Performance of the Choledocholithiasis Diagnostic Score in Patients with Acute Cholecystitis.

INTRODUCTION: The prevalence of choledocholithiasis among patients with acute cholecystitis is estimated to be between 9 and 16.5%. There are no validated algorithms to predict choledocholithiasis in this group of patients. AIM: The aim of this study was to evaluate the performance of the choledocholithiasis diagnostic score proposed by the American Society for Gastrointestinal Endoscopy, in patients with acute cholecystitis. MATERIAL/METHODS: A retrospective cross-sectional study, covering a 4-year period at a secondary care hospital, was performed. All patients with an encoded diagnosis of acute cholecystitis and with at least one of the following procedures were included: endoscopic retrograde cholangiopancreatography (ERCP), endoscopic ultrasound, magnetic resonance cholangiopancreatography, and intraoperative cholangiography. RESULTS: Among 4,369 patients with the diagnosis of acute cholecystitis, 40 (0.92%) had clinical or sonographic suspicion of choledocholithiasis. Their mean age was 68.1 ± 15 years, and 22 (55%) were men. Thirty-one of the patients included (77.5%) had a high risk of choledocholithiasis, and 9 (22.5%) had an intermediate risk. In 16 (51.6%) of the 31 patients with a high risk, the diagnosis of choledocholithiasis was confirmed. In 2 (22.2%) of the 9 patients with an intermediate risk, the diagnosis of choledocholithiasis was also confirmed. The high risk score for choledocholithiasis had a positive predictive value of 52% and a sensitivity of 89%. The intermediate risk score for choledocholithiasis had a positive predictive value of 22% and a sensitivity of 11%. DISCUSSION AND CONCLUSIONS: Suspicion of choledocholithiasis in patients with acute cholecystitis was a rare event (<1%). The sensitivity of the high risk score was approximately the same as found in published series with patients with suspected choledocholithiasis overall (86%), while the positive predictive value was substantially lower (52 vs. 79.8%). Therefore, in patients with acute cholecystitis and suspected choledocholithiasis, this score should not be used to screen for common bile duct stones, and a sensitive method should be used prior to ERCP.

Introdução: A prevalência de coledocolitíase em doentes com colecistite aguda é estimada entre 9 e 16.5%. Não existem algoritmos validados para o diagnóstico de coledocolitíase neste grupo de doentes. Objectivo: Avaliar a performance do score de coledocolitíase proposto pela American Society for Gastrointestinal Endoscopy, em doentes com coleciste aguda. Material/Métodos: Foi realizado um estudo retrospectivo transversal, durante um período de 4 anos num hospital de cuidados secundários. Foram incluídos todos os doentes com diagnóstico codificado de colecistite aguda e pelo menos um dos seguintes procedimentos: colangiopancreatografia retrógrada, ecoendoscopia, colangiopancreatografia por ressonância magnética e colangiografia intra-operatória. Resultados: Em 4,369 doentes com diagnóstico de colecistite aguda, 40 (0.92%) tiveram suspeita clínica ou ecográfica de coledocolitíase. A idade média foi 68.1 ± 15 anos e 22 (55%) eram homens. Dos doentes incluídos, 31 (77.5%) tinham score elevado de coledocolitíase e 9 (22.5%) tinham score intermédio. Em 16/31 (51.6%) doentes com score elevado o diagnóstico de coledocolitíase foi confirmado. Em 2/9 (22.2%) doentes com score intermédio foi também confirmada coledocolitíase. O score elevado de probabilidade de coledocolitíase teve um valor preditivo positivo de 52% e uma sensibilidade de 89%. O score intermédio de probabilidade teve um valor preditivo positivo de 22% e uma sensibilidade de 11%. Discussão e Conclusões: A suspeita de coledocolitíase em doentes com colecistite aguda foi um evento raro (<1%). A sensibilidade do score elevado de probabilidade foi semelhante ao reportado na literatura (86%), mas o valor preditivo positivo foi significativamente menor (52 vs. 79.8%). Assim, em doentes com colecistite aguda e suspeita de coledocolitíase este score não deve ser utilizado, devendo ser realizado um método de diagnóstico antes da CPRE.

Adenoma Detection Rate: I Will Show You Mine if You Show Me Yours.

