus disease 2019 (COVID-19) pandemic has affected routine endoscopy service across the gastroenterology community. This led to the suspension of service provision for elective cases. AIM: To assess the potential barriers for resuming the endoscopy service in Egypt. METHODS: A national online survey, four domains, was disseminated over a period of 4 wk in August 2020. The primary outcome of the survey was to determine the impact of the COVID-19 pandemic on the endoscopy service and barriers to the full resumption of a disabled center(s). RESULTS: A hundred and thirteen Egyptian endoscopy centers participated in the survey. The waiting list was increased by ≥ 50% in 44.9% of areas with clusters of COVID-19 cases (n = 49) and in 35.5% of areas with sporadic cases (n = 62). Thirty nine (34.8%) centers suffered from staff shortage, which was considered a barrier against service resumption by 86.4% of centers in per-protocol analysis. In multivariate analysis, the burden of cases in the unit locality, staff shortage/recovery and the availability of separate designated rooms for COVID-19 cases could markedly affect the resumption of endoscopy practice (P = 0.029, < 0.001 and 0.02, respectively) and Odd's ratio (0.15, 1.8 and 0.16, respectively). CONCLUSION: The COVID-19 pandemic has led to restrictions in endoscopic volumes. The staff shortage/recovery and the availability of COVID-19 designed rooms are the most important barriers against recovery. Increasing working hours and dividing endoscopy staff into teams may help to overcome the current situation.

Optimization of biliary drainage in inoperable distal malignant strictures.

BACKGROUND: Given most patients with distal malignant biliary obstruction present in the non-resectable stage, palliative endoscopic biliary drainage with fully covered metal stent (FCMS) or uncovered metal stent (UCMS) is the only available measure to improve patients' quality of life. Half covered metal stent (HCMS) has been recently introduced commercially. The adverse effects and stent function between FCMS and UCMS have been extensively discussed. AIM: To study the duration of stent patency of HCMS and compare it with FCMS and UCMS to optimize biliary drainage in inoperable patients with distal malignant obstruction. Secondary aims in our study included evaluation of patients' survival and the rates of adverse events for each type of stent. METHODS: We studied 210 patients and randomized them into three equal groups; HCMS, FCMS and UCMS were inserted endoscopically. RESULTS: Stent occlusion occurred in (18.6%, 17.1% and 15.7% in HCMS, FCMS and UCMS groups, respectively, P = 0.9). Stent migration occurred only in patients with FCMS (8.6% of patients). Cholangitis and cholecystitis occurred in 11.4% and 5.7% of patients, respectively, in FCMS. Tumor growth occurred only in 10 cases among patients with UCMS after a median of 140 d, sludge occurred in nine, seven and one patients in HCMS, FCMS and UCMS, respectively (P = 0.04). CONCLUSION: Given the prolonged stent functioning time, the use of HCMS is preferred over the use of UCMS and FCMS for optimizing biliary drainage in patients with distal malignant biliary obstruction.

Prospective Comparison of Transient Elastography Using Two Different Devices: Performance of FibroScan and FibroTouch.

PURPOSE: Transient elastography (TE) using FibroScan (FS) has been established to non-invasively assess liver fibrosis and steatosis. The aim of this study was to compare the recently introduced FibroTouch (FT) device with the established FS with respect to liver stiffness and CAP. PATIENTS AND METHODS: Thirty-nine patients with and without liver disease were included. All patients were measured three times with FS (FibroScan 530 compact, Echosens, France) and FT (FibroTouch-FT100, Wuxi Hisky Med, China). For FS, M and XL probe were used according to the manufacturer's specifications. For steatosis, CAP and the comparable FT equivalent UAP (ultrasound attenuation parameter) was determined. Finally, FT and FS were explored in liver tissue-mimicking phantoms. RESULTS: LS between FS and FT correlated well with r=0.91. Root-mean-square (RMS) of the coefficient of variation for LS was better in FS (11.1% vs 27.4%). Bland-Altman analysis showed a 3.1 kPa mean overestimation of LS by FT. In addition, UAP strongly and linearly depended on the BMI following UAP=3.02 × BMI+186. In phantoms, a similar relation was found with UAP (phantom)= 3.78 × BMI + 146 suggesting that UAP is directly calculated from entered BMI instead of assessing shear-wave attenuation. Consequently, RMS-CV was lower for FT (6.0% vs 9.7%). However, if using different BMI, CV-RMS for FT increased to 12.7%. LS of a patient with manifest liver cirrhosis and ascites was 38.8 kPa using the FS-XL probe but almost normal with FT (7.2 kPa). CONCLUSION: Although LS by FT shows good correlation with LS-FS, it has larger variation, continuously overestimates LS and completely fails in ascites. Moreover, FT-UAP seems to be a misleading parameter for steatosis assessment because it is at least in part calculated from mandatory entered patient data. In conclusion, novel LS cut-off values need to be defined for LS-FT and usage of UAP is not recommended.