Mechanical Perspective on Increasing Brush Cytology Yield.

Brush cytology is a sampling technique extensively used for mucosal surfaces, particularly to identify malignancies. A sample is obtained by rubbing the brush bristles over the stricture or lesion several times until cells are trapped. Brush cytology detection rate varies, with malignancy confirmed in 15-65% of cases of adenocarcinoma-associated biliary strictures and 44-80% of cases of cholangiocarcinoma. Despite the widespread use of brush cytology, there is no consensus to date defining the optimal biliary brushing parameters for the collection of suspicious lesions, such as the number of passes, brushing rate, and force applied. The aim of this work is to increase the brush cytology diagnostic yield by elucidating the underlying mechanical phenomena. First, the mechanical interactions between the brush bristles and sampled tissue are analyzed. During brushing, mucus and detached cells are transferred to the space between the bristles through the capillary rise and flow eddies. These mass transfer mechanisms and their dependence on mucus rheology as a function of pH, brush displacement rate, and bristle geometry and configuration are examined. Lastly, results from ex vivo brushing experiments performed on porcine stomachs are presented. Clinical practitioners from a variety of disciplines can apply the findings of this study to outline clear procedures for cytological brushing to increase the sensitivity and specificity of the brushings.

Identification and control of two outbreaks of unrelated New Delhi metallo-ß-lactamase-producing carbapenem-resistant Escherichia coli traced to the same endoscope defect.

We report 2 outbreaks of genetically unrelated carbapenem-resistant New Delhi metallo-ß-lactamase-producing Escherichia coli caused by contaminated duodenoscopes. Using endoscopes with disposable end caps, adherence to the manufacturer's reprocessing instructions, routine audits, and manufacturer evaluation are critical in preventing such outbreaks.

Pancreatic cyst dilemma: Between physical and biochemical markers.

Physical analysis of the pancreatic cystic lesions (PCLs) fluid as expressed by the rheological behavior ("string sign") can improve the diagnostic yield and should be integrated in every multimodal PCLs workup.

Heparanase as a potential player in SARS-CoV-2 infection and induced coagulopathy.

During the current formidable COVID-19 pandemic, it is appealing to address ideas that may invoke therapeutic interventions. Clotting disorders are well recognized in patients infected with severe acute respiratory syndrome (SARS) caused by a novel coronavirus (SARS-CoV-2), which lead to severe complications that worsen the prognosis in these subjects. Increasing evidence implicate Heparan sulfate proteoglycans (HSPGs) and Heparanase in various diseases and pathologies, including hypercoagulability states. Moreover, HSPGs and Heparanase are involved in several viral infections, in which they enhance cell entry and release of the viruses. Herein we discuss the molecular involvement of HSPGs and heparanase in SARS-CoV-2 infection, namely cell entry and release, and the accompanied coagulopathy complications, which assumedly could be blocked by heparanase inhibitors such as Heparin and Pixatimod.

Endoscopic dilation of benign post-esophagectomy anastomotic strictures: long-term outcomes and risk of recurrence.

BACKGROUND: Benign esophageal anastomotic strictures often require repeat dilation to relieve dysphagia. Little is known about the factors that affect their remediation. The purpose of this article was to retrospectively evaluate the long-term clinical results of endoscopic dilation in the treatment of benign anastomotic strictures after esophagectomy, and to identify factors associated with stricture recurrence. METHODS: A single-center retrospective analysis (using electronic records) was performed on patients who underwent endoscopic dilation for esophageal anastomotic strictures. Long-term clinical effectiveness, including technical and clinical success, and complication rate were assessed. Factors independently related to recurrence were evaluated. RESULTS: Between January 2014 and December 2017, a total of 35 patients who had benign anastomotic strictures after esophagectomy underwent 182 endoscopic dilation procedures. Technical success was 100%. Thirty-two patients (91%) had initial relief of dysphagia. The clinical success, defined as resolution of dysphagia and achieving luminal patency of 13 mm or more, was achieved in 24 patients (69%). Strictures recurred in 43% of patients, and refractory strictures were identified in 10/35 (29%). Proximal anastomosis and the presence of anastomotic foreign bodies were found to be risk factors for refractory strictures. The complication rate was low (4%) and adverse events were mild. No major complications (perforations, severe bleeding) or treatment-related deaths occurred in this series. CONCLUSIONS: Endoscopic dilation has a high technical and a good clinical success rate. However, anastomotic strictures are often refractory and frequently recur.

Primary synovial sarcoma of the mediastinum: a rare tumor diagnosed by endoscopic ultrasound-fine needle biopsy (EUS-FNB)-Cytomorphologic, immunohistochemical, and molecular analysis.

