Improvement of adenoma detection rate by two computer-aided colonic polyp detection systems in high adenoma detectors: a randomized multicenter trial.

BACKGROUND: This study aimed to evaluate the benefits of a self-developed computer-aided polyp detection system (SD-CADe) and a commercial system (CM-CADe) for high adenoma detectors compared with white-light endoscopy (WLE) as a control. METHODS: Average-risk 50-75-year-old individuals who underwent screening colonoscopy at five referral centers were randomized to SD-CADe, CM-CADe, or WLE groups (1:1:1 ratio). Trainees and staff with an adenoma detection rate (ADR) of ≥35% were recruited. The primary outcome was ADR. Secondary outcomes were the proximal adenoma detection rate (pADR), advanced adenoma detection rate (AADR), and the number of adenomas, proximal adenomas, and advanced adenomas per colonoscopy (APC, pAPC, and AAPC, respectively). RESULTS: The study enrolled 1200 participants. The ADR in the control, CM-CADe, and SD-CADe groups was 38.3%, 50.0%, and 54.8%, respectively. The pADR was 23.0%, 32.3%, and 38.8%, respectively. AADR was 6.0%, 10.3%, and 9.5%, respectively. After adjustment, the ADR and pADR in both intervention groups were significantly higher than in controls (all P<0.05). The APC in the control, CM-CADe, and SD-CADe groups was 0.66, 1.04, and 1.16, respectively. The pAPC was 0.33, 0.53, and 0.64, respectively, and the AAPC was 0.07, 0.12, and 0.10, respectively. Both CADe systems showed significantly higher APC and pAPC than WLE. AADR and AAPC were improved in both CADe groups versus control, although the differences were not statistically significant. CONCLUSION: Even in high adenoma detectors, CADe significantly improved ADR and APC. The AADR tended to be higher with both systems, and this may enhance colorectal cancer prevention.

Computer-aided detection, mucosal exposure device, their combination, and standard colonoscopy for adenoma detection: a randomized controlled trial.

BACKGROUND AND AIMS: Computer-aided detection (CADe) and a mucosal exposure device can improve adenoma detection rate (ADR). Potential benefits of combining the 2 modalities have never been studied. This study aimed to compare ADR differences among CADe alone, endocuff-assisted colonoscopy (EAC) alone, and the combination of CADe and EAC (CADe+EAC) with standard colonoscopy. METHODS: This prospective randomized controlled study included 1245 participants who underwent screening colonoscopy. Participants were randomized to CADe, EAC, CADe+EAC, and standard colonoscopy as a control. The primary outcome was ADR. Secondary outcomes were proximal ADR (pADR), advanced ADR (AADR), and the number of adenomas per colonoscopy (APCs). RESULTS: ADRs from the control, CADe, EAC, and CADe+EAC groups were 41.9%, 52.2%, 54.0%, and 58.8%, respectively; pADRs were 25.2%, 33.3%, 34.9%, and 37.0%, respectively; AADRs were 7.7%, 8.3%, 8.3%, and 13.6%, respectively; and APCs were .76, 1.11, 1.18, and 1.31, respectively. Significant increases in ADR and pADR were observed between the intervention and control groups (P < .05 in all comparisons). The AADR was significantly higher only in the CADe+EAC group than in the control group (P = .02). The adjusted incidence rate ratios of APCs were significantly higher in the intervention groups versus the control group (P < .01 in all comparisons). CONCLUSIONS: CADe+EAC significantly improve ADR and AADR over standard colonoscopy. However, although CADe or EAC alone can substantially increase the detection of adenomas, they do not lead to increased detection of advanced adenomas unless used in combination. (Clinical trial registration number: TCTR20200929003.).

Risk factors of active upper gastrointestinal bleeding in patients with COVID-19 infection and the effectiveness of PPI prophylaxis.

