National survey regarding the timing of endoscopic procedures during the COVID-19 pandemic.

BACKGROUND: During the COVID-19 pandemic, several questions have arisen about which endoscopic procedures (EPs) must be performed and which ones can be postponed. The aim of this study was to conduct a nationwide survey regarding the appropriate timing of EPs during the COVID-19 pandemic. METHODS: This prospective study was performed through a nationwide electronic survey. The survey consisted of 15 questions divided into three sections. The first evaluated the agreement for EPs classified as "time sensitive" and "not time sensitive". Two other sections assessed "high-priority" and "low-priority" scenarios. Agreement was considered when > 75% of respondents answered a question in the same direction. RESULTS: The response rate was 27.2% (214/784). Among the respondents, agreement for the need to perform EP in < 72 h was only reached for variceal bleeding (93.4%). Dysphagia with alarm symptoms was the scenario in which the highest percentage of physicians (95.9%) agreed that an EP needed to be performed within a month. Less than 30% of endoscopists would perform an EP within the first 72 h for patients with mild cholangitis, non-variceal upper gastrointestinal bleeding without hemodynamic instability, or severe anaemia without overt bleeding. In time-sensitive clinical scenarios suggestive of benign disease, none of the scenarios reached agreement in any sense. Among the time-sensitive clinical scenarios suggestive of malignancy, > 90% of the surveyed respondents considered that EP could not be postponed for > 8 weeks. CONCLUSIONS: There was no consensus among endoscopists about the timing of EPs in patients with pathologies considered time sensitive or in those with high-priority pathologies. Agreement was only reached in five (17%) of the evaluated clinical scenarios.

EUS-guided biliary drainage in patients with distal malignant biliary obstruction requires fewer interventions and has a lower cost compared to ERCP biliary drainage.

INTRODUCTION: Endoscopic retrograde cholangiopancreatography (ERCP) biliary drainage is considered the reference standard in patients with biliary obstruction, but it is not free of complications. EUS-guided biliary drainage (EUS-BD) is considered an alternative in patients with failed ERCP; however, data are scarce as to whether EUS-BD could be considered a first option. OBJECTIVE: The aim of our study was to compare the need for reintervention and cost between ERCP biliary drainage vs. EUS-BD. MATERIAL AND METHODS: We conducted a retrospective and comparative study of patients with distal malignant biliary obstruction with biliary drainage with ERCP + plastic stent (ERCP-PS) vs. ERCP + metal stent (ERCP-MS) vs. EUS-BD. RESULTS: 124 patients were included, divided into three groups: ERCP-PS, 60 (48.3%) patients; ERCP-MS, 40 (32.2%) patients; and EUS-BD, 24 (19.3%) patients. The need for reinterventions (67 vs. 37 vs. 4%, respectively), the number of procedures [3 (1-10) vs. 2 (1-7) vs. 1 (1-2)], and the costs (4550 ± 3130 vs. 5555 ± 3210 vs. 2375 ± 1020 USD) were lower in the EUS-BD group. No differences in terms of complications were detected. CONCLUSION: EUS-BD requires fewer reinterventions and has a lower cost compared to drainage by ERCP with metal or plastic stents.

A low-residue diet before colonoscopy tends to improve tolerability by patients with no differences in preparation quality: a randomized trial.

BACKGROUND: The pre-colonoscopy diet traditionally involves 24 h of a clear liquid diet (CLD) in combination with a lavage solution; however, this preparation is poorly tolerated. AIM: To compare the impact on the quality of bowel cleansing and tolerability of a CLD versus a low-residue diet (LRD). METHODS: We performed a randomized trial. Subjects were randomized to CLD or LRD the day before of elective colonoscopy. All subjects received a 4-L preparation of single-dose PEG beginning 16 h prior to colonoscopy. The Boston bowel preparation scale was used to evaluate bowel cleansing; an adequate-quality preparation was defined as a score ≥ 2 per segment. RESULTS: A total of 205 subjects were included with a mean age (SD) of 55.6 (12.6) years; 133 (64.9%) of them were female. A total of 105 subjects were randomized to receive CLD and 100 to LRD. No significant differences in bowel preparation quality were observed between groups according to the section of colon: right colon (70% vs. 73%, p = 0.08), transverse colon (82% vs. 79%, p = 0.062), or left colon (80% vs. 78.7%, p = 0.28). There was a tendency toward less-frequent nausea (p = 0.08) and vomiting (p = 0.07) in patients with LRD. No differences between groups regarding ADR (12% vs. 10%) were noted. CONCLUSIONS: An LRD before colonoscopy resulted in a tendency toward improved tolerability by patients, with no differences in the quality of bowel preparation.