Primary synovial sarcoma is exceedingly rare in the mediastinum. The differential diagnosis of this rare tumor is complex as a wide array of primary and metastatic tumors occur in this site.A definite diagnosis might be challenging even after tissue sampling. Immunohistochemistry can be very helpful and supportive for the diagnosis, but still inadequate in some cases as these tumors can mimic histopathologically other soft tissue tumors. Hence, in some case, an advanced pathological molecular analysis is needed.Endoscopic ultrasound (EUS) is an important diagnostic tool for mediastinal tumors. While EUS-fine needle aspiration (EUS-FNA) samples are usually inadequate for advanced pathological analysis, tissue acquisition by the newer generation of EUS-fine needle biopsy (EUS-FNB) needles might be sufficient.Here, we present the first report on primary mediastinal synovial sarcoma diagnosed by an immunohistochemical and FISH analysis performed on EUS-FNB tissue sample.

New technique: removal of embedded esophageal partially covered stent by endoscopic sub-stent space dissection.

Both fully (FCSEMS) and partially (PCSEMS) covered self-expandable metal stents are used for the endoscopic management of leaks, perforations, and fistulas. PCSEMS have lower migration rates as their uncovered flanges allow for anchorage into the surrounding tissue, but this consequently makes them difficult to be removed, with reported cases of esophageal perforation during the removal of the embedded PCSEMS. Stent-in-stent technique is mostly used, where a FCSEMS is placed co-axially into an existing PCSEMS causing pressure necrosis and facilitating subsequent removal of both stents. This technique, although effective, is expensive, requiring the use of a second stent. In this report, we describe a series of 3 patients with embedded PCSEMS removed by a new endoscopic technique, i.e., endoscopic sub-stent space dissection, without using a second stent.

Endoscopic treatment of post-cholecystectomy bile leaks: a tertiary center experience.

BACKGROUND: Post-cholecystectomy bile leak is relatively a well-known surgical complication. Several potential treatment modalities for such leaks are used. The early use of ERCP to exclude significant bile duct injury and to treat the leak by various endoscopic means is supported by a large bulk of data. However, there is no consensus as to the optimal endoscopic intervention. METHODS: A retrospective review of ERCP database was done to identify all cases of bile leak related to cholecystectomy. Patient records including surgical and endoscopic reports were reviewed, and telephone interviews were conducted to collect data. RESULTS: During the period 2004-2016, 100 patients (53 men, 47 women; mean age, 55 years) with post-cholecystectomy bile leak were referred for ERCP. Cholecystectomy was done laparoscopically in 82 patients (with an open conversion rate of 13%). In the majority of cases (77%), the leak was diagnosed by ongoing bile flow from the drains. The most common symptoms were pain (17%) and fever (4%). The most common site of the leak was the cystic duct stump (79%) followed by subvesical ducts (7%). Low grade leaks were seen in 84% of cases. Treatment included stent insertion alone (9%), sphincterotomy alone (11%), combination stent/sphincterotomy (76%) and others (1%). Failed ERCP was encountered in 3%. Endoscopic therapy was successful in 90 patients (90%). In subgroup analysis, success rate of procedures with stent insertion (with or without sphincterotomy) is significantly higher compared to procedures without stent insertion (95.3% vs 72.7%, p < 0.05). The failure rate of sphincterotomy alone procedures (3/11, 27%) is much higher compared to procedures with stent insertion (4/85, 5%) with p < 0.05. Four patients (4%) developed post-ERCP pancreatitis (mild to moderate) and one patient (1%) suffered from retroperitoneal perforation. CONCLUSION: The optimal endoscopic intervention for post-cholecystectomy bile leak should include temporary insertion of a biliary stent.

Physician adherence to societal guidelines following colonoscopy with polypectomy.

BACKGROUND: Colorectal cancer is a significant cause of mortality and morbidity in western countries. Polypectomy reduces the incidence and mortality of colorectal cancer. Following polypectomy, recommendations regarding the frequency and duration of surveillance rely mostly on features of the resected polyps and are summarized in various gastroenterological societal guidelines. In this study, we aimed to delineate the accuracy of current post-polypectomy surveillance recommendations and to check whether active intervention would lead to an improvement in accuracy and consistency with societal guidelines. METHODS: We prospectively collected polypectomy reports over a 3-month period in 2 tertiary medical centers. We then performed an intervention that included: 1) presentation of results from 1st phase; 2) re-affirming the guidelines in a departmental meeting; 3) addition of a dedicated reporting form for post-polypectomy surveillance recommendations in the patients' electronic medical file. Finally, we conducted a second prospective collection of post-polypectomy recommendations, over a second 3-month period. RESULTS: Prior to the intervention, 76% of the colonoscopies with polypectomy had a recommendation for surveillance, compared to 85% after the intervention (P=0.003). Prior to the intervention, 65% of patients received a recommendation consistent with societal guidelines, compared with 78% after the intervention (P=0.001). CONCLUSION: Intervention, including re-affirmation of the current guidelines and creation of a dedicated reporting platform, significantly increases the number of follow-up recommendations after polypectomy and their consistency with societal guidelines.