BACKGROUND: Colorectal cancer (CRC) is the first cause of cancer-related mortality in Portugal. CRC screening reduces disease-specific mortality. Colonoscopy is currently the preferred method for screening as it may contribute to the reduction of CRC incidence. This beneficial effect is strongly associated with the adenoma detection rate (ADR). AIM: Our aim was to evaluate the quality of colonoscopy at our unit by measuring the currently accepted quality parameters and publish them as benchmarking indicators. METHODS: From 5,860 colonoscopies, 654 screening procedures (with and without previous fecal occult blood testing) were analyzed. RESULTS: The mean age of the patients was 66.4 ± 7.8 years, and the gender distribution was 1:1. The overall ADR was 36% (95% confidence interval [CI] 32-39), the mean number of adenomas per colonoscopy was 0.66 (95% CI 0.56-0.77), and the sessile serrate lesion detection rate was 1% (95% CI 0-2). The bowel preparation was rated as adequate in 496 (76%) patients. The adjusted cecal intubation rate (CIR) was 93.7% (95% CI 91.7-95.8). Most colonoscopies were performed under monitored anesthesia care (53%), and 35% were unsedated. The use of sedation (propofol or midazolam based) was associated with a higher CIR with an odds ratio of 3.60 (95% CI 2.02-6.40, p < 0.001). CONCLUSION: Our data show an above-standard ADR. The frequency of poor bowel preparation and the low sessile serrated lesion detection rate were acknowledged, and actions were implemented to improve both indicators. Quality auditing in colonoscopy should be compulsory, and while many units may do so internally, this is the first national report from a high-throughput endoscopy unit.

History matching through dynamic decision-making.

History matching is the process of modifying the uncertain attributes of a reservoir model to reproduce the real reservoir performance. It is a classical reservoir engineering problem and plays an important role in reservoir management since the resulting models are used to support decisions in other tasks such as economic analysis and production strategy. This work introduces a dynamic decision-making optimization framework for history matching problems in which new models are generated based on, and guided by, the dynamic analysis of the data of available solutions. The optimization framework follows a 'learning-from-data' approach, and includes two optimizer components that use machine learning techniques, such as unsupervised learning and statistical analysis, to uncover patterns of input attributes that lead to good output responses. These patterns are used to support the decision-making process while generating new, and better, history matched solutions. The proposed framework is applied to a benchmark model (UNISIM-I-H) based on the Namorado field in Brazil. Results show the potential the dynamic decision-making optimization framework has for improving the quality of history matching solutions using a substantial smaller number of simulations when compared with a previous work on the same benchmark.

Non-anesthesiologist administration of propofol sedation for colonoscopy is safe in low risk patients: results of a noninferiority randomized controlled trial.

BACKGROUND AND STUDY AIMS: Propofol provides the best sedation in colonoscopy. The safety of non-anesthesiologist administration of propofol (NAAP) is still a matter of debate. The aim of the current study was to evaluate sedation safety, colonoscopy quality, and patient satisfaction with NAAP. PATIENTS AND METHODS: The study was a single-blinded, noninferiority, randomized controlled trial comparing NAAP (Group A) with anesthesiologist-administered sedation (Group B) performed at a single academic institution. Patients (18 - 80 years) who underwent colonoscopy and were at low anesthetic risk (American Society of Anesthesiologists class I - II) were included. The primary end point was the incidence of adverse events. Secondary end points were propofol dose, patient satisfaction and pain, colonoscopy quality indicators, and procedure and recovery times. RESULTS: A total of 277 patients were included in the analysis. The incidence of adverse events was 39.3 % in Group A and 39.0 % in Group B (absolute difference - 0.3 %, 95 % confidence interval [CI] - 12.0 % to 11.4 %; P = 0.959). There were no sentinel adverse events. The following interventions (Group A vs. Group B) were necessary: atropine administration (0 % vs. 5.5 %; P = 0.004); airway repositioning (8.7 % vs. 4.7 %; P = 0.196); increased oxygen administration (6.7 % vs. 3.9 %; P = 0.317), and increased fluid rate (2.7 % vs. 0.8 %; P = 0.379). There were no differences in cecal intubation and adenoma detection rates. Recovery times were longer in Group B (58 ±â€Š33 vs. 67 ±â€Š29 minutes; P = 0.032). There were no differences in mean propofol dose, withdrawal time, painless colonoscopy, satisfaction, and amnesia. All but two patients (Group B) were willing to repeat the colonoscopy. CONCLUSIONS: NAAP is equivalent to anesthesiologist-administered sedation in the rate of adverse events in a low risk population. TRIAL REGISTRATION: ClinicalTrials.gov (NCT02067065).

Role of endoscopic retrograde cholangiopancreatography in the management of benign biliary strictures: What's new?

Benign biliary strictures comprise a heterogeneous group of diseases. The most common strictures amenable to endoscopic treatment are post-cholecystectomy, post-liver transplantation, related to primary sclerosing cholangitis and to chronic pancreatitis. Endoscopic treatment of benign biliary strictures is widely used as first line therapy, since it is effective, safe, noninvasive and repeatable. Endoscopic techniques currently used are dilation, multiple plastic stents insertion and fully covered self-expandable metal stents. The main indication for dilation alone is primary sclerosing cholangitis related strictures. In the vast majority of the remaining cases, temporary placement of multiple plastic stents with/without dilation is considered the treatment of choice. Although this approach is effective, it requires multiple endoscopic sessions due to the short duration of stent patency. Fully covered self-expandable metal stents appear as a good alternative to plastic stents, since they have an increased radial diameter, longer stent patency, easier insertion technique and similar efficacy. Recent advances in endoscopic technique and various devices have allowed successful treatment in most cases. The development of novel endoscopic techniques and devices is still ongoing.