Efficacy and tolerability of low-volume (2 L) versus single- (4 L) versus split-dose (2 L + 2 L) polyethylene glycol bowel preparation for colonoscopy: randomized clinical trial.

BACKGROUND AND AIM: To compare the efficacy and tolerability of a low-volume (2-L) polyethylene glycol (PEG) regimen for colonoscopy compared to single (4-L) or split-dose (2-L + 2-L) regimens. METHODS: In-hospital patients who were candidates for colonoscopy were randomly assigned to: group 1 single-dose (PEG 4 L the day before the study, n = 60); group 2: split-dose (2 L the day before and 2 L on the day of the procedure, n = 61); and group 3: low-volume 2-L PEG solution (the day of the procedure, n = 59). A blinded evaluation of the quality of colonic preparation was assessed by the Boston bowel preparation scale. RESULTS: Satisfactory bowel preparation of the right colon was more frequently reported for group 3 than for group 1 (70% vs 53%, P = 0.045), in the transverse colon it was 82% versus 69% (P = 0.032), and on the left side of the colon it was 80% versus 67.7% (P = 0.028). Compared to group 2, satisfactory bowel preparation in group 3 was similar in the transverse colon and left colon. Nausea, vomiting, and abdominal discomfort were less frequent in patients of group 3. Patients in group 3 had fewer sleep disorders and fewer hours of sleep loss compared to patients in the other groups. CONCLUSIONS: Preparation with 2 L caused less abdominal discomfort and fewer sleep disorders. The split dose had a better quality of preparation in the right colon. Both preparations were clearly better than the 4-L preparation.

EUS-guided tissue acquisition in patients with solid pseudopapillary neoplasms of the pancreas.

OBJECTIVES: Endoscopic ultrasound-guided tissue acquisition (EUS-TA) has been the most common method used for the preoperative cytopathological diagnosis of solid tumors of the pancreas. There are only a few reported cases about the role of endoscopic ultrasound-guided fine needle biopsy (EUS-FNB) in the pre-operative diagnosis of solid pseudopapillary neoplasms (SPN). This study aimed to evaluate the diagnostic yield of EUS-TA,including endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) andEUS-FNB, in patients with SPN. METHODS: We performed a retrospective analysis of patients with EUS-TA for SPN diagnosis in 2 referral centers. The primary outcome was the diagnostic yield of EUS-TA compared to the surgical specimen. RESULTS: Seventy-four patients with SPN of the pancreas were identified. Eighteen had a EUS-TA (10 EUS-FNB and 8 EUS-FNA). The median age of the patients was 31 years (IQR 21-38), and all patients were women. The most common presenting symptom was abdominal pain. Most of the tumors were in the head of the pancreas (9/18; 50%). The median tumor size by EUS was 4.5 cm (min-max 2-15 cm). The most common appearance on EUS was a solid lesion (n = 8/18, 44.4%). A definitive presurgical cytopathological diagnosis was obtained in 16/18 patients (88.8%) with EUS-TA. The sensitivity and positive predictive value of the EUS-TA were 94% each. One patient in the EUS-FNB group developed mild acute pancreatitis. CONCLUSION: The diagnostic yield of the EUS-TA in SPN is high. In most cases, the diagnosis was obtained with the first procedure. No differences in the diagnostic yield or AEs between EUS-FNA vs. EUS-FNB needles were seen.

Clinical and Endoscopic Differences Between Patients With Barrett's Esophagus With and Without Dysplasia/Adenocarcinoma.

INTRODUCTION: Barrett's esophagus (BE) is the main precursor of esophageal adenocarcinoma (EAC). This study aimed to identify the risk factors associated with BE progression to dysplasia or EAC in a Latin population. METHODS: The study is a retrospective analysis of a single-center cohort of patients with BE, evaluated from 2002 to 2012. RESULTS: We identified 420 patients with BE; 281 (66.9%) of them were men with a mean age of 57.2 ± 15.3 years. Among all BE patients evaluated, 81 (19.3%) had progression to some degree of dysplasia/EAC. The mean follow-up was 5.6 years. Multivariate analysis showed that age (OR = 1.03), cigarette smoking (OR = 3.05), long-segment BE (OR = 4.81), and a visible lesion on BE (OR = 6.94) were associated with progression to dysplasia/EAC. CONCLUSION: In Latin patients with BE, age, cigarette smoking, long-segment BE, and the presence of lesions were associated with the presence of dysplasia/EAC.

