RESUMO
BACKGROUND AND AIMS: Nonanesthesiologist-administered propofol (NAAP) is increasingly accepted, but data are limited on drug administration using target-controlled infusion (TCI) in clinical practice. TCI adjusts the drug infusion based on patient-specific parameters, maintaining a constant drug dose to reduce the risk of adverse events (AEs) because of drug overdosing and to enhance patient comfort. The aims of this study were to assess the rate of AEs and to evaluate patient satisfaction with NAAP using TCI in a retrospective cohort of 18,302 procedures. METHODS: Low-risk patients (American Society of Anesthesiologists score I and II) undergoing outpatient GI endoscopic procedures, including EGDs and colonoscopies, were sequentially enrolled at IRCCS San Raffaele Hospital (Milan, Italy) between May 2019 and November 2021. RESULTS: Data from 7162 EGDs and 11,140 colonoscopies were analyzed. Mean patient age was 59.1 ± 14.8 years, and mean body mass index was 24.9 ± 3.7 kg/m2. The male-to-female ratio was equal at 8798 (48.1%):9486 (51.9%). AEs occurred in 240 procedures (1.3%) out of the total cohort, with no differences between EGDs and colonoscopies (100 [1.4%] and 140 [1.2%], respectively; P = .418). Most patients (15,875 [98.9%]) indicated they would likely repeat the procedure with the same sedation protocol. Age (odds ratio, 1.02; 95% confidence interval, 1.01-1.03; P < .008) was the only independent factor associated with overall AEs. CONCLUSIONS: NAAP using TCI is an effective and safe sedation method for routine endoscopy. The proper propofol dosage based on individual patients and the presence of trained operators are crucial for NAAP sedation management.
Assuntos
Anestésicos Intravenosos , Colonoscopia , Endoscopia Gastrointestinal , Satisfação do Paciente , Propofol , Humanos , Propofol/administração & dosagem , Propofol/efeitos adversos , Masculino , Feminino , Pessoa de Meia-Idade , Estudos Retrospectivos , Idoso , Colonoscopia/métodos , Endoscopia Gastrointestinal/métodos , Anestésicos Intravenosos/administração & dosagem , Anestésicos Intravenosos/efeitos adversos , Adulto , Infusões Intravenosas , Hipnóticos e Sedativos/administração & dosagem , Hipnóticos e Sedativos/efeitos adversosRESUMO
Clinically significant portal hypertension (CSPH) in patients with compensated advanced chronic liver disease indicates an increased risk of decompensation and death. While invasive methods like hepatic venous-portal gradient measurement is considered the gold standard, non-invasive tests (NITs) have emerged as valuable tools for diagnosing and monitoring CSPH. This review comprehensively explores non-invasive diagnostic modalities for portal hypertension, focusing on NITs in the setting of hepatitis B and hepatitis C virus-related cirrhosis. Biochemical-based NITs can be represented by single serum biomarkers (e.g., platelet count) or by composite scores that combine different serum biomarkers with each other or with demographic characteristics (e.g., FIB-4). On the other hand, liver stiffness measurement and spleen stiffness measurement can be assessed using a variety of elastography techniques, and they can be used alone, in combination with, or as a second step after biochemical-based NITs. The incorporation of liver and spleen stiffness measurements, alone or combined with platelet count, into established and validated criteria, such as Baveno VI or Baveno VII criteria, provides useful tools for the prediction of CSPH and for ruling out high-risk varices, potentially avoiding invasive tests like upper endoscopy. Moreover, they have also been shown to be able to predict liver-related events (e.g., the occurrence of hepatic decompensation). When transient elastography is not available or not feasible, biochemical-based NITs (e.g., RESIST criteria, that are based on the combination of platelet count and albumin levels) are valid alternatives for predicting high-risk varices both in patients with untreated viral aetiology and after sustained virological response. Ongoing research should explore novel biomarkers and novel elastography techniques, but current evidence supports the utility of routine blood tests, LSM, and SSM as effective surrogates in diagnosing and staging portal hypertension and predicting patient outcomes.