BACKGROUND: Gastrointestinal (GI) bleeding is one of the most impactful complications in patients hospitalized from COVID-19 infection. Limited study has focused on patients with upper GI bleeding (UGIB). This study aimed to identify the risk factors of patients who were hospitalized from COVID-19 infection and developed UGIB as well as the effectiveness of proton pump inhibitor (PPI) prophylaxis in those patients. METHODS: This study was comprised of two phases. The first phase was the retrospective enrollment of patients who were admitted due to COVID-19 infection and developed UGIB between April and August 2021 to evaluate the associated factors of active UGIB. The second phase was a retrospective analysis after PPI prophylaxis protocol from September - October 2021 to assess the benefit of PPI use in those patients. RESULTS: Of 6,373 patients hospitalized, 43 patients (0.7%) had evidence of UGIB. The majority were male 28 (65.1%) with a mean age of 69.1 ± 11.8 years. Twenty-four of 43 patients (55.8%) needed mechanical ventilation, 35 patients (81.4%) received systemic corticosteroids, and 10 patients (23.3%) were taking anticoagulants for venous thromboembolic prophylaxis. Seven of 43 patients (16%) had active UGIB. There was no significant difference in the number of patients taking antiplatelets, anticoagulants, or steroids and the severity of COVID-19 infection between the two groups. An emergency endoscopy or endoscopic hemostasis were performed in 6/7 (85.7%) patients. The multivariate logistic regression analysis revealed two significant factors associated with active UGIB including higher of Glasgow-Blatchford score (GBS) per point (OR = 7.89; 95%CI 1.03-72.87; p = 0.04) and an absence of PPI use (OR 4.29; 95%CI 1.04-19.51; p = 0.04). After prescribing PPI as a prophylaxis, there was a slightly lower incidence of UGIB (0.6% vs 0.7%) in addition to an absence of active UGIB (0% vs 16%). CONCLUSION: Our study demonstrated that the absence of PPI and higher GBS were significant risk factors for active UGIB which required therapeutic endoscopy in patients with COVID-19 infection. We suggest that short-term PPI prophylaxis should be prescribed in those patients once they need hospitalization regardless of the severity of COVID-19 infection to minimize the severity of UGIB.

A comparison of the antegrade core trap and reverse bevel needles for EUS-guided fine-needle biopsy sampling of liver mass: a prospective randomized cross over study.

BACKGROUND: Data on the use of EUS-guided fine-needle biopsy (EUS-FNB) of solid liver mass (SLM) for pathology is limited. METHODS: To prove superiority of the diagnostic rate of the newly designed modified Menghini-type needle with a beveled side-slot near the needle tip with slot cutting edge directed 20-gauge antegrade bevel (group A) over the original 22-gauge reverse bevel (group B) for EUS-guided fine-needle biopsy (EUS-FNB) of solid liver mass (SLM) in a prospective crossover randomized controlled trial. RESULTS: The overall diagnostic accuracy rate of the 52 passes was 86.5% (45/52) and of group A versus B were 88.5% (23/26) versus 84.6% (22/26), respectively, p = 0.858. Tissue adequacy levels of both groups were not significantly different (grade A: B: C = 18:6:2 versus 16:7:3), p = 0.839). Grading of blood contamination of both groups was not significantly different. However, it was found that the group-A needles could biopsy tissue of significantly longer length than that of the group B; 1.3 cm (SD = 0.76) versus 0.8 cm (SD = 0.54); p = 0.007. CONCLUSION: The use of EUS-FNB of SLM is highly effective with similar levels of efficacy and number of adverse events between both types of needles. THE TRIAL REGISTRATION NUMBER: Thai Clinical Trial Registration No. TCTR2018081002.

Linked color imaging, mucosal exposure device, their combination, and standard colonoscopy for adenoma detection: a randomized trial.

BACKGROUND AND AIMS: By different mechanisms, image-enhancement techniques (linked color imaging [LCI]) and mucosal exposure devices (Endocuff-assisted colonoscopy [EAC]) can improve the adenoma detection rate (ADR) during screening colonoscopy. The impact of the combination of the 2 techniques has never been studied. This study aimed to compare the ADR between the combination of LCI and EAC (LCI+EAC), LCI alone, EAC alone, and standard high-definition (HD) colonoscopy. METHODS: This prospective randomized controlled trial included participants who underwent screening colonoscopy. Participants were randomized to LCI+EAC, LCI, EAC, and standard HD colonoscopy. All colonoscopies were performed by endoscopists with a recorded ADR ≥35%. The primary outcome was the ADR. Secondary outcomes were proximal ADR (pADR) and the mean number of adenomas per colonoscopy (APC). RESULTS: One thousand participants were included in the study. The LCI+EAC group provided the highest ADR and pADR. The ADRs in the LCI+EAC, LCI, EAC, and standard HD colonoscopy groups were 57.2%, 52.8%, 51.6%, and 47.6%, respectively, with pADRs of 38.4%, 34.8%, 33.6%, and 28.0%, respectively. The mean numbers of APC were 1.28, 1.20, 1.16, and .89, respectively. After a multiple comparison adjustment, a significant difference in pADR was only observed between the LCI+EAC and standard HD colonoscopy groups (difference, 10.3 percentage points; 95% confidence interval, .02%-17.4%; P = .05). The incidence rate ratios of the adenoma numbers were significantly higher in the LCI+EAC (1.43), LCI (1.34), and EAC (1.30) groups relative to the standard HD colonoscopy group (.89) (P < .009 for all comparisons). CONCLUSIONS: The combination of LCI and EAC can significantly improve the detection of pADR and APC but not ADR by high-ADR performers. (Clinical trial registration number: TCTR20190319001.).