Rapid diagnosis of spontaneous bacterial peritonitis using leukocyte esterase reagent strips in emergency department: uri-quick clini-10SG® vs. Multistix 10SG®.

BACKGROUND AND AIM: Bacterial peritonitis (SBP) is the most frequent infection in patients with cirrhosis causing significant mortality. Delay in SBP diagnosis is a serious problem. The aim of this study was to evaluate the diagnostic yield of Uri-Quick Clini-10SG® vs. Multistix 10SG® reagent strips in an Emergency Department. MATERIAL AND METHODS: A prospective study of consecutive patients with ascites and paracentesis attending to Emergency Department from March 2005 to February 2007 was made. SBP was defined by ≥ 250 neutrophiles /mm³. The ascites obtained at bedside was immediately tested in a dry test tube with both the Uri-Quick Clini 10SG® and MultistixSG10®. The Uri-Quick Clini 10SG® and Multistix SG10®. Strips were considered positive at grade ≥ 3 (≥ 125 leukocytes/mL). RESULTS: A total of 223 ascitic fluid samples were obtained. There were 49 episodes of SBP. Median age was 54 (range 18-87 year) years; 62.3% were female. The sensitivity, specificity, PPV, NPV, and 95% CI for Uri-Quick Clini 10SG® were 79.6 (64-87), 98.2 (94-99), 90.5 (78-96) and 93.9 (89-96), respectively. For MultistixSG10® the values were 77.5 (64-88), 97.7 (93-98), 90 (77.9-96.2), and 94 (89.4-96.6), respectively. CONCLUSION: The use of reagent strip is useful for SBP diagnosis in an emergency setting. The high PPV allow start antibiotic treatment. In areas without the resources to perform conventional ascites fluid analyses, these strips could be presently used.

Inflammatory myofibroblastic tumour of the liver. Case report.

Inflammatory myofibroblastic tumour (IMT), also called inflammatory pseudotumour, is an uncommon neoplastic benign lesion histopathologically characterized by fibroblast and myofibroblast proliferation, with inflammatory cell infiltration. Systemic inflammatory response can appear although specific pathogens are rarely found. We present a case of a woman in whom liver abscess was initially suspected The absence of microorganisms in the tissue obtained by needle aspiration biopsy and the lack of antibiotic therapy response indicated hepatic resection that lead to diagnosis of IMT of the liver, which has to be differentiated from abscess and abscessed tumours. The aim of this case report is to analyze the clinical presentation, course, diagnostic methods, therapies, and existing evidence of the possible pathogenic mechanisms leading to this neoplasm.

Patients With Unexplained Dilated Pancreatic Duct Have High Risk of Biliopancreatic Malignancy Detected by EUS.

INTRODUCTION: Patients with unexplained dilated common bile duct (CBD) and/or dilated main pancreatic duct (MPD) on noninvasive abdominal imaging tests are often referred for endoscopic ultrasound (EUS) in order to rule out biliopancreatic cancer. The aim of the study was to evaluate the diagnostic yield of EUS in this patient group. METHODS: A prospective study was conducted. Patients with unexplained dilated CBD and/or MPD on abdominal imaging, who underwent EUS, were enrolled. RESULTS: Fifty-four patients underwent EUS (CBD dilation n=38, MPD dilation n=5 or both n=11). In 31/54 patients (57.4%), EUS revealed pathologic findings. Sixteen patients (29.6%) had EUS evidence of biliopancreatic cancer and 15 patients (27.7%) had benign pathology. Ten (62.5%) of the patients with biliopancreatic cancer had MPD dilation. MPD dilation was significantly associated with malignancy (P=0.017). CONCLUSION: Patients with unexplained dilated MPD on noninvasive image have a high risk of biliopancreatic malignancy detected by EUS.

Bacterial meningitis in cirrhotic patients: case series and description of the prognostic role of acute renal failure.

AIM: To analyze the mortality risk factors in cirrhotic patients with bacterial meningitis (BM). BACKGROUND: Cirrhotic patients are susceptible to infections. Despite its high mortality rate, BM has not been extensively studied in this group of patients. STUDY: BM patients diagnosed with cirrhosis, between 1987 and 2008, were studied. BM was defined as the presence of signs or symptoms of meningitis and a cerebrospinal fluid (CSF) leukocyte count >100/mm3 or the presence of bacteria in CSF. RESULTS: We identified 4955 infections among 7591 cirrhotic patients; 12 (0.2%) had BM. The mean age at diagnosis was 60±16 years. Abnormal mental status (83%), fever (67%), and neck stiffness (67%) were the most frequent clinical presentations. The sensitivity of CSF culture was 75% (Streptococcus pneumoniae, 2; Staphylococcus aureus, 2; Listeria monocytogenes, 1; Group B Streptococcus, 1; Streptococcus agalactiae, 1; Streptococcus bovis, 1; and Escherichia coli, 1), and its correlation with blood culture was 78%. Five patients died. On admission, the serum creatinine level was 1.63±0.93 mg/dL. A serum creatinine level ≥1.3 mg/dL was associated with increased mortality (P=0.028). The model for end-stage liver disease score, gastrointestinal bleeding, bilirubin level >3.5 mg/dL, hepatic encephalopathy, diabetes mellitus, and results of cytology and biochemistry tests of CSF were not associated with mortality. CONCLUSIONS: BM in cirrhotic patients is associated with a high mortality rate. The clinical and microbiologic features of BM in cirrhotic patients differ from those in the general population. A serum creatinine level ≥1.3 mg/dL on admission is associated with a higher risk of mortality.

Endoscopic treatment with argon plasma coagulation in postradiation proctopathy.

INTRODUCTION: Postradiation proctopathy (PP) is a major complication in patients who receive radiotherapy for cancer. Medical treatments of this entity are unsatisfactory. Argon plasma coagulation (APC) had been shown to be successful with low complications. The aim was to describe our experience with APC in the management of PP. METHODS: We conducted a retrospective analysis of electronic- and paper-based records of patients with PP managed with APC. RESULTS: Nineteen patients with PP were included, nine were women. Median age was 64 years, and follow-up was 29 months. The most frequent cause of radiotherapy for cancer was cervicouterine and prostate ENDOSCOPIC FINDINGS: Moderate disease was observed in nine patients; mild and severe diseases were observed in five patients each. At endoscopy, telangiectasias were present in 15, ulcers in five, and active bleeding in two patients. Median of APC sessions was two (one to seven). Mean dose of APC was 30 W (30-40 W) and 1.7 l (1.5-2.0 l). Median time for relief of symptoms was 3 months. All patients were asymptomatic at the end of treatment, and bleeding was controlled at the end of treatment in all patients. Recurrence of bleeding presented in one patient at 4 months. No complications were related to the APC treatment. CONCLUSIONS: According to our data, APC is successful in treatment of PP, with few sessions and low morbidity and null mortality.

Antibiotic prophylaxis for cirrhotic patients with upper gastrointestinal bleeding.

BACKGROUND: Bacterial infections are a frequent complication in patients with cirrhosis and upper gastrointestinal bleeding. Antibiotic prophylaxis seems to decrease the incidence of bacterial infections. Oral antibiotics, active against enteric bacteria, have been commonly used as antibiotic prophylaxis in patients with cirrhosis and upper gastrointestinal bleeding. This is an update of a Cochrane review first published in 2002. OBJECTIVES: To assess the benefits and harms of antibiotic prophylaxis in cirrhotic patients with upper gastrointestinal bleeding. SEARCH STRATEGY: We searched The Cochrane Hepato-Biliary Group Controlled Trials Register, The Cochrane Central Register of Controlled Trials (CENTRAL) in The Cochrane Library, MEDLINE, EMBASE, and Science Citation Index EXPANDED until June 2010. In addition, we handsearched the references of all identified studies. SELECTION CRITERIA: Randomised clinical trials comparing different types of antibiotic prophylaxis with no intervention, placebo, or another antibiotic to prevent bacterial infections in cirrhotic patients with upper gastrointestinal bleeding. DATA COLLECTION AND ANALYSIS: Three authors independently assessed trial quality, risk of bias, and extracted data. We contacted study authors for additional information. Association measures were relative risk (RR) for dichotomous outcomes and mean difference (MD) for continuous outcomes. MAIN RESULTS: Twelve trials (1241 patients) evaluated antibiotic prophylaxis compared with placebo or no antibiotic prophylaxis. All trials were at risk of bias. Antibiotic prophylaxis compared with no intervention or placebo was associated with beneficial effects on mortality (RR 0.79, 95% CI 0.63 to 0.98), mortality from bacterial infections (RR 0.43, 95% CI 0.19 to 0.97), bacterial infections (RR 0.36, 95% CI 0.27 to 0.49), rebleeding (RR 0.53, 95% CI 0.38 to 0.74), days of hospitalisation (MD -1.91, 95% CI -3.80 to -0.02), bacteraemia (RR 0.25, 95% CI 0.15 to 0.40), pneumonia (RR 0.45, 95% CI 0.27 to 0.75), spontaneous bacterial peritonitis (RR 0.29, 95% CI 0.15 to 0.57), and urinary tract infections (RR 0.23, 95% CI 0.12 to 0.41). No serious adverse events were reported. The trials showed no significant heterogeneity of effects. Another five trials (650 patients) compared different antibiotic regimens. Data could not be combined as each trial used different antibiotic regimen. None of the examined antibiotic regimen was superior to the control regimen regarding mortality or bacterial infections. AUTHORS' CONCLUSIONS: Prophylactic antibiotic use in patients with cirrhosis and upper gastrointestinal bleeding significantly reduced bacterial infections, and seems to have reduced all-cause mortality, bacterial infection mortality, rebleeding events, and hospitalisation length. These benefits were observed independently of the type of antibiotic used; thus, no specific antibiotic can be preferred. Therefore, antibiotic selection should be made considering local conditions such as bacterial resistance profile and treatment cost.