Assuntos
Biomarcadores , Técnicas de Imagem por Elasticidade , Hipertensão Portal , Cirrose Hepática , Humanos , Hipertensão Portal/complicações , Hipertensão Portal/fisiopatologia , Hipertensão Portal/diagnóstico , Hipertensão Portal/etiologia , Cirrose Hepática/complicações , Cirrose Hepática/sangue , Cirrose Hepática/diagnóstico , Técnicas de Imagem por Elasticidade/métodos , Biomarcadores/sangue , Hepatite B/complicações , Hepatite B/diagnóstico , Contagem de Plaquetas , Hepatite C/complicações , Hepatite C/diagnóstico , Baço/diagnóstico por imagemRESUMO
BACKGROUND AND AIMS: EUS-guided gallbladder drainage (EUS-GBD) with lumen-apposing metal stents (LAMSs) has been reported as a rescue treatment with encouraging results for the relief of jaundice in patients with distal malignant biliary obstruction (DMBO) and after failure of both ERCP and EUS-guided choledochoduodenostomy. METHODS: This was a multicenter retrospective analysis of all cases of consecutive EUS-GBD with LAMSs used as a rescue treatment for patients with DMBO in 14 Italian centers from June 2015 to June 2020. Primary endpoints were technical and clinical success, whereas the secondary endpoint was the adverse event (AE) rate. RESULTS: Forty-eight patients (52.1% women) with a mean age of 74.3 ± 11.7 years were included in the study. Biliary stricture was related to pancreatic adenocarcinoma (85.4%), duodenal adenocarcinoma (2.1%), cholangiocarcinoma (4.2%), ampullary cancer (2.1%), colon cancer (4.2%), and metastatic breast cancer (2.1%). The mean diameter of the common bile duct was 13.3 ± 2.8 mm. LAMSs were placed transgastrically in 58.3% of cases and transduodenally in 41.7%. Technical success was 100%, whereas clinical success was 81.3%, with a mean total bilirubin reduction after 2 weeks of 66.5%. The mean procedure time was 26.4 minutes, and the mean hospital stay was 9.2 ± 8.2 days. AEs occurred in 5 patients (10.4%): 3 were classified as intraprocedural and 2 were classified as delayed because they occurred after >15 days. When the American Society for Gastrointestinal Endoscopy lexicon was used, 2 AEs were mild and 3 were moderate (2 buried LAMSs). The mean follow-up was 122 days. CONCLUSIONS: Our study shows that EUS-GBD with LAMSs used as a rescue treatment for patients affected by DMBO represents a valuable option in terms of technical and clinical success rates, with an acceptable AE rate. To the best of our knowledge, this is the largest study concerning the use of this procedure. (Clinical trial registration number: NCT03903523.).
Assuntos
Adenocarcinoma , Ampola Hepatopancreática , Colestase , Neoplasias do Ducto Colédoco , Neoplasias Pancreáticas , Humanos , Feminino , Pessoa de Meia-Idade , Idoso , Idoso de 80 Anos ou mais , Masculino , Vesícula Biliar , Estudos Retrospectivos , Adenocarcinoma/complicações , Neoplasias Pancreáticas/complicações , Neoplasias do Ducto Colédoco/complicações , Endossonografia/métodos , Stents/efeitos adversos , Colestase/etiologia , Colestase/cirurgia , Drenagem/métodos , Ultrassonografia de Intervenção/efeitos adversos , Resultado do TratamentoRESUMO
BACKGROUND AND AIMS: EUS-guided choledochoduodenostomy (EUS-CDS) with a lumen-apposing metal stent (LAMS) has been proposed as an alternative procedure in patients with distal malignant biliary obstruction (DMBO) and failed ERCP. METHODS: This multicenter, retrospective analysis included all cases of EUS-CDS with LAMS performed in patients with DMBO and failed ERCP in 23 Italian centers from January 2016 to July 2020. Primary endpoints were technical and clinical success. Secondary endpoints were the assessment of the adverse event (AE) rate and variables associated with technical success. RESULTS: Two hundred fifty-six patients (44.9% women) with a mean age of 73.9 ± 12.6 years were included in the study. The most common etiology of DMBO was pancreatic adenocarcinoma (75%), followed by ampullary cancer (8.6%) and cholangiocarcinoma (6.6%). The common bile duct median diameter was 17.3 ± 3.9 mm. Technical and clinical success were achieved in 239 of 256 (93.3%), and 230 of 239 (96.2%) patients, respectively. The mean follow-up was 151 ± 162 days. Twenty-seven AEs occurred in 25 of 239 patients (10.5%) (3 mild, 21 moderate, and 3 severe). No fatal AEs occurred. Reinterventions to manage AEs with endoscopic or radiologic procedures occurred in 22 patients (9.2%). CONCLUSIONS: The results of our study show that EUS-CDS with LAMSs in patients with DMBO and failed ERCP represent a viable alternative in terms of effectiveness and safety with acceptable AE rates. (Clinical trial registration number: NCT03903523.).