Usefulness of mean number of adenomas per positive screenee for identifying meticulous endoscopists among those who achieve acceptable adenoma detection rates.

BACKGROUND: Adenoma detection rate (ADR) is a quality indicator for colonoscopy. However, many missed adenomas have subsequently been identified after colonoscopies performed by endoscopists with ADR ≥ 25 %. Adenomas per positive participant (APP; mean number of adenomas detected by an endoscopist among screenees with positive findings) correlates well inversely with adenoma miss rate. This study aimed to evaluate whether APP added additional information on the detection rate for advanced adenomas (AADR) and proximal adenomas (pADR) and among endoscopists with acceptable ADRs (≥ 25 %). METHODS: A total of 47 endoscopists performed 7339 screening colonoscopies that were retrospectively reviewed. Using a cutoff APP value of 2.0, endoscopist performance was classified as high or low APP. Endoscopist ADRs were also classified as acceptable (25 % - 29 %), high standard (30 % - 39 %) and aspirational (≥ 40 %). Generalized linear models were used to assess the relationship between AADR or pADR, and ADR and APP, after adjusting for potential confounders. RESULTS: After adjusting for endoscopist performance and patient characteristics, endoscopists with high APP had a significant 2.1 percentage point increase in AADR (95 %CI 0.3 to 3.9; P = 0.02) and a 2.1 percentage point increase in pADR (95 %CI - 0.8 to 5.1; P = 0.15) compared to endoscopists with low APP. In total, 11 (24 %), 18 (38 %), and 18 (38 %) endoscopists were classified as having acceptable, high standard, and aspirational ADRs, respectively. APP values higher than the cutoff were found in 18 %, 44 %, and 72 % of endoscopists with acceptable, high standard, and aspirational ADRs, respectively (P = 0.02). CONCLUSION: APP is helpful for identifying more meticulous endoscopists who can detect a greater number of advanced adenomas. Endoscopists who achieved an only acceptable ADR had the lowest APP.

Endoscopic ultrasound guided fine needle biopsy (EUS-FNB) from peritoneal lesions: a prospective cohort pilot study.

BACKGROUND: Diagnostic laparoscopy is often a necessary, albeit invasive, procedure to help resolve undiagnosed peritoneal diseases. Previous retrospective studies reported that EUS-FNA is feasible on peritoneal and omental lesions, however, EUS-FNA provided a limited amount of tissue for immunohistochemistry stain (IHC). AIM: This pilot study aims to prospectively determine the effectiveness of EUS-FNB regarding adequacy of tissue for IHC staining, diagnostic rate and the avoidance rate of diagnostic laparoscopy or percutaneous biopsy in patients with these lesions. METHODS: From March 2017 to June 2018, patients with peritoneal or omental lesions identified by CT or MRI at the King Chulalongkorn Memorial Hospital, Bangkok, Thailand were prospectively enrolled in the study. All Patients underwent EUS-FNB. For those with negative pathological results of EUS-FNB, percutaneous biopsy or diagnostic laparoscopy was planned. Analysis uses percentages only due to small sample sizes. RESULTS: A total of 30 EUS-FNB passes were completed, with a median of 3 passes (range 2-3 passes) per case. For EUS-FNB, the sensitivity, specificity, PPV, NPV and accuracy of EUS-FNB from peritoneal lesions were 63.6%, 100%, 100%, 20% and 66.7% respectively. Adequate tissue for IHC stain was found in 25/30 passes (80%). The tissues from EUS results were found malignant in 7/12 patients (58.3%). IHC could be done in 10/12 patients (83.3%). Among the five patients with negative EUS results, two underwent either liver biopsy of mass or abdominal paracentesis, showing gallbladder cancer and adenocarcinoma. Two patients refused laparoscopy due to advanced pancreatic cancer and worsening ovarian cancer. The fifth patient had post-surgical inflammation only with spontaneous resolution. The avoidance rate of laparoscopic diagnosis was 58.3%. No major adverse event was observed. CONCLUSIONS: EUS-FNB from peritoneal lesions provided sufficient core tissue for diagnosis and IHC. Diagnostic laparoscopy can often be avoided in patients with peritoneal lesions.

