Biopsias endoscópicas en la era de la inmunoterapia y oncogenética: ¿podemos cumplir los requerimientos? / Endoscopic biopsies in the era of immunotherapy and oncogenetics: can we meet the requirements?

Pancreatic ductal adenocarcinoma has increased its incidence in recent years. In approximately half of the cases, the diagnosis is made when the disease is in the metastatic stage. In advanced stages, treatment with immunotherapy is included with promising results. Histopathological diagnosis is required for the administra - tion of chemotherapy. Endosonography biopsy has benefits due to its high sensitivity and specificity, absence of the need for hospitalization, and low adverse events. Fine biopsy needles are classified according to two characteristics: diameter (19, 22 and 25 G) and tissue acquisition mechanism (FNA and FNB). The emergence of immunotherapy guided by tumor oncogenetics requires an increase in sample size. There are no significant differences between the presence of the pathologist in taking the sample (rapid on-side evaluation, ROSE) over the macroscopic visualization of the biopsy by the endosonographer (macroscopic on-side evaluation, MOSE). The use of FNB for biopsy is recommended over FNA with ROSE when it is necessary to make a diagnosis or genetic study and it is not possible to perform it with the ROSE modality. The factors that determine an adequate sample collection are the location of the biopsy (pancreas 54.3% vs. lymph nodes/metastasis 76.5%) and the diameter/type of needle.

El adenocarcinoma ductal pancreático ha presentado un aumento de su incidencia en los últimos años En aproximadamente la mitad de los casos se realiza el diagnóstico cuando la enfermedad se encuentra en etapa metastásica. En etapas avanzadas se incluye el tratamiento con inmunoterapia con resultados promisorios. Para la administración de quimioterapia se requiere el diagnóstico histopatológico. La biopsia por endosonografía presenta beneficios debido a su alta sensibilidad y especificidad, ausencia de necesidad de hospitalización y bajos eventos adversos. Las agujas finas de biopsia se clasifican según dos características: diámetro (19, 22 y 25 G) y mecanismo de adquisición del tejido (FNA y FNB). La aparición de la inmunoterapia guiada por la oncogenética tumoral requiere un incremento del tamaño de las muestras. No existen diferencias significativas entre la presencia del anatomopatólogo en la toma de la muestra ( rapid on-side evaluation, ROSE) por sobre la visualización macroscópica de la biopsia por parte del endosonografista (macroscopic on-side evaluation, MOSE). Se recomienda el uso de FNB para toma de biopsia por sobre FNA con ROSE cuando es necesario hacer diagnóstico, estudio genético y no es posible realizarlo con modalidad ROSE. Los factores que determi - nan una toma de muestra adecuada son la localización de la biopsia (páncreas 54,3% vs. linfonodos/metástasis 76,5%) y el diámetro/tipo de aguja

What Are the Ready-to-Use Endoscope Channels Hiding?: Unraveling the Risks of Safe Reuse.

Contamination due to failures or omissions in the reprocessing steps of gastrointestinal endoscopes is common in clinical practice. Ensuring the proper execution of each step is a challenge for reprocessing personnel. This cross-sectional study was conducted in an endoscopy setting between March and May 2021. We performed interviews about reprocessing practices, analyzed the life history of the equipment, and performed inspections through a borescope video of gastrointestinal endoscope channels that were stored and ready for use. A borescope is a complementary tool used to validate endoscope reprocessing, evaluate the internal visualization of channels, and identify changes that can compromise the safety of its use, which are often not detected in the leak test. Thirteen biopsy channels from stored gastrointestinal endoscopes were inspected. We found that 85% had stains and grooves, 69% contained moisture, and 46% had debris. There was at least one noncompliance issue in all of the channels inspected.

Borescope examination and microbial culture results of endoscopes in a tertiary care hospital led to changes in storage protocols to improve patient safety.

BACKGROUND: Flexible endoscopes are highly versatile and useful medical instruments, and their proper reprocessing is critical to patient health and safety. The value of routine visual inspections and surveillance of endoscopes in a tertiary care hospital was assessed by performing borescope examinations and microbial sampling on respiratory, gastro-intestinal (GI), and urological endoscopes. METHODS: A total of 42 endoscopes were cultured, and 36 endoscopes were examined with a borescope. The flush-brush-flush method was used to culture the endoscopes. Collected water was suctioned through a membrane filter device which was plated on a blood agar plate and incubated. A borescope was used to perform endoscope inspection in an antegrade and retrograde approach. RESULTS: Positive microbial cultures were seen in 28% of respiratory, 22% of GI, and 30% of urological endoscopes. Borescope examinations revealed multiple abnormalities and damage including channel shredding, filamentous debris, water retention, discoloration, dents, and red particles. CONCLUSIONS: Borescope examination and microbial culturing should be used routinely to assure endoscopic safety. Borescope examination enabled us to visualize structural damage, foreign material and moisture within endoscopes. The structural damages and the particles found in endoscopes resulted in timely repair and discontinuation of this type of distal end protectors in our facility.