Assuntos
Adenocarcinoma , Ampola Hepatopancreática , Neoplasias dos Ductos Biliares , Colestase , Neoplasias do Ducto Colédoco , Neoplasias Pancreáticas , Adenocarcinoma/complicações , Adenocarcinoma/cirurgia , Idoso , Idoso de 80 Anos ou mais , Neoplasias dos Ductos Biliares/complicações , Ductos Biliares Intra-Hepáticos , Colangiopancreatografia Retrógrada Endoscópica/métodos , Coledocostomia/métodos , Colestase/complicações , Colestase/cirurgia , Neoplasias do Ducto Colédoco/complicações , Neoplasias do Ducto Colédoco/cirurgia , Drenagem/métodos , Endossonografia/métodos , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Neoplasias Pancreáticas/complicações , Estudos Retrospectivos , Stents/efeitos adversos , Ultrassonografia de Intervenção/efeitos adversosRESUMO
BACKGROUND AND AIMS: There is increasing interest in expanding the use of lumen-apposing metal stents (LAMSs) in patients with pancreatic fluid collections (PFCs). The aim of this study was to determine whether there is a hospital volume threshold for which patient outcomes could be optimized. METHODS: Data from a large multicenter series of patients with PFCs treated with LAMSs were retrieved. Rate of adverse events (AEs) was the primary outcome. Multivariable models with restricted cubic splines were used to identify a hospital volume threshold by plotting hospital volume against the log odds ratio (OR) of AE rate. Propensity score matching was applied to obtain 2 well-balanced groups according to hospital volume, and univariate/multivariate logistic regression analysis was performed to identify significant predictors of AEs. RESULTS: Overall, 516 patients were included. Increasing hospital volume was associated with a reduced AE rate (P = .03), and the likelihood of experiencing an AE declined as hospital volume increased up to 15 cases. After propensity score matching, 175 patients in the high-volume (>15 cases) and 132 in the low-volume hospital group were compared. Overall, 41 AEs were observed (13.3%), of which 14 (8%) and 27 (20.4%) occurred at high-volume and low-volume centers, respectively (P = .001). Severe and fatal events were observed more frequently in low-volume centers (6% vs 1.7% and 2.2% vs 0%, respectively; P = .05). In multivariate analysis, main pancreatic duct injury (OR, 2.62; 95% confidence interval [CI], 1.26-4.67; P = .02), presence of abnormal vessels (OR, 2.93; 95% CI, 1.41-5.02; P = .006), and institutional experience (OR, 2.95; 95% CI, 1.48-5.90; P = .002) were significant predictors of AEs. CONCLUSIONS: With 15 procedures representing the minimum number of cases associated with the lowest risk for postprocedural AEs, hospital volume is associated with improved outcomes. (Clinical trial registration number: NCT03903523.).