Low rate of recurrent bleeding after double-balloon endoscopy-guided therapy in patients with overt obscure gastrointestinal bleeding.

BACKGROUND: Double-balloon endoscopy (DBE) provides both diagnosis and treatment in overt obscure gastrointestinal bleeding (OGIB). The aim of this study was to evaluate the rebleeding rate after DBE. METHODS: This retrospective review was conducted between January 2006 and July 2018, 166 patients with overt OGIB who underwent DBE were enrolled. Therapeutic intervention was defined as endoscopic treatment, embolization, or surgery. Primary outcome was rebleeding rate after DBE. The patients were divided into 3 groups based on their DBE; (1) positive DBE requiring therapeutic intervention (G1), (2) positive DBE without therapeutic intervention required (G2) and (3) negative DBE (G3). Cumulative incidence of rebleeding was estimated using the Kaplan-Meier method. Cox regression was used to assess the association of DBE with rebleeding risk. This study was approved by our Institutional Review Board. RESULTS: Sixty-eight patients (41%) were categorized in G1, 34 patients (20%) in G2 and 64 patients (39%) in G3. Overall rebleeding occurred in 24 patients (15%). The cumulative incidence of rebleeding for G1 was the lowest. The 1-year and 2-year cumulative probability of developing rebleeding after DBE in G1 were 3.5% and 3.5%, 8.2% and 14.0% in G2, and 18.2% and 20.6% in G3, respectively (p = 0.02). After adjusting for bleeding severity and comorbidities, patients with positive DBE requiring therapeutic intervention had a significantly lower rate of rebleeding when compared with patients who did not receive intervention (hazard ratio 0.17; 95% CI 0.03-0.90). CONCLUSION: DBE-guided therapeutic intervention was associated with a lower risk of rebleeding when compared with those with negative and positive DBE without therapeutic intervention. One-fifth of patients with overt OGIB had false negative after DBE.

The Secondary Quality Indicator to Improve Prediction of Adenoma Miss Rate Apart from Adenoma Detection Rate.

OBJECTIVES: Adenoma detection rate (ADR) cannot distinguish between endoscopists who detect one adenoma and those who detect ≥2 adenomas. Hypothetically, adenoma miss rate (AMR) may be significant for endoscopists with high ADRs who examine the rest of colon with less care after detecting first polyp. Our objective was to evaluate other quality indicators plus ADR vs. ADR alone in prediction of AMR. METHODS: We conducted a cross-sectional study of asymptomatic participants aged 50-75 years who underwent back-to-back screening colonoscopies by four faculty endoscopists. Each round of colonoscopy was performed by two of the endoscopists in a randomized order. During each round of colonoscopy, all detected polyps were removed. The second endoscopist was blinded to the results of the first. The total number of adenomas per positive participant (APP), the total number of adenomas per colonoscopy (APC), the additional adenomas found after the first adenoma per colonoscopy (ADR-Plus), and ADR were calculated for prediction of AMR. RESULTS: In all, 200 participants underwent back-to-back colonoscopies. There were no significant differences in ADRs of four endoscopists (44, 50, 54, and 46%). APPs were 1.91, 2.12, 2.19, and 2.43. APCs were 0.84, 1.06, 1.18, and 1.12. ADR-Plus were 0.40, 0.56, 0.64, and 0.66, respectively. AMRs differed significantly between the endoscopists (36, 27, 21, and 13%; P=0.01). There was no correlation between ADR and AMR (r=-0.25; P=0.75). Whereas APP exhibited a strong inverse correlation with AMRs (r=-0.99; P<0.01). APC and ADR-Plus appeared to be inversely correlated with AMR, however this was not statistically significant (r=-0.82; P=0.18 and r=-0.93; P=0.07, respectively). CONCLUSIONS: Among high-ADR endoscopists, AMRs still varied. APP may be a promising secondary indicator for distinguishing between the one-and-done polyp endoscopist and the meticulous endoscopist. The evaluation of influence of new metrics on colorectal cancer (CRC) prevention requires a larger population-based study.