Storage of gastrointestinal endoscopes: when is the safe time for re-use?

OBJECTIVES: to identify the safe storage time for the use of flexible gastrointestinal endoscopes after high-level disinfection, as well as the defining criteria for this time. METHODS: an integrative literature review was carried out in the Virtual Health Library, PubMed, Scopus, and Web of Science, considering original articles published since 2000. RESULTS: eleven articles were selected, whose storage times ranged from 1 to 56 days, with a predominance of one to seven days (73%). Several criteria were used to define this time, predominantly the premise of efficient processing (100%), use of alcohol flush (64%), use of drying cabinets (18%), among others. CONCLUSIONS: the criteria for determining the storage time did not show a consensus for clinical practice. Expanding the discussion of this theme with the definition of the minimum necessary conditions is of fundamental importance for the reduction of risks and safety of the procedure and the patient.

Uso de la enteroscopía intraoperatoria como método diagnóstico en pacientes con sangrado gastrointestinal de origen oscuro. Experiencia inicial / Use of intraoperative enteroscopy as a diagnostic method in patients with obscure gastrointestinal bleeding. Initial experience

Introducción: el sangrado gastrointestinal de origen oscuro es una entidad poco frecuente y se reserva a los casos en los que ya se ha realizado exploración del intestino delgado (endoscópica/radiológica) sin encontrar la causa. Actualmente el estándar de oro es la videocápsula, que se ha descrito como una técnica segura, útil y eficaz para el diagnóstico y tratamiento de las enfermedades del intestino delgado. Objetivo: describir variables demográficas, indicaciones, hallazgos, segmento explorado, tratamiento y tiempo de procedimiento quirúrgico de la enteroscopía transoperatoria en 15 pacientes con diagnóstico de sangrado de tubo digestivo de origen oscuro. Material y métodos: se incluyeron 15 pacientes adultos con el diagnóstico de sangrado de origen oscuro con panendoscopía y colonoscopía negativa a sangrado. A todos se les realizó laparotomía exploradora y enteroscopía transoperatoria con un gastroduodenoscopio. Resultados: se realizaron 15 enteroscopías transoperatorias con gastroduodenoscopio; 10 en mujeres y 5 en hombres, con promedio de edad de 67.2 años. Se exploró la tercera y cuarta porción del duodeno, yeyuno e íleon terminal. Los diagnósticos encontrados fueron enfermedad de Crohn en 1 paciente (6.66%), adenomas en 2 (13.3%), divertículo yeyunal en 6 (40%) y angiectasias en 6 casos (40%). La localización fue en yeyuno [12 casos (80%)] e íleon [3 casos (20%)]. Conclusiones: la enteroscopía intraoperatoria es una alternativa diagnóstica en el sangrado de origen oscuro cuando no se cuente con la enteroscopía doble balón o la videocápsula endoscópica.

Background: Bleeding of dark origin is a rare entity and it is reserved for cases in which exploration of the small intestine has already been performed (endoscopic / radiological) without finding the cause. Currently, the gold standard is the videocapsule which has been described as a safe, useful and effective technique for the diagnosis and treatment of diseases of the small intestine. Objective: The objective was to describe demographic variables, indications, findings, explored segment, treatment and time of the surgical procedure of the intraoperative enteroscopy in 15 patients with a diagnosis of gastrointestinal bleeding of dark origin. Material and methods: 15 adult patients with the diagnosis of bleeding of dark origin with panendoscopy and negative colonoscopy to bleeding were included. All of these underwent exploratory laparotomy and intraoperative enteroscopy with a gastroduodenoscope. Results: 15 intraoperative enteroscopies were performed with a gastroduodenoscope; 10 women and 5 men with an average age of 67.2 years. Third and fourth portions of the duodenum, jejunum, and terminal ileum were explored. The diagnoses found were Crohn's disease 1 (6.66%), Adenomas 2 (13.3%), jejunal diverticulum 6 (40%) and angiectasias in 6 cases (40%). The location was in jejunum, 12 cases (80%) and ileum, 3 cases (20%). Conclusions: Intraoperative enteroscopy is a diagnostic alternative in bleeding of dark origin when there is no double balloon enteroscopy or endoscopic video capsule.

Processamento endoscópico: quais são os gaps na prática clínica? / Endoscopic processing: what are the gaps in clinical practice?