Assuntos
Drenagem , Pancreatopatias , Estudos de Coortes , Drenagem/métodos , Endossonografia/métodos , Hospitais , Humanos , Pancreatopatias/etiologia , Pancreatopatias/cirurgia , Estudos Retrospectivos , Stents/efeitos adversos , Resultado do TratamentoRESUMO
OBJECTIVES: To generate a prognostic model based on a nomogram for adverse event (AE) prediction after lumen-apposing metal stents (LAMS) placement in patients with pancreatic fluid collections (PFC). METHODS: Data from a large multicenter series of PFCs treated with LAMS placement were retrieved. AE (overall and excluding mild events) prediction was calculated through a logistic regression model and a nomogram was created and internally validated after bootstrapping. Results were expressed in terms of odds ratio (OR) and 95% confidence interval (CI). Discrimination was assessed by c-statistics and calibrated by comparing deciles of predicted and observed ORs. RESULTS: Overall, 516 patients were included (males 68%, mean age 61.6 ± 15.2 years). PFCs were predominantly walled-off necrosis (52.1%). Independent predictors of AE occurrence were injury of main pancreatic duct (OR in the case of leak 2.51, 95% CI 1.06-5.97, P = 0.03; OR in the case of complete disruption 2.61, 1.53-4.45, P = 0.01), abnormal vessels (OR in the case of perigastric varices 2.90, 1.31-6.42, P = 0.008; OR in the case of pseudoaneurysm 2.99, 1.75-11.93, P = 0.002), using a multigate technique (OR 3.00, 1.28-5.24; P = 0.05), and need of percutaneous drainage (OR 2.81, 1.03-7.65, P = 0.04). By nomogram, a score beyond 200 points corresponded to a 50% probability of AE occurrence. The model was confirmed even when excluding mild AEs and it showed optimal discrimination (c-index 76.8%, 95% CI 74-79), confirmed after internal validation. CONCLUSION: Patients with preprocedural evidence of pancreatic duct leak/disruption, vessel alteration, requiring percutaneous drainage or a multigate technique are at higher risk for AE.
Assuntos
Nomogramas , Pancreatopatias , Masculino , Humanos , Pessoa de Meia-Idade , Idoso , Drenagem/métodos , Pancreatopatias/etiologia , Suco Pancreático , Stents/efeitos adversos , Metais/efeitos adversosRESUMO
Background and Objectives: Endoscopic ultrasound-guided gastroenteric anastomosis (EUS-GEA) using lumen-apposing metal stents (LAMS) is emerging as a minimally invasive alternative to surgery across several indications. The aim of this survey is to investigate the perceived feasibility of this technique nationwide, within a working group skilled in interventional endosonography. Materials and Methods: Endoscopists were asked to answer to 49 items on a web-based questionnaire about expertise, peri- and intra-procedural aspects in the three main settings of EUS-GEA performance, budget/refund, and future perspectives. Statistical analysis was performed through SPSS® (IBM Corp. Released 2017. IBM SPSS Statistics for Windows, Version 25.0. Armonk, NY: IBM Corp.). Results: Sixty endosonographers belonging to forty Italian centers were I-EUS app users and were all invited to participate. In total, 29 participants from 24 Italian centers completed the survey. All the participants were endosonographers with a broad range of experience both in the field of EUS (only 10.3% with more than 20 years of experience) and duodenal stenting (only 6.9% placed more than 10 stents in 2020), whereas 86.2% also performed ERCP. A total of 27.6% of participants performed EUS-GEA (3.4% more than 20 during their career); on the other hand, 79.3% of participants routinely performed drainage of peri-pancreatic fluid collections, 62.1% performed biliary drainage, and 62.1% performed gallbladder drainage with LAMS. A total of 89.7% of participants thought that EUS-GEA could be useful in their daily clinical practice, with 100% concluding that this procedure will need to be performed in referral centers in the near future; however, in 55.2% of cases, organizational obstacles may occur and affect the diffusion of the procedure. With regard to indications: 44.8% of participants performed the procedure with palliative intent for malignant indication (96.6% pancreatic adenocarcinoma), and 13.6% also for benign indication. A total of 20.7% of participants experienced adverse events (none severe or fatal, 66.6% moderate). A total of 62.1% of participants considered the procedure technically challenging, although 82.8% considered the risk of adverse events acceptable when considering the benefit. Conclusions: To our knowledge, this is the first survey assessing the perceived feasibility of EUS-guided anastomoses after its advent. There are currently wide variations in practice nationwide, which demonstrate a need to define technical, qualitative, and peri-procedural requirements to carry out this procedure. Therefore, a standardization of these requirements is needed in order to overcome the technical, economical, and organizational obstacles relative to its diffusion.