A combination of clinical risk stratification and fecal immunochemical test results to prioritize colonoscopy screening in asymptomatic participants.

BACKGROUND: Stool-based colonoscopy is the preferred strategy for colorectal cancer (CRC) screening. The Asia-Pacific Colorectal Screening System (APCS) score also is helpful in stratifying the risk for advanced neoplasia in the asymptomatic population. The combination of the fecal immunochemical test (FIT) result and clinical risk stratification may be more helpful in stratifying the risk. OBJECTIVE: To evaluate the value of the combination of FIT and APCS scores in stratifying asymptomatic participants for colonoscopy. DESIGN: Cross-sectional study. SETTING: University hospital. PATIENTS: A total of 948 asymptomatic participants eligible for screening colonoscopy. INTERVENTIONS: FIT, APCS score evaluation, screening colonoscopy. MAIN OUTCOME MEASUREMENTS: The prevalence of colorectal neoplasia in 4 different groups of participants according to FIT and APCS score evaluations. RESULTS: The prevalence of non-advanced and advanced neoplasia in the 4 groups (high risk with positive FIT result, high risk with negative FIT result, moderate risk with positive FIT result, and moderate risk with negative FIT result) was 44% versus 36.9%, 30.1% versus 11.6%, 27.1% versus 12%, and 22.6% versus 6.4%, respectively (P < .001). Participants with both high-risk scores and positive FIT results had a significantly higher detection rate of advanced neoplasia (6.15-fold, 95% confidence interval, 3.72-10.17) compared with the other 3 groups. Seven cancers were discovered; 4 were in the high-risk with positive FIT result group. LIMITATIONS: Hospital-based study. CONCLUSION: In countries with limited resources, participants with positive FIT results and high-risk scores by APCS should be given priority for colonoscopy because this group is most likely to have advanced neoplasia. However, this strategy needs to be confirmed for its cost-effectiveness in a large, population-based study. ( CLINICAL TRIAL REGISTRATION NUMBER: TCTR20140228001.).

Combination of EUS-FNA and elastography (strain ratio) to exclude malignant solid pancreatic lesions: A prospective single-blinded study.

BACKGROUND: Negative results of EUS-FNA for solid pancreatic lesions (SPL) can be false ones. Combination with strain ratio (SR) may ensure a correct benign diagnosis of SPL. AIMS: We prospectively evaluated the sensitivity rate of EUS-FNA and EUS elastography using the strain ratio method for diagnosing SPL. METHODS: Thirty-eight patients with SPL identified by CT or MRI between January 2013 and November 2013 were included in our prospective study. EUS diagnoses were made using SR by an endosonographer who was blinded to all clinical information. In SPL with adequate cellularity, the results of EUS-FNA were combined with strain ratio to diagnose SPL and the diagnostic value was calculated. RESULTS: Benign SPL were diagnosed in nine patients with surgical or guided-biopsy pathology (n = 3) and benign cells from FNA with stable disease during the 12-month follow-up time (n = 6). Using the best cut-off strain ratio level at 3.17, sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and accuracy rate of EUS elastography were 86.2%, 66.7%, 89.3%, 60%, and 81.6%, respectively. For the 28 patients who underwent EUS-FNA with results of adequate cellularity; EUS-FNA alone versus combination of results of cytology and SR provided sensitivity, specificity, PPV, NPV, and accuracy rate at 90% versus 95.2, 100% versus 71.4%, 100% versus 90.9%, 80% versus 83.3, and 92.9% versus 89.3%, respectively. CONCLUSIONS: In this prospective single-blinded study, the negative results of both EUS-FNA and SR were more reliable to exclude malignant SPL. The sensitivity of EUS elastography by SR was not superior to EUS-FNA. © 2015 Journal of Gastroenterology and Hepatology Foundation and Wiley Publishing Asia Pty Ltd.

Comparison of urgent video capsule endoscopy and urgent double-balloon endoscopy in massive obscure gastrointestinal bleeding.