Self-Expandable Metal Stents for Colorectal Cancer: From Guidelines to Clinical Practice.

INTRODUCTION: Colonic self-expandable metal stent placement is widely used for palliation of obstructive colorectal cancer. The European recommendations for stent placement as a bridge to elective surgery in obstructive colorectal cancer were recently reviewed. The aim of this study was to evaluate the efficacy and safety of stent placement in obstructive colorectal cancer and to discuss these recent guidelines. MATERIALS AND METHODS: Demographic characteristics, procedure indications, complications and final outcome in patients with obstructive colorectal cancer who underwent endoscopic stent placement between January 2012 and June 2015 were retrospectively analyzed. Statistical analysis was performed with SPSS V22. RESULTS: Thirty-six patients were included, 20 (56%) women, mean age 70.6 ± 10.9 years. Stent placement as a bridge to elective surgery was performed in 75% (n = 27) of patients and with palliation intent in 25% (n = 9). In 94% (n = 34) of procedures, technical and clinical success was achieved. A total of eleven (11%) complications were observed: 2 migrations and 9 perforations. No procedure related death was recorded. When stents were placed as a bridge to surgery, average time between endoscopic procedure and surgery was 11.7 ± 9.4 days (excluding three patients who underwent neoadjuvant chemotherapy). Six perforations were recorded in this group: one overt and five silent (three during surgery and two after histopathological examination of the resected specimen). Twenty-one patients underwent adjuvant chemotherapy. During the follow-up period of 14.7 ± 10.9 months recurrence was observed in five patients. None of the recurrence occurred in the group of patients with perforation. CONCLUSIONS: In this study, stent placement was an effective procedure in obstructive colorectal cancer. It was mainly used as a bridge to elective surgery. However, a significant rate of silent perforation was observed, which may compromise the oncological outcome of these potentially curable patients. Prospective real life studies are warranted for a better definition of actual recommendations.

INTRODUÇÃO: A colocação de próteses metálicas autoexpansíveis é um procedimento endoscópico amplamente realizado como tratamento paliativo do cancro colo-rectal. As recomendações europeias para a colocação de prótese como ponte para a cirurgia na obstrução por cancro colo-rectal foram revistas recentemente. O objetivo deste estudo foi avaliar a eficácia e segurança da colocação de próteses na obstrução maligna por cancro colo-rectal e discutir as últimas recomendações publicadas. MATERIAIS E MÉTODOS: Análise retrospectiva das características demográficas, indicações, complicações e resultados da colocação de próteses metálicas autoexpansíveis em doentes com cancro colo-rectal obstrutivo entre janeiro de 2012 e junho de 2015. A análise estatística foi realizada com SPSS V22. RESULTADOS: Foram incluídos 36 doentes, 20 (56%) do sexo feminino, com idade média de 70.6 ± 10.9 anos. As próteses foram colocadas como ponte para cirurgia em 75% (n = 27) dos casos e com intuito paliativo em 25% (n = 9). Em 94% (n = 34) dos procedimentos obteve-se sucesso técnico e clínico. No total registaram-se 11 (31%) complicações: 2 migrações e 9 perfurações. Não se registou mortalidade associada ao procedimento. Nos casos como ponte para a cirurgia, o tempo médio entre o procedimento endoscópico e a cirurgia foi de 11.7 ± 9.4 dias (excluídos três doentes submetidos a quimioterapia neoadjuvante). Observaram-se seis perfurações neste grupo de doentes: uma perfuração clínica e cinco silenciosas (três intra-operatoriamente e duas após avaliação anatomopatológica da peça operatória). Vinte e um doentes foram submetidos a quimioterapia adjuvante. Após um tempo médio de seguimento de 14.7 ± 10.9 meses, registaram-se cinco casos de recorrência. Nenhum dos casos de recorrência ocorreu no grupo de doentes com perfuração. CONCLUSÕES: Nesta amostra, a colocação de prótese revelou-se um procedimento endoscópico eficaz. Na maioria dos doentes foi utilizada como ponte para a cirurgia. No entanto, verificou-se uma taxa significativa de perfuração silenciosa que poderá comprometer o resultado oncológico de doentes tratados com intuito curativo. Estudos prospetivos da prática real podem ser úteis para uma melhor definição das recomendações atuais.