Assuntos
Colestase , Endossonografia , Stents , Ultrassonografia de Intervenção , Adenocarcinoma , Anastomose Cirúrgica , Colangiopancreatografia Retrógrada Endoscópica/métodos , Colestase/etiologia , Colestase/terapia , Endossonografia/métodos , Estudos de Viabilidade , Humanos , Neoplasias Pancreáticas , Stents/efeitos adversos , Inquéritos e Questionários , Resultado do Tratamento , Ultrassonografia de Intervenção/métodosRESUMO
BACKGROUND: Endoscopic ultrasound (EUS)-guided biliary drainage is becoming an option for palliation of malignant biliary obstruction. Lumen-apposing metal stents (LAMS) are replacing self-expandable metal stents (SEMS). The aim of this meta-analysis was to evaluate the efficacy and safety of LAMS and SEMS for EUS-guided choledochoduodenostomy (EUS-CDS). METHODS: A meta-analysis was performed using PRISMA protocols. Electronic databases were searched for studies on EUS-CDS. The primary outcome was clinical success. Secondary outcomes were technical success, reintervention, and adverse events. We used the random effects model with the DerSimonian-Laird estimation, and the results were depicted using forest plots. Subgroup analyses were also performed with data stratified by selected variable. RESULTS: Overall, 31 studies (820 patients) were included. The pooled rates of clinical and technical success were 93.6â% (95â% confidence interval [CI] 88.6â%-96.5â%) and 94.8â% (95â%CI 90.2â%-97.3â%) for LAMS, and 91.7â% (95â%CI 88.1â%-94.2â%) and 92.7â% (95â%CI 89.9â%-94.9â%) for SEMS, respectively. The pooled rates of adverse events were 17.1â% (95â%CI 12.5â%-22.8â%) for LAMS and 18.3â% (95â%CI 14.3â%-23.0â%) for SEMS. The pooled rates of reintervention were 10.9â% (95â%CI 7.7â%-15.3â%) for LAMS and 13.9â% (95â%CI 9.6â%-19.7â%) for SEMS.âSubgroup analyses confirmed these results. CONCLUSIONS: This meta-analysis showed that LAMS and SEMS are comparable in terms of efficacy for EUS-CDS. Clinical and technical success, post-procedure adverse events, and reintervention rates were similar between LAMS and SEMS use; however, adverse events require further investigation.