Objetivo: Identificar na prática clínica gaps que interferem na efetividade do processamento endoscópico. Método: Revisão integrativa de artigos publicados entre 2008­2020, identificados em bases de dados por meio de descritores controlados em Ciências da Saúde, adotando-se a estratégia PICO. Os gaps identificados foram classificados segundo nível de evidência (IA, IB, IC, II). Resultados: Foram encontrados 18 artigos registrando 64 gaps, 26,6% no nível de evidência IA e 40,6% IB, predominando: ausência/inadequação da secagem (55,5%), limpeza manual sem escovação dos canais/escovas inapropriadas (50%), omissão do teste de vedação (38,8%), inadequações no armazenamento (33,3%) e no uso da solução desinfetante (27,7%), tempo de imersão ou monitorização da concentração mínima eficaz, ausência de pré-limpeza (16,6%), transporte incorreto para a sala de processamento (11,1%). Conclusão: As diretrizes fortemente recomendadas por entidades internacionais e nacional têm sido descumpridas, representando aspectos críticos no processamento dos endoscópios que implicam em potenciais falhas na segurança do paciente.

Objective: This paper aimed to identify gaps in clinical practice that interfere with the effectiveness of endoscopic processing. Method: Integrative review of articles published between 2008 and 2020, identified in databases through controlled descriptors in Health Sciences, adopting the PICO strategy. The identified gaps were classified according to the level of evidence (IA, IB, IC, II). Results: Eighteen articles were found, recording 64 gaps, 26.6% at the level of evidence IA and 40.6% IB, predominating: absence/inadequate drying (55.5%), manual cleaning without brushing the inappropriate channels/brushes (50%), omission of the sealing test (38.8%), inadequate storage (33.3%) and use of the disinfectant solution (27.7%), time of immersion or monitoring of the minimum effective concentration, absence of pre-cleaning (16.6%), incorrect transportation to the processing room (11.1%). Conclusion: It was concluded that guidelines strongly recommended by international and national entities have been breached, representing critical aspects in the processing of endoscopes that imply potential failures in patient safety.

A prática do processamento de gastroscópios, colonoscópios e duodenoscópios nos serviços de saúde intra - hospitalares / The practice of processing gastroscopes, colonoscopes and duodenoscopes in intra-hospital health services

Procedimentos endoscópicos representam um importante recurso diagnóstico e terapêutico amplamente utilizado nos serviços de saúde. Entretanto, durante o exame, ao entrar em contato com o trato gastrointestinal, o endoscópio se torna altamente contaminado pela microbiota humana. Portanto, a limpeza meticulosa e desinfecção desse equipamento é extremamente crítica na prevenção de infecção e segurança do seu uso. Diante disso, objetivou-se avaliar a prática do processamento de gastroscópios, colonoscópios e duodenoscópios nos serviços de saúde intra ­ hospitalares. Tratou-se de um estudo transversal, com apoio da Secretaria de Estado de Saúde de Minas Gerais (SES-MG), realizado em oito serviços de endoscopia intrahospitalares em Belo Horizonte, sendo avaliado o processamento de 22 equipamentos endoscópicos e 60 amostras dos canais dos equipamentos. A coleta de dados ocorreu por meio de entrevista, observação das práticas adotadas, análise microbiológica dos canais de ar/água e, no duodenoscópio acrescentou-se a análise do canal do elevador, somado à aplicação de teste de proteína após a limpeza. A análise dos dados se deu por meio de estatística descritiva, com cálculo de frequências, medidas de tendência central. A maioria dos serviços dispuham de endoscópios com média global de uso de 7,3 anos. As manutenções preventivas ocorriam em média a cada 90 dias. Protocolos de processamento não estavam ao alcance dos profissionais de forma facilitada em 50% (4/8) dos serviços. A auditoria do processo de limpeza é realizada em 62,5% (5/8) dos serviços, por meio de teste adenosina trifosfato (ATP) bioluminescência. Nenhum serviço possuía rotina de vigilância dos pacientes submetidos a procedimentos endoscópicos. Todas as etapas do processamento apresentaram não conformidades com as diretrizes nacionais e internacionais, destacando-se a etapa da limpeza como a de maior desafio, seguida da secagem, pré-limpeza, teste de vedação e armazenamento. Na pré-limpeza, verificou-se que 86,4% (19/22) dos equipamentos não era padronizada a compressa para limpeza externa do equipamento, sendo adotada a gaze. O teste de vedação não foi realizado em 36,4% (8/22) dos equipamentos. Na limpeza, 72,7% (17/22) dos endoscópios não foram imersos em solução detergente e 63,6% (14/22) dos equipamentos, os canais eram friccionados com esvova de tamanho único. Nenhum serviço havia padronização de tempo para a secagem final dos canais. No armazenamento, os armários convencionais em MDF foram encontrados em 37,5% (3/8) dos serviços, sem qualquer ventilação. Quanto ao potencial de contaminação, após o processamento verificou-se um predomínio de Pseudomonas, sendo que 28,5% eram resistentes a carbepenem e 21,4% com perfil intermediário. Serratia marcescens resistente a carbapenem foi isolada em 33,3% das amostras. Em relação aos testes de avaliação da limpeza, 33% (2/6) dos duodenoscópios apresentavam resíduos de proteína no canal do elevador. Conclui-se que as práticas cotidianas do processamento de endoscópios em serviços de saúde não têm sido realizadas conforme as evidências e as recomendações científicas.