BACKGROUND/AIMS: Urgent video capsule endoscopy (VCE) and urgent double-balloon endoscopy (DBE) provide high diagnostic yields in overt obscure gastrointestinal bleeding (OGIB). However, no studies have specifically compared VCE and DBE in massive OGIB. The aim of this study was to compare the diagnostic yield and clinical outcomes of the two approaches. METHODOLOGY: Between October 2010 and March 2013, there were 1,672 consecutive patients with gastrointestinal bleeding and 30 massive OGIB were identified. After non-diagnostic EGD and colonoscopy, VCE and DBE were performed in tandem within 72hr after hospitalization. RESULTS: Of these, 30 patients were identified as massive OGIB. DBE identified more bleeding lesions than VCE (26(87%) vs. 18(60%), p<0.05). Only DBE was positive in 8 patients (27%). No patient had positive VCE and negative DBE. VCE demonstrated only fresh blood without identifiable lesions in 8 (27%) patients, and all had bleeding lesions identified subsequently by DBE. The number of patients with therapeutic intervention guided by DBE was higher than those with VCE-guided intervention (17(57%) vs. 11(37%); p<0.05). Four patients (13%) had a negative study by both tests, and no further bleeding was reported. CONCLUSIONS: In massive OGIB, urgent DBE had a higher diagnostic yield than VCE. (ClinicalTrials.gov number, NCT01654770)

Advances in diagnostic endoscopy for duodenal, including ampullary, adenoma.

Currently, the strategy for real-time endoscopic diagnosis of duodenal, including ampullary, adenoma is still unclear. In the era of high-definition and magnification endoscopy, using this modality for the detection and diagnosis of these neoplasms is very challenging for endoscopists. Over the past 10 years, many instruments have been developed to improve the detection rate of duodenal and ampullary polyps and to distinguish between adenoma and non-adenoma. The present review will focus on these novel methods and their usefulness in the diagnosis of ampullary and non-ampullary adenoma.

Flexible spectral imaging color enhancement plus probe-based confocal laser endomicroscopy for gastric intestinal metaplasia detection.

BACKGROUND AND AIM: Probe-based confocal laser endomicroscope (pCLE) has been applied for the early detection and confirmation of many gastrointestinal neoplasms; however, its use in gastric intestinal metaplasia (GIM) detection has not yet been validated. The objective of this study was to assess the diagnostic yield of magnifying flexible spectral imaging color enhancement (ME-FICE) plus pCLE for GIM detection. METHODS: Sixty patients with previous histology confirmed as GIM underwent a surveillance EGD. Standard and 100× ME-FICE were used as a screening mode to depict GIM by light-blue crest, large long crest, and villous pattern criteria. Then, pCLE was followed to confirm the presence of GIM. In each patient, two biopsies were obtained from one positive area, and the other two were taken from the negative area. All specimens were interpreted by a clinically blinded pathologist. The reading results by ME-FICE and by ME-FICE plus pCLE were assessed for sensitivity, specificity, positive predictive value, negative predictive value (NPV), false-positive rate, false-negative rate, and accuracy. RESULTS: Of the 59 areas suspicious for GIM in 45 patients, 44 areas were confirmed as GIM by histology. The overall criteria from ME-FICE plus pCLE provided the highest sensitivity, specificity, positive predictive value, NPV, and accuracy at 96%, 90%, 86%, 97%, and 92%, respectively. There were two false-negatives (4%) and seven false-positives (10%). No early gastric cancer was detected in any. CONCLUSION: Combining ME-FICE with pCLE provides high sensitivity and NPV for GIM detection. The prompt histology reading by this technique may avoid unnecessary biopsy (Clinical trial registration number: NCT01489397).

Comparison of long-term outcome of patients with Wilson's disease presenting with acute liver failure versus acute-on-chronic liver failure.

OBJECTIVE: Wilson's disease (WD) is an inherited disorder of copper metabolism, leading to hepatic and neuropsychiatric manifestations. The long-term outcome of patients with Wilson's disease presenting with acute liver failure (ALF) versus those with acute-on-chronic liver failure (ACLF) has not been well documented. The authors' aimed to compare the clinical presentations and long-term outcome after standard treatments between patients with ALF versus those with ACLF. MATERIAL AND METHOD: The authors performed a retrospective review of 39 patients with Wilson's disease, at the King Chulalongkorn Memorial Hospital between January 2003 and December 2011. Primary outcome of the present study was liver complications or deaths from any cause. ACLF was defined as an acute hepatic insult in patients with previously diagnosed or undiagnosed chronic liver disease, whereas ALF was defined as an occurrence in the absence of any preexisting liver disease. RESULTS: Twenty-two of 39 patients (56.4%) presented predominantly with hepatic symptoms with the mean duration of follow-up of 7.7 +/- 8.5 years. Ten of them (45%) presented with ALF, whereas 12 patients (55%) presented with ACLF. Patients with ALF showed a significantly earlier age of onset of presenting symptoms than those with ACLF (15.4 +/- 4.5 vs. 28.1 +/- 13.0 years; p < 0.05). The mean baseline of 24-hour urinary copper in patients with ALF was higher than those found in ACLF (1,645 +/- 1,406 vs. 441 +/- 434 mg/day; p < 0.05, respectively). Fourteen patients (63.6%) improved with supportive care and chelating agents. No significant difference of clinical improvement was found between patients presented with ALF and ACLF (80% vs. 50%; p = 0.19). By using the survival analysis, the mean duration time to liver complications or all cause of death in patients with ALF was significantly longer than those with ACLF (16.2 +/- 2.3 years vs. 8.5 +/- 3.2 years; p = 0.012) as well as higher cumulative percent of free a period from liver complication or death during a 9-year period (80% vs. 21%, p = 0.012). CONCLUSION: Patients with Wilson's disease presenting with acute-on-chronic liver failure manifested symptoms later and had more liver complications than patients with acute liver failure, as well as a lower cumulative free period from liver complication or death.

EUS-guided radiofrequency ablation plus chemotherapy versus chemotherapy alone for pancreatic cancer (ERAP): An observational open-label pilot study.

Background: No study has compared EUS-guided radiofrequency ablation (EUS-RFA) plus systemic chemotherapy (CMT) with CMT alone for unresectable pancreatic ductal adenocarcinoma. Methods: This study compared the results of treatment in patients receiving EUS-RFA plus concomitant CMT (group A; n = 14) with those receiving CMT (group B; n = 14) as a pilot study. Results: From July 2017 to August 2018, 4 and 2 patients from groups A and B, respectively, withdrew from the study because of progression of the disease. In total, 10 and 12 patients from groups A and B, respectively, completed the study. All 30 EUS-RFA procedures were successful. Mean maximal tumor diameter before treatment of group A (n = 10) versus B (n = 12) was 62.2 ± 21.0 versus 50.5 ± 22.0 mm, respectively (P = not significant). After treatment, no statistically significant difference in mean maximal tumor diameter was found between both groups. However, in group B, mean maximal tumor diameter was significantly increased from 50.5 ± 22.0 to 56.3 ± 18.7 mm, respectively (P = 0.017). Tumor necrosis occurred in group A versus B at 10 of 10 (100%) versus 6 of 12 (50%) patients, respectively (P = 0.014). After treatment, group A patients could reduce the mean narcotic pain drug dosage at 26.5 mg of morphine equivalent per day (from 63.6 to 37.1 mg, P = 0.022), whereas group B patients could not reduce the dosage of pain-controlled medication. No statistically significant difference in 6-month mortality rate was found. In group A, 1 procedure-related nonsevere adverse event (n = 1 of 30 [3.3%]) occurred in 1 patient (n = 1 of 14 [7.1%]). Conclusions: In this study, the mean tumor diameter of group B was significantly increased after the treatment. Group A had a significantly higher rate of necrosis of tumor and required less narcotic.

Success rate and cannulation time between precut sphincterotomy and double-guidewire technique in truly difficult biliary cannulation.

BACKGROUND AND AIM: Precut sphincterotomy (PS) is usually indicated in failed standard biliary cannulation (BC). PS requires experienced endoscopists, and contains significant risk. Double-guidewire (DG) cannulation seems to be easier, and might be useful after failed standard BC. We aimed to compare cannulation time, success rate, and complication rates between the two techniques. METHODS: Patients who failed standard BC within 10 min by the expert were defined as truly difficult BC and randomized into both groups. In the DG group, the first guidewire was left in the pancreatic duct, and then a catheter, pre-inserted with another guidewire, was used for the BC. In the PS group, a fistulotomy technique was used. RESULTS: From June 2008 to October 2009, 534 patients underwent endoscopic retrograde cholangiopancreatography. Forty-four patients (8.2%) who failed standard BC were randomized into the DG group (n = 23) and the PS group (n = 21). Median cannulation times and success rates in the DG and PS groups were 172 versus 394 s (P < 0.001), and 73.9% versus 80.9% (P = 0.724), respectively. The pancreatitis rate and serum amylase at 24 h in the DG and PS groups were 21.7% versus 14.3% (P = 0.701) and 937 versus 195 mg/dL (P = 0.020), respectively. Two from each group developed mild bleeding. No perforation occurred. CONCLUSION: In truly difficult BC, the DG technique requires a significant shorter duration for BC, with a comparable success rate to the PS technique. The post-procedure serum amylase level in the DG group was significantly higher, and there was a trend of more pancreatitis.

Outcome of endoscopic retrograde cholangiopancreatography during live endoscopy demonstrations.

BACKGROUND: A number of factors may result in lower than expected success rates for endoscopic retrograde cholangiopancreatography (ERCP) performed by overseas experts during live demonstrations (LDs). Stratifying the degree of ERCP difficulty may help in the assessment of procedure outcomes, but no prior reports have done so. This study aimed to compare the success rate and complications of ERCP between procedures performed in live demonstrations and for matched control subjects. METHODS: From 2004 to 2011, a total of 82 patients who underwent ERCP during live demonstrations at the Endoscopy Unit of King Chulalongkorn Memorial Hospital were reviewed. The control for each patient was a patient admitted to the same ERCP unit with matched indications at the time closest to the demonstration course who had matching gender and techniques in therapeutic interventions during ERCP. The success rates and complications between the two groups were compared based on the grading scale for the degree of difficulty according to Cotton and colleagues. RESULTS: For standard ERCP cases (levels 1-2), the success rate, complication rate, and duration of the procedure (DOP) did not differ significantly. In contrast, the success rate for complex ERCPs (levels 3-4) performed during LD was significantly lower (73% vs. 90%; P = 0.006). The complication rates and DOP were not significantly different (P = 0.31 and 0.23, respectively). The overall success rate was significantly lower for LD procedures than for control procedures (81% vs. 91%; P = 0.02). CONCLUSIONS: In this series, the standard ERCP performed during LD was associated with success and complication rates similar to those for the control subjects. Complex ERCP cases were, however, associated with lower success rates than those for the control subjects. A high proportion of complex ERCP cases during live demonstration can influence the overall success rate of ERCPs performed by overseas experts.

Cocktail sedation containing propofol versus conventional sedation for ERCP: a prospective, randomized controlled study.

BACKGROUND: ERCP practically requires moderate to deep sedation controlled by a combination of benzodiazepine and opiod. Propofol as a sole agent may cause oversedation. A combination (cocktail) of infused propofol, meperidine, and midazolam can reduce the dosage of propofol and we hypothesized that it might decrease the risk of oversedation. We prospectively compare the efficacy, recovery time, patient satisfactory, and side effects between cocktail and conventional sedations in patients undergoing ERCP. METHODS: ERCP patients were randomized into 2 groups; the cocktail group (n = 103) and the controls (n = 102). For induction, a combination of 25 mg of meperidine and 2.5 mg of midazolam were administered in both groups. In the cocktail group, a bolus dose of propofol 1 mg/kg was administered and continuously infused. In the controls, 25 mg of meperidine or 2.5 mg/kg of midazolam were titrated to maintain the level of sedation. RESULTS: In the cocktail group, the average administration rate of propofol was 6.2 mg/kg/hr. In the control group; average weight base dosage of meperidine and midazolam were 1.03 mg/kg and 0.12 mg/kg, respectively. Recovery times and patients' satisfaction scores in the cocktail and control groups were 9.67 minutes and 12.89 minutes (P = 0.045), 93.1and 87.6 (P <0.001), respectively. Desaturation rates in the cocktail and conventional groups were 58.3% and 31.4% (P <0.001), respectively. All desaturations were corrected with temporary oxygen supplementation without the need for scope removal. CONCLUSIONS: Cocktail sedation containing propofol provides faster recovery time and better patients' satisfaction for patients undergoing ERCP. However, mild degree of desaturation may still develop. TRIAL REGISTRATION: ClinicalTrials.gov, NCT01540084.