Assuntos
Coledocostomia , Stents Metálicos Autoexpansíveis , Coledocostomia/efeitos adversos , Drenagem , Endossonografia , Humanos , Stents Metálicos Autoexpansíveis/efeitos adversos , Stents/efeitos adversos , Resultado do Tratamento , Ultrassonografia de IntervençãoRESUMO
BACKGROUND: Conventional endoscopic resection techniques such as endoscopic mucosal resection (EMR) or endoscopic submucosal dissection (ESD), represent the standard of care for treatment of superficial gastrointestinal lesions. In 2012 a novel technique called underwater endoscopic mucosal resection (U-EMR) was described by Binmoeller and colleagues. This substantial variation from the standard procedure was afterwards applied at endoscopic submucosal dissection (U-ESD) and recently proposed also for peroral endoscopic myotomy (U-POEM) and endoscopic full-thickness resection (U-EFTR). METHODS: This paper aims to perform a comprehensive review of the current literature related to supporting the underwater resection techniques with the aim to evaluate their safety and efficacy. RESULTS: Based on the current literature U-EMR appears to be feasible and safe. Comparison studies showed that U-EMR is associated with higher "en-bloc" and R0 resection rates for colonic lesions, but lower "en-bloc" and R0 resection rates for duodenal non-ampullary lesions, compared to standard EMR. In contrast to U-EMR, little evidence supporting U-ESD are currently available. A single comparison study on gastric lesions showed that U-ESD had shorter procedural times and allowed a similar "en-bloc" resection rates compared to standard ESD. No comparison studies between U-ESD and ESD are available for colonic lesions. Finally, only some anecdotal experiences have been reported for U-POEM or U-EFTR, and the feasibility and effectiveness of these techniques need to be further investigated. CONCLUSIONS: Further prospective studies are necessary to better explore the advantages of underwater techniques compared to the respective standards of care, especially in the setting of U-ESD where consistent data are lacking and where standardization of the technique is needed.
Assuntos
Ressecção Endoscópica de Mucosa/métodos , Neoplasias Gastrointestinais/cirurgia , Mucosa Intestinal/cirurgia , Pólipos Intestinais/cirurgia , Bases de Dados Factuais , Ressecção Endoscópica de Mucosa/efeitos adversos , Humanos , Resultado do Tratamento , ÁguaRESUMO
BACKGROUND AND AIMS: Gallbladder carcinoma is a rare but aggressive malignant neoplasm. The incidence of intra- or post-operative incidental gallbladder carcinoma diagnosis following laparoscopic cholecystectomy is estimated to be 1-2%. Aggressive re-resection is warranted as the majority of patients have residual disease either in the liver or the lymph nodes. However the use of a minimally invasive surgical approach (MISA) to perform a radicalization in these patients has not been investigated yet. We retrospectively analyzed surgical and oncologic outcome of a small selected cohort of patients with incidental gallbladder carcinoma whom underwent redo radicalization surgery by MISA. MATERIAL AND METHODS: From April 2012 to June 2014 at our department six patients (three females and three males) with incidental findings of gallbladder carcinoma pT1b (stage I) following laparoscopic cholecystectomy, and referred to our center from other secondary-level referral hospitals, underwent a redo surgery for radicalization by means of laparoscopic (n. 3) or robotic approach (n. 3). A retrospective analysis of prospective collected data was performed. RESULTS: The redo procedure consisted of a liver resection (segments IVb + V) and lymph nodes clearance of hepatoduodenal hilum and common hepatic artery. Conversion rate was zero. Median operative time was 290 (250-310) min. Estimate blood loss was 175 (100-350) ml. Total hospital stay was 6 (5-10) days. All liver resections were performed without inflow vascular clamping. One patient was re-operated for hemoperitoneum while peri-operative mortality was zero. Oncologically, an R0 resection was always achieved with a mean number of lymph nodes retrieved of 17,5 (14-22). The stage of the neoplasm was confirmed in all cases but one, who was found to have a pN1 status (stage IIIb). At 21 (6-32) months follow-up all patients are alive and no recurrence has been observed. CONCLUSIONS: Our data suggest that radicalization of patients with stage I incidental postoperative gallbladder carcinoma can be done by a MISA without compromising the oncologic outcome. Larger studies are needed to validate these results.
Assuntos
Colecistectomia Laparoscópica/métodos , Neoplasias da Vesícula Biliar/cirurgia , Procedimentos Cirúrgicos Robóticos/métodos , Perda Sanguínea Cirúrgica , Feminino , Humanos , Tempo de Internação , Masculino , Recidiva Local de Neoplasia , Estadiamento de Neoplasias , Duração da Cirurgia , Reoperação , Estudos RetrospectivosRESUMO
Despite advances in gastrointestinal (GI) surgery, post-operative complications are not entirely avoidable [...].