Endoscopic procedures are an important diagnosis and therapeutic resource broadly used in health services. However, during the procedure, when contacting the gastrointestinal tract, the endoscope becomes highly contaminated by human microbiota. A thorough cleaning and disinfection of these equipment is of critical importance in the prevention of infection and safety of its use. Therefore, the aim was to evaluate the practice of processing gastroscopes, colonoscopes and duodenoscopes in intra-hospital health services. The study was a crosssectional one, supported by Minas Gerais State Department of Health, performed in eight inhospital endoscopic services in Belo Horizonte. Data collection occurred through interviews, observation of practices, microbiological analysis of air/water channels, and in the duodenoscope, was added analysis of the elevator channel, adding to protein test applications after cleaning. 60 samples from the equipment channels were analyzed. Data analysis was performed using descriptive statistics, with frequency calculation, measures of central tendency. The majority of services had endoscopes with global average use of 7,3 years. Preventive maintenance occurred in an average cicle of 90 days. At pre-cleaning, it was found that 86.4% (19/22) of the endoscopes did not standardized compress for the equipment external cleaning, and gause was adopted. The sealing test was not used at 36.4% (8/22) of the equipment. For cleaning, 63.6% (14/22) of endoscopes did not had compatible brushes for each channel, and 72.7% (17/22) of the equipments were not immersed in a detergent solution. At storage, conventional MDF cabinets were found, at 37.5% (3/8) of services, without any air circulation. Processing protocols at 50% (4/8) of services were not available to professionals in an easy way. All processing steps presented nonconformities with national and international guidelines, highlighting the cleaning stage as the most challenging one, followed by drying, pre-cleaning, sealing test and storage. The cleaning process audit took place at 62.5% (5/8) of services, through adenosine triphosphate (ATP) bioluminescence. As for disinfection, all services monitored the solution with MEC tape. None of the services had a surveillance routine of patients undergoing endoscopic procedures. As for the contamination potential, after processing there was a predominance of Pseudomonas, 28.5% were resistant to carbepenem and 21.4% had an intermediate profile. Serratia marcescens carbapenem resistant, was isolated at 33.3% of the samples. Regarding cleaning validation tests, 33% (2/6) of duodenoscopes showed protein residues in the elevator channel. It is concluded that the daily practices endoscopes processing in health services have not been carried out in accordance with scientific evidence and recommendations.

Efficacy and Safety of Flexible Endoscopic Management of Zenker's Diverticulum.

Zenker's diverticulum (ZD), a pulsion diverticulum of hypopharynx is a rare but treatable cause of morbidity in geriatric population. Traditionally a surgical disease but due to its associated high morbidity, flexible endoscopy has become a lucrative option. We reviewed 997 patients from 23 original studies who underwent flexible endoscopic diverticulotomy (FED) of ZD. Composite technical and clinical success rate for the study cohort was 99.4% and 87.9%, respectively. Composite failure rate was 10.0% but close to half of them (45.3%) had success with repeat endoscopic intervention. Composite rate for symptom recurrence after long-term follow-up was 13.6% but more than half (61.8%) had success with repeat endoscopic intervention. Bleeding (6.6%) and perforation (5.3%) were 2 most common complications of FED. All bleeding events were successfully managed with observation or endoscopic therapy. Majority of perforation events (4.4%) were successfully managed with conservative care and only 0.9% required invasive management. No mortality was reported. Efficacy and safety of FED of ZD remained same irrespective of diverticulum size or prior surgical/endoscopic treatment. FED with diverticuloscope (FEDD) and FED with cap (FEDC) had comparable technical success rate (99.6% vs. 100.0%) but FEDD had higher clinical success rate compared with FEDC (86.8% vs. 75.4%). FEDD had twice the risk of symptom recurrence than FEDC (16.5% vs. 9.5%). FEDD had a comparable bleeding risk to FEDC (3.3% vs. 4.0%) but a much lower perforation rate (2.3% vs. 10.3%). Upper esophageal sphincterotomy and adequate length of septotomy are the cornerstones of FED. FED can be considered a safe and efficacious treatment modality for patients with ZD.

Tratamiento actual para el divertículo de Zenker / Current treatment of Zenker´s diverticulum

Introducción: la cirugía es el tratamiento de elección para los divertículos de Zenker, pero existen diferencias en relación con el acceso a utilizar: abierto o endoscópico.Objetivo: comparar los resultados del tratamiento quirúrico del divertículo de Zenker de acuerdo con el acceso utilizado. Métodos: se realizó una revisión bibliográfica en PubMed/Medline con las palabras: divertículo, Zenker, faringoesofágico, cricofaríngeo, diverticulectomía, diverticulopexia, diverticulotomía, diverticulostomía publicados entre 2006 y 2016. Se incluyeron estudios con más de 40 casos, comparativos o no, en los idiomas inglés, español, portugués, francés e italiano. Las variables estudiadas fueron: indicaciones quirúrgicas, recidiva del divertículo, tiempo quirúrgico, tiempo para la alimentación oral, estadía hospitalaria, reoperaciones, complicaciones, mejoría de los síntomas y mortalidad. Resultados: no se encontraron ensayos aleatrorizados. Se incluyeron cuatro revisiones sistemáticas y un metanálisis, además de un grupo de estudios que comparan los accesos peroral y transcervical y otros que comparan los resultados entre diferentes técnicas de los accesos endoscópico y convencional. La mayoría de los estudios son de carácter retrospectivo.Para evaluar los resultados a largo plazo se tomaron los artículos con seguimiento mayor de 12 meses. Conclusiones: con el acceso abierto se logran mejores resultados a largo plazo, pero tiene más complicaciones inmediatas. Es preferible usarlo en pacientes jóvenes y cuando existen condiciones anatómicas desfavorables para la endoscopia. El tratamiento endoscópico constituye una opción adecuada para pacientes de alto riesgo quirúrgico y anestésico(AU)

Introduction: Surgery is the treatment of choice in Zenker´s diverticula, but there are different opinions about the access to be used, that is, open or endoscopicObjective: To compare the results of the surgical treatment results of Zenker´s diverticulum according to the access employed. Methods: A literature review was made in PubMed/Medline using the keywords: diverticulum, Zenker, pharyngoesophageal, crycopharyngeal, diverticulectomy, diverticulopexy, diverticulotomy, diverticulostomy in articles published from 2006 to 2016. There were included several studies of more than 40 cases, either comparative or not in English, Spanish, French, Italian and Portuguese languages. The studied variables were surgical indications, recurrence, surgical time, length of time for oral feeding, hospital stay, reoperations, complications, symptoms improvement and mortality. Results: Randomized studies were not found. Four systematic reviews, one meta-analysis, comparative studies on perioral and transcervical access and others which compare the results of the endoscopic and of the conventional access were all included. Most of them were retrospective. For evaluation of long-term results, those articles with follow-up periods over 12 months were taken. Conclusions: The open access provides better long-term results, but it has more immediate complications. It is advisable to use it in young patients and when anatomic conditions are unfavorable for the endoscopic treatment. Finally, the endoscopic treatment is an adequate choice for patients with high surgical and anesthetic risk(AU)

Tratamiento actual para el divertículo de Zenker / Current treatment of Zenker´s diverticulum

Introducción: la cirugía es el tratamiento de elección para los divertículos de Zenker, pero existen diferencias en relación con el acceso a utilizar: abierto o endoscópico. Objetivo: comparar los resultados del tratamiento quirúrico del divertículo de Zenker de acuerdo con el acceso utilizado. Métodos: se realizó una revisión bibliográfica en PubMed/Medline con las palabras: divertículo, Zenker, faringoesofágico, cricofaríngeo, diverticulectomía, diverticulopexia, diverticulotomía, diverticulostomía publicados entre 2006 y 2016. Se incluyeron estudios con más de 40 casos, comparativos o no, en los idiomas inglés, español, portugués, francés e italiano. Las variables estudiadas fueron: indicaciones quirúrgicas, recidiva del divertículo, tiempo quirúrgico, tiempo para la alimentación oral, estadía hospitalaria, reoperaciones, complicaciones, mejoría de los síntomas y mortalidad. Resultados: no se encontraron ensayos aleatrorizados. Se incluyeron cuatro revisiones sistemáticas y un metanálisis, además de un grupo de estudios que comparan los accesos peroral y transcervical y otros que comparan los resultados entre diferentes técnicas de los accesos endoscópico y convencional. La mayoría de los estudios son de carácter retrospectivo.Para evaluar los resultados a largo plazo se tomaron los artículos con seguimiento mayor de 12 meses. Conclusiones: con el acceso abierto se logran mejores resultados a largo plazo, pero tiene más complicaciones inmediatas. Es preferible usarlo en pacientes jóvenes y cuando existen condiciones anatómicas desfavorables para la endoscopia. El tratamiento endoscópico constituye una opción adecuada para pacientes de alto riesgo quirúrgico y anestésico(AU)

Introduction: Surgery is the treatment of choice in Zenker´s diverticula, but there are different opinions about the access to be used, that is, open or endoscopic. Objective: To compare the results of the surgical treatment results of Zenker´s diverticulum according to the access employed. Methods: A literature review was made in PubMed/Medline using the keywords: diverticulum, Zenker, pharyngoesophageal, crycopharyngeal, diverticulectomy, diverticulopexy, diverticulotomy, diverticulostomy in articles published from 2006 to 2016. There were included several studies of more than 40 cases, either comparative or not in English, Spanish, French, Italian and Portuguese languages. The studied variables were surgical indications, recurrence, surgical time, length of time for oral feeding, hospital stay, reoperations, complications, symptoms improvement and mortality. Results: Randomized studies were not found. Four systematic reviews, one meta-analysis, comparative studies on perioral and transcervical access and others which compare the results of the endoscopic and of the conventional access were all included. Most of them were retrospective. For evaluation of long-term results, those articles with follow-up periods over 12 months were taken. Conclusions: The open access provides better long-term results, but it has more immediate complications. It is advisable to use it in young patients and when anatomic conditions are unfavorable for the endoscopic treatment. Finally, the endoscopic treatment is an adequate choice for patients with high surgical and anesthetic risk(AU)

Effectiveness of current disinfection procedures against biofilm on contaminated GI endoscopes.

BACKGROUND AND AIMS: Attention to patient safety has increased recently due to outbreaks of nosocomial infections associated with GI endoscopy. The aim of this study was to evaluate current cleaning and disinfection procedures of endoscope channels with high bioburden and biofilm analysis, including the use of resistant mycobacteria associated with postsurgical infections in Brazil. METHODS: Twenty-seven original endoscope channels were contaminated with organic soil containing 10(8) colony-forming units/mL of Pseudomonas aeruginosa, Staphylococcus aureus, or Mycobacterium abscessus subsp bolletii. Biofilms with the same microorganisms were developed on the inner surface of channels with the initial inoculum of 10(5) colony-forming units/mL. Channels were reprocessed following current protocol, and samples from cleaning and disinfection steps were analyzed by bioluminescence for adenosine triphosphate, cultures for viable microorganisms, and confocal microscopy. RESULTS: After contamination, adenosine triphosphate levels increased dramatically, and high bacterial growth was observed in all cultures. After cleaning, adenosine triphosphate levels decreased to values comparable to precontamination levels, and bacterial growth was demonstrated in 5 of 27 catheters, 2 with P aeruginosa and 3 with M abscessus. With regard to induced biofilm, a remarkable reduction occurred after cleaning, but significant microbial growth inhibition occurred only after disinfection. Nevertheless, viable microorganisms within the biofilm were still detected by confocal microscopy, more so with glutaraldehyde than with peracetic acid or O-phataladehyde. CONCLUSION: After the complete disinfection procedure, viable microorganisms could still be detected within the biofilm on endoscope channels. Prevention of biofilm development within endoscope channels should be a priority in disinfection procedures, particularly for ERCP and EUS.

Fecal microbiota transplant by push enteroscopy to treat diarrhea caused by Clostridium difficile.

Clostridium difficile is the major etiological agent of pseudomembranous colitis and is found in up to 20% of adult inpatients. The recommended treatment is antibiotic therapy with metronidazole and/or vancomycin. However, the recurrence rate may reach up to 25% and it increases in each episode. The newest alternative to treat diarrhea due to recurrent Clostridium difficile is fecal microbiota transplantation. The procedure was performed in 12 patients, with a 6-month follow-up on 10 of them. Of the ten cases, bacterial recurrence was diagnosed in only one patient, after a course of antibiotic to treat urinary tract infection, without presenting with diarrhea. The particularity of our study, besides being an unprecedented event in South America, is the way to perform the infusion of fecal microbiota by enteroscopy.

Escalas de predicción en el pronóstico del paciente con hemorragia digestiva alta no varicosa / Predicting scales for prognosis of patients with non-variceal upper gastrointestinal bleeding

La hemorragia digestiva alta no varicosa constituye una importante causa de morbilidad y mortalidad en el mundo. Para su manejo se ha impuesto la necesidad de usar escalas pronósticas para definir la conducta a seguir con un empleo óptimo de los recursos médicos, de manera tal que se garantice una asistencia de calidad al paciente. El objetivo del trabajo es realizar un resumen de los aspectos positivos y negativos de las escalas, relacionar los parámetros que contemplan y las posibilidades de su aplicación en Cuba. Se efectuó una búsqueda en los registros bibliográficos existentes de las bases de datos de PUBMED y EBSCO. Se utilizaron las palabras claves, en idiomas español e inglés: hemorragia digestiva alta no varicosa y escalas pronósticas. Se realizó una revisión de los diferentes modelos; se relacionaron a los autores principales de las escalas; se dividieron en preendoscópicas y endoscópicas y se caracterizaron las más utilizadas. La información recogida permitió obtener una visión general, al mostrar las diferentes variantes existentes y clasificar al paciente según el riesgo que presenta, de acuerdo con los índices pronósticos obtenidos después de la aplicación de la escala. Se concluye que las escalas pronósticas permiten evaluar la necesidad de intervención urgente, la probabilidad de sangrado, la necesidad de cirugía o la mortalidad aguda en la toma de decisiones médicas y su uso está en correspondencia con las particularidades de cada contexto(AU)

The non-variceal upper gastrointestinal bleeding is a major cause of morbidity and mortality worldwide. The need for prognostic scales to define the course of action regarding the optimal use of medical resources has imposed, so that patient care quality is guaranteed. The aim of this paper is to go over the positive and negative aspects of the scales, to relate the parameters included and the possibilities of its application in Cuba. A search was conducted on existing bibliographic records in PubMed and EBSCO databases. Keywords in Spanish and English were used, such as non-variceal upper gastrointestinal bleeding, and prognostic scales. A review of different models was performed; the principal authors of the scales were related; scales were divided into pre-endoscopic and endoscopic and the most used were characterized. The information collected allowed for an overview, showing the various existing variants and classify patients according to risks, according to forecasts indices obtained after the scale application. It is concluded that the prognostic scales to assess the need for urgent intervention, the bleeding likelihood, surgery or acute mortality in medical decision making and their use is in line with each context particularities(AU)

Escalas de predicción en el pronóstico del paciente con hemorragia digestiva alta no varicosa / Predicting scales for prognosis of patients with non-variceal upper gastrointestinal bleeding

La hemorragia digestiva alta no varicosa constituye una importante causa de morbilidad y mortalidad en el mundo. Para su manejo se ha impuesto la necesidad de usar escalas pronósticas para definir la conducta a seguir con un empleo óptimo de los recursos médicos, de manera tal que se garantice una asistencia de calidad al paciente. El objetivo del trabajo es realizar un resumen de los aspectos positivos y negativos de las escalas, relacionar los parámetros que contemplan y las posibilidades de su aplicación en Cuba. Se efectuó una búsqueda en los registros bibliográficos existentes de las bases de datos de PUBMED y EBSCO. Se utilizaron las palabras claves, en idiomas español e inglés: hemorragia digestiva alta no varicosa y escalas pronósticas. Se realizó una revisión de los diferentes modelos; se relacionaron a los autores principales de las escalas; se dividieron en preendoscópicas y endoscópicas y se caracterizaron las más utilizadas. La información recogida permitió obtener una visión general, al mostrar las diferentes variantes existentes y clasificar al paciente según el riesgo que presenta, de acuerdo con los índices pronósticos obtenidos después de la aplicación de la escala. Se concluye que las escalas pronósticas permiten evaluar la necesidad de intervención urgente, la probabilidad de sangrado, la necesidad de cirugía o la mortalidad aguda en la toma de decisiones médicas y su uso está en correspondencia con las particularidades de cada contexto.

The non-variceal upper gastrointestinal bleeding is a major cause of morbidity and mortality worldwide. The need for prognostic scales to define the course of action regarding the optimal use of medical resources has imposed, so that patient care quality is guaranteed. The aim of this paper is to go over the positive and negative aspects of the scales, to relate the parameters included and the possibilities of its application in Cuba. A search was conducted on existing bibliographic records in PubMed and EBSCO databases. Keywords in Spanish and English were used, such as non-variceal upper gastrointestinal bleeding, and prognostic scales. A review of different models was performed; the principal authors of the scales were related; scales were divided into pre-endoscopic and endoscopic and the most used were characterized. The information collected allowed for an overview, showing the various existing variants and classify patients according to risks, according to forecasts indices obtained after the scale application. It is concluded that the prognostic scales to assess the need for urgent intervention, the bleeding likelihood, surgery or acute mortality in medical decision making and their use is in line with each context particularities.

Leopard skin sign: the use of narrow-band imaging with magnification endoscopy in celiac disease / Signo de la "piel de leopardo": el uso de endoscopía con magnificación y narrow banding en enfermedad celiaca

Celiac disease (CD) is an immune reaction to gluten containing foods such as rye, wheat and barley. This condition affects individuals with a genetic predisposition; it targets the small bowel and may cause symptoms including diarrhea, malabsorption, weight loss, abdominal pain and bloating. The diagnosis is made by serologic testing of celiac-specific antibodies and confirmed by histology. Certain endoscopic characteristics, such as scalloping, reduction in the number of folds, mosaic-pattern mucosa or nodular mucosa, are suggestive of CD and can be visualized under white light endoscopy. Due to its low sensitivity, endoscopy alone is not recommended to diagnose CD; however, enhanced visual identification of suspected mucosal abnormalities through the use of new technologies, such as narrow band imaging with magnification (NBI-ME), could assist in targeting biopsies and thereby increasing the sensitivity of endoscopy. This is a case series of seven patients with serologic and histologic diagnoses of CD who underwent upper endoscopies with NBI-ME imaging technology as part of their CD evaluation. By employing this imaging technology, we could identify patchy atrophy sites in a mosaic pattern, with flattened villi and alteration of the central capillaries of the duodenal mucosa. We refer to this epithelial pattern as ôLeopard Skin Signõ. Since epithelial lesions are easily seen using NBI-ME, we found it beneficial for identifying and targeting biopsy sites. Larger prospective studies are warranted to confirm our findings.

La enfermedad celiaca (EC) es una reacción inmune a los alimentos que contienen gluten como el centeno, el trigo y la cebada. Esta condición afecta a las personas con predisposición genética, comprometiendo al intestino delgado causando síntomas como diarrea, mala absorción, pérdida de peso, dolor abdominal y meteorismo. El diagnóstico se hace con estudios serológicos de anticuerpos específicos celiacos y es confirmado por histología. Algunas características endoscópicas tales como ôscallopingõ, reducción en el número de pliegues, patrón mucoso tipo mosaico o mucosa nodular, son sugestivos de EC y se pueden observar con endoscopía de luz blanca. Debido a su baja sensibilidad la endoscopía por sí sola no se recomienda para diagnosticar EC, sin embargo, una visualización cuidadosa de las anormalidades mucosas sospechosas a través de nuevas tecnologías como ôNarrow Band Imaginingõ con magnificación (NBI-ME) puede ayudar a dirigir las biopsias y así incrementar la sensibilidad de la endoscopía. Esta es una serie de siete casos con diagnóstico serológico e histológico de EC a quienes se les realizó una endoscopía digestiva alta con NBI-ME. En ellos se pudo identificar sitios de atrofia parcelar en un patrón de mosaico, con vellosidades aplanadas y alteración de los capilares de la mucosa duodenal. Nos referimos a esta alteración como el ôSigno de la Piel de Leopardoõ. Como las lesiones epiteliales se ven fácilmente usando NBI-ME, lo encontramos beneficioso para identificar y dirigir los sitios donde tomar las biopsias. Estudios prospectivos más grandes deben realizarse para confirmar nuestros hallazgos.

Eficacia del proceso de limpieza y desinfección de los endoscopios en un hospital de nivel III / Efficacy of the cleaning and disinfection processes of endoscopes in a level III hospital

Objetivos: Determinar la eficacia del proceso de limpieza y desinfección de los endoscopios en un hospital de nivel III, y determinar los agentes patógenos más comunes encontrados antes y después del proceso. Material y métodos: Estudio descriptivo tipo serie de casos realizado en agosto, setiembre y octubre del 2010. Se evaluaron 50 ciclos de limpieza y desinfección de endoscopios. Para el aislamiento de microorganismos patógenos se utilizaron medios de cultivos y las pruebas de coagulasa, oxidasa y de pigmentos, medio Agar selectivo (Agar Verde Brillante, Agar Xilosa Lisina Desoxicolato, Agar con Sulfito de Bismuto), y medio Agar Mc Conkey. Resultados: La media del recuento de microorganismos antes del proceso de limpieza y desinfección de los endoscopios fue 835,3 ± 1 114,6 UFC/ml, la mediana 233 UFC/ml. Después del proceso la media fue 236,3 ± 700,7 UFC/ml y la mediana 10 UFC/ml, esta diferencia fue estadísticamente significativa (p= 0,000001). La carga bacteriana antes del proceso fue positiva en 88% y después del proceso en 26%. Se encontró diferencia estadísticamente significativa para Pseudomonas aeruginosa (p=0,006) y Salmonella enterica (p=0,00001). La carga bacteriana después del décimo día de activación del desinfectante fue positiva en 55% y antes del noveno día, 19%. Conclusiones: El proceso de limpieza y desinfección de los endoscopios no es efectivo. Los microorganismos patógenos más frecuentes fueron: Salmonella entérica, Pseudomonas aeruginosa y Escherichia coli. El desinfectante de alto nivel (glutaraldehído al 2%) no es efectivo después del décimo día de haber sido activado. (AU)

Objectives: To determine the efficacy of the cleaning and disinfection processes of endoscopes in a level III hospital, and to determine the most common pathogens found before and after these procedures. Methods: Case series from August to October 2010. A total of 50 cycles of cleaning-disinfection procedures were evaluated. Culture media (Brilliant blue agar, xylose-lisine-deoxycholate, sulfite bismute, Mc Conkey) as well as coagulase and oxidase tests were used. Results: The mean count of bacteria before the procedures was 835.3 ± 1,114.6 UFC/ml; the median count was 233 UFC/ml; respective values after the procedures were 236.3 ± 700.7 UFC/ml and 10 UFC/ml, respectively, a statistical difference was found (p=0.000001). Bacterial load was positive before the procedures in 88%, and 26% after them. A statistical significant difference was found for Pseudomonas aeruginosa (p = 0.006) and Salmonella entérica (p=0.00001). Bacterial load was positive in 55% after 10 days of using the disinfectant and it was 19% after the ninth day. Conclusions: The cleaning-disinfection process is not effective. Salmonella enterica, Pseudomonas aeruginosa and Escherichia coli were the most frequent isolated pathogens. The high level disinfectant (2% glutaraldehyde) is not effective after the tenth day. (AU)