Rescuing the Rescuer: Fractured Dormia Basket and a Second Basket Rescue Technique.

Mechanical lithotripsy is one of the well-known rescue methods for impacted common bile duct (CBD) stones. A fractured Dormia basket with a captured stone is an unusual complication and poses a special management problem. In the past, surgical intervention was the standard method. Various nonsurgical techniques have been reported. If the impaction is at the level of the papilla, extending the sphincterotomy might be sufficient. Stent insertion, endoscopic mechanical lithotripsy, extracorporeal shock wave lithotripsy, endoscopic laser lithotripsy, and transhepatic choledochoscopic lithotripsy have all been reported. In this case, we used a second basket, which is readily available and less expensive, as a rescue technique. HOW TO CITE THIS ARTICLE: Khamaysi I, Hajj E. Rescuing the Rescuer: Fractured Dormia Basket and a Second Basket Rescue Technique. Euroasian J Hepato-Gastroenterol 2020;10(1):45-46.

In Vitro and Randomized, Double-Blind, Placebo-Controlled Trial to Determine the Efficacy and Safety of Nine Antiacne Medicinal Plants.

The present in vitro and randomized, double-blind, placebo-controlled trial aims to determine the efficacy and safety of nine Mediterranean antiacne medicinal plants. The antimicrobial, antisebum, and anti-inflammatory activities of the plant extracts were evaluated in cells from the immortalized human keratinocytes (HaCaT) and human monocytic cell line (THP-1) as well as in a double-blind, randomized, and placebo-controlled trial. Most of the extracts showed no significant cytotoxic effects on HaCaT cells up to 250 µg/ml. Inula helenium (IH) and Saponaria officinalis (SO) inhibited sebum production at 90 µg/ml and 30 µg/ml, respectively. The inhibition effect of SO on the growth of Cutibacterium acnes was 1.2 times higher than that of chloramphenicol. IH and SO extracts significantly inhibited the lipopolysaccharide- (LPS-) induced IL-6 and TNF-α production in THP-1 cells reaching the control levels of untreated cells at a concentration of 250 µg/ml. SO, IH, and Solanum nigrum (SN) extracts inhibited the nitric oxide (NO) production in a dose-dependent manner. Based on these results, an antiacne herbal cream (AHC) was prepared from different portions of extracts from SO, IH, and SN, and its efficacy was evaluated in a double-blind, randomized, and controlled efficacy study with 41 acne patients, ages 18-24, who were asked to apply AHC (n = 27) or a placebo (n = 14) two to three times daily for six weeks. Results obtained indicate that the AHC has unique synergistic effects that halt sebum production, combined with highly antiseptic and anti-inflammatory activity, in which 54.95% (t = 19.37 P < 0.001) of acne inflammatory and noninflammatory lesions disappeared after two weeks, 85.3%, after five weeks (t = 14.19 P < 0.001), and 91.4%, at the end of the sixth week of application (t = 5.7 P < 0.001). In conclusion, SO, IH, and SN as single extracts and in combination as AHC showed significant antimicrobial, antisebum, and anti-inflammatory activities in vitro and in a double-blind, randomized, and controlled antiacne efficacy. Therefore, AHC represents an interesting alternative treatment for acne.

Heparanase in Acute Pancreatitis.

Acute pancreatitis (AP) is one of the most common diseases in gastroenterology, affecting 2% of all hospitalized patients. Nevertheless, neither the etiology nor the pathophysiology of the disease is fully characterized, and no specific or effective treatment has been developed. Heparanase (Hpa) is an endoglycosidase that cleaves heparan sulfate (HS) side chains of heparan sulfate proteoglycans (HSPGs) into shorter oligosaccharides, activity that is highly implicated in cell invasion associated with cancer metastasis and inflammation. Given that AP is a typical inflammatory disease, we investigated whether Hpa plays a role in AP. Our results provide keen evidence that Hpa expression and activity are significantly increased following cerulein-induced AP in wild type mice. In parallel to the classic manifestations of AP, namely elevation of amylase and lipase levels, pancreas edema and inflammation as well as induction of cytokines and signaling molecules, have been detected in this experimental model of the disease. Noteworthy, these features were far more profound in transgenic mice overexpressing heparanase (Hpa-Tg), suggesting that these mice can be utilized as a model system to reveal the molecular mechanism by which Hpa functions in AP. Further support for the involvement of Hpa in the pathogenesis of AP emerged from our observation that treatment of experimental AP with PG545 or SST0001(= Ronepastat), two potent Hpa inhibitors, markedly attenuated the biochemical, histological and immunological manifestations of the disease. Hpa, therefore, emerges as a potential new target in AP, and Hpa inhibitors are hoped to prove beneficial in AP along with their promising efficacy as anti-cancer compounds.