RESUMO
Rapid climate change or climate crisis is one of the most serious emergencies of the 21st century, accounting for highly impactful and irreversible changes worldwide. Climate crisis can also affect the epidemiology and disease burden of gastrointestinal diseases because they have a connection with environmental factors and nutrition. Gastrointestinal endoscopy is a highly intensive procedure with a significant contribution to greenhouse gas (GHG) emissions. Moreover, endoscopy is the third highest generator of waste in healthcare facilities with significant contributions to carbon footprint. The main sources of direct carbon emission in endoscopy are use of high-powered consumption devices (e.g. computers, anesthesia machines, wash machines for reprocessing, scope processors, and lighting) and waste production derived mainly from use of disposable devices. Indirect sources of emissions are those derived from heating and cooling of facilities, processing of histological samples, and transportation of patients and materials. Consequently, sustainable endoscopy and climate change have been the focus of discussions between endoscopy providers and professional societies with the aim of taking action to reduce environmental impact. The term "green endoscopy" refers to the practice of gastroenterology that aims to raise awareness, assess, and reduce endoscopy´s environmental impact. Nevertheless, while awareness has been growing, guidance about practical interventions to reduce the carbon footprint of gastrointestinal endoscopy are lacking. This review aims to summarize current data regarding the impact of endoscopy on GHG emissions and possible strategies to mitigate this phenomenon. Further, we aim to promote the evolution of a more sustainable "green endoscopy".
RESUMO
In this editorial, we explore the challenges of managing noncurative resections in early gastric cancer after endoscopic submucosal dissection (ESD), starting from the consideration recently made by Zhu et al. Specifically, we evaluate the management of eCura C1 lesions, where decisions regarding further interventions are pivotal yet contentious. Collaboration among endoscopists, surgeons, and pathologists is underscored to refine risk assessment and personalize therapeutic management. Recent advancements in ESD techniques and interdisciplinary collaboration offer opportunities for outcome optimization in managing eCura C1 lesions. Moreover, despite needing further clinical validation, molecular biomarkers have emerged as promising tools for enhancing prognostication. This manuscript highlights the ongoing research attempts to define treatment paradigms effectively and evaluates the potential of emerging options, ultimately aiming to improve patient care and outcomes in this complex clinical scenario.
RESUMO
Gut microbiota is recognized nowadays as one of the key players in the development of several gastro-intestinal diseases. The first studies focused mainly on healthy subjects with staining of main bacterial species via culture-based techniques. Subsequently, lots of studies tried to focus on principal esophageal disease enlarged the knowledge on esophageal microbial environment and its role in pathogenesis. Gastro Esophageal Reflux Disease (GERD), the most widespread esophageal condition, seems related to a certain degree of mucosal inflammation, via interleukin (IL) 8 potentially enhanced by bacterial components, lipopolysaccharide (LPS) above all. Gram- bacteria, producing LPS), such as Campylobacter genus, have been found associated with GERD. Barrett esophagus (BE) seems characterized by a Gram- and microaerophils-shaped microbiota. Esophageal cancer (EC) development leads to an overturn in the esophageal environment with the shift from an oral-like microbiome to a prevalently low-abundant and low-diverse Gram--shaped microbiome. Although underinvestigated, also changes in the esophageal microbiome are associated with rare chronic inflammatory or neuropathic disease pathogenesis. The paucity of knowledge about the microbiota-driven mechanisms in esophageal disease pathogenesis is mainly due to the scarce sensitivity of sequencing technology and culture methods applied so far to study commensals in the esophagus. However, the recent advances in molecular techniques, especially with the advent of non-culture-based genomic sequencing tools and the implementation of multi-omics approaches, have revolutionized the microbiome field, with promises of implementing the current knowledge, discovering more mechanisms underneath, and giving insights into the development of novel therapies aimed to re-establish the microbial equilibrium for ameliorating esophageal diseases..
