Management and follow-up of gallbladder polyps: updated joint guidelines between the ESGAR, EAES, EFISDS and ESGE.

MAIN RECOMMENDATIONS: 1. Primary investigation of polypoid lesions of the gallbladder should be with abdominal ultrasound. Routine use of other imaging modalities is not recommended presently, but further research is needed. In centres with appropriate expertise and resources, alternative imaging modalities (such as contrast-enhanced and endoscopic ultrasound) may be useful to aid decision-making in difficult cases. Strong recommendation, low-moderate quality evidence. 2. Cholecystectomy is recommended in patients with polypoid lesions of the gallbladder measuring 10 mm or more, providing the patient is fit for, and accepts, surgery. Multidisciplinary discussion may be employed to assess perceived individual risk of malignancy. Strong recommendation, low-quality evidence. 3. Cholecystectomy is suggested for patients with a polypoid lesion and symptoms potentially attributable to the gallbladder if no alternative cause for the patient's symptoms is demonstrated and the patient is fit for, and accepts, surgery. The patient should be counselled regarding the benefit of cholecystectomy versus the risk of persistent symptoms. Strong recommendation, low-quality evidence. 4. If the patient has a 6-9 mm polypoid lesion of the gallbladder and one or more risk factors for malignancy, cholecystectomy is recommended if the patient is fit for, and accepts, surgery. These risk factors are as follows: age more than 60 years, history of primary sclerosing cholangitis (PSC), Asian ethnicity, sessile polypoid lesion (including focal gallbladder wall thickening > 4 mm). Strong recommendation, low-moderate quality evidence. 5. If the patient has either no risk factors for malignancy and a gallbladder polypoid lesion of 6-9 mm, or risk factors for malignancy and a gallbladder polypoid lesion 5 mm or less, follow-up ultrasound of the gallbladder is recommended at 6 months, 1 year and 2 years. Follow-up should be discontinued after 2 years in the absence of growth. Moderate strength recommendation, moderate-quality evidence. 6. If the patient has no risk factors for malignancy, and a gallbladder polypoid lesion of 5 mm or less, follow-up is not required. Strong recommendation, moderate-quality evidence. 7. If during follow-up the gallbladder polypoid lesion grows to 10 mm, then cholecystectomy is advised. If the polypoid lesion grows by 2 mm or more within the 2-year follow-up period, then the current size of the polypoid lesion should be considered along with patient risk factors. Multidisciplinary discussion may be employed to decide whether continuation of monitoring, or cholecystectomy, is necessary. Moderate strength recommendation, moderate-quality evidence. 8. If during follow-up the gallbladder polypoid lesion disappears, then monitoring can be discontinued. Strong recommendation, moderate-quality evidence. SOURCE AND SCOPE: These guidelines are an update of the 2017 recommendations developed between the European Society of Gastrointestinal and Abdominal Radiology (ESGAR), European Association for Endoscopic Surgery and other Interventional Techniques (