Bariatric surgery for non-alcoholic steatohepatitis in obese patients.

BACKGROUND: Nonalcoholic fatty liver disease (NAFLD) is increasingly recognised as a condition associated with overweight or obesity that may progress to end-stage liver disease. NAFLD histology resembles alcohol-induced liver injury, but occurs in patients with no history of alcohol abuse. NAFLD has a broad spectrum of clinical and histological manifestations, ranging from simple fatty liver to hepatic steatosis with inflammation, advanced fibrosis, and cirrhosis. The inflammatory stage is known as non-alcoholic steatohepatitis (NASH). Recent reports indicate that weight loss induced by bariatric procedures could be beneficial for NASH treatment. OBJECTIVES: To assess the benefits and harms of bariatric surgery for NASH in obese patients. SEARCH STRATEGY: We searched The Cochrane Hepato-Biliary Group Controlled Trials Register, the Cochrane Central Register of Controlled Trials (CENTRAL) in The Cochrane Library, MEDLINE, EMBASE, and Science Citation Index Expanded to October 2009. SELECTION CRITERIA: All randomised clinical trials evaluating any bariatric procedure versus no intervention, placebo (sham procedure), or other interventions in patients with NASH regardless of publication status, number of patients randomised, language, or blinding. Quasi-randomised clinical studies were to be considered for the review if no randomised clinical trials were identified. If included, their bias towards positive findings was to be considered. DATA COLLECTION AND ANALYSIS: We extracted data in duplicate, and we planned to analyse the data by intention-to-treat. MAIN RESULTS: We could not find any randomised clinical trials or quasi-randomised clinical studies that fulfilled the inclusion criteria. Our search resulted in twenty-one prospective or retrospective cohort studies, in which improvement on steatosis or inflammation scores was reported. However, four studies also described some deterioration in the degree of fibrosis. AUTHORS' CONCLUSIONS: The lack of randomised clinical trials and quasi-randomised clinical studies precludes us to assess the benefits and harms of bariatric surgery as a therapeutic approach for patients with NASH. Limitations of all other studies with inferior design did not allow us to draw any unbiased conclusion on bariatric surgery for treatment of NASH.

[Surgical treatment of familial adenomatous polyposis with an open technique. Experience of a third level Latin American center]. / Tratamiento quirúrgico de la poliposis adenomatosa familiar con técnica abierta. Experiencia de un centro latinoamericano de tercer nivel.

INTRODUCTION: The ileal pouch-anal anastomosis (IPAA) and ileorectal anastomosis (IRA) are the preferred surgical methods in patients with familial adenomatous polyposis (FAP). OBJECTIVE: To describe the results obtained from the surgical treatment in patients with FAP related to morbidity, mortality, rectal cancer and overall survival. METHODS: We studied a retrospective cohort including all patients operated on with IPAA or IRA for FAP during the period of 1969 to 2000 at the Instituto Nacional de Ciencias Medicas y Nutricion Salvador Zubiran. RESULTS: Twenty-six patients were included. IRA was performed in 9 patients and IPAA in 17. Surgical morbidity was observed in 5 patients (19.2%). Mean postoperative follow-up was 68.8 +/- 58.8 months (median 52.5 months, range 0-240 months). Functional results were similar in both groups. The five year survival in patients with IPAA and IRA was 100% and 55.6%, respectively (P = 0.035). CONCLUSIONS: In our institution, postoperative morbidity and mortality in patients with FAP are similar to those published in the literature. IPAA seems to offer better results related to survival with similar functional results and postoperative complications.