RESUMO
Eosinophilic Gastrointestinal Disorders (EGIDs) are a group of conditions characterized by abnormal eosinophil accumulation in the gastrointestinal tract. Among these EGIDs, Eosinophilic Esophagitis (EoE) is the most well documented, while less is known about Eosinophilic Gastritis (EoG), Eosinophilic Enteritis (EoN), and Eosinophilic Colitis (EoC). The role of endoscopy in EGIDs is pivotal, with applications in diagnosis, disease monitoring, and therapeutic intervention. In EoE, the endoscopic reference score (EREFS) has been shown to be accurate in raising diagnostic suspicion and effective in monitoring therapeutic responses. Additionally, endoscopic dilation is the first-line treatment for esophageal strictures. For EoG and EoN, while the literature is more limited, common endoscopic findings include erythema, nodules, and ulcerations. Histology remains the gold standard for diagnosing EGIDs, as it quantifies eosinophilic infiltration. In recent years, there have been significant advancements in the histological understanding of EoE, leading to the development of diagnostic scores and the identification of specific microscopic features associated with the disease. However, for EoG, EoN, and EoC, precise eosinophil count thresholds for diagnosis have not yet been established. This review aims to elucidate the role of endoscopy and histology in the diagnosis and management of the three main EGIDs and to analyze their strengths and limitations, their interconnection, and future research directions.
RESUMO
BACKGROUND AND AIMS: Adequate bowel cleansing is essential for colonoscopy quality. A novel 1 L polyethylene glycol plus ascorbate (1 L PEG+ASC) solution has been recently introduced. Nevertheless, the efficacy of 1 L PEG+ASC as compared to that of high-volume bowel preparation in both inpatients and outpatients is still unclear. PATIENTS AND METHODS: This single-blinded, non-inferiority study randomized patients undergoing colonoscopy to receive split-dose 1 L PEG+ASC or 4 L PEG. The primary endpoint was the overall cleansing success. Secondary endpoints were excellent cleansing and high-quality cleansing of the right colon, as well as lesions detection rate, patient compliance, tolerability and safety. RESULTS: Overall, 478 patients were randomized to 1 L PEG+ASC (N = 236) or 4 L PEG (N = 242). The 1 L PEG+ASC showed higher cleansing success rate (91.8% vs 83.6%; P=0.01) and a high-quality cleansing of the right colon (52.3% and 38.5%; P=0.004) compared to 4 L PEG. Moreover, 1 L PEG+ASC achieved a higher cleansing success in out-patients (96.3%% vs 88.6%; P=0.018), and a similar success rate in the in-patients (84.7% vs 76.7%; P=0.18). Adenoma detection rate, tolerability and incidence of adverse events were comparable between preparations. CONCLUSIONS: The 1 L PEG+ASC showed higher efficacy in achieving adequate colon cleansing compared with 4 L PEG, particularly in the right colon. No differences in the tolerability and safety were detected.
Assuntos
Catárticos , Polietilenoglicóis , Humanos , Polietilenoglicóis/efeitos adversos , Catárticos/efeitos adversos , Colonoscopia , Laxantes , Colo , Ácido Ascórbico/efeitos adversosRESUMO
Pancreatic fluid collections (PFCs), including pancreatic pseudocysts (PPs) and walled-off pancreatic necrosis (WON), are common complications of pancreatitis and pancreatic surgery. Historically, the treatment of these conditions has relied on surgical and radiological approaches; however, it has later shifted toward an endoscopy-based approach. With the development of dedicated lumen-apposing metal stents (LAMS), interventional Endoscopic Ultrasound (EUS)-guided procedures have become the standard approach for PFC drainage. However, there is still limited consensus on several aspects of the multidisciplinary management of PFCs. The interventional endoscopy and ultrasound (i-EUS) group is an Italian network of clinicians and scientists with special interest in biliopancreatic interventional endoscopy, especially interventional EUS. This manuscript describes the first part of the results of a consensus conference organized by i-EUS with the aim of providing evidence-based guidance on aspects such as indications for treating PFCs, the timing of intervention, and different technical strategies for managing patients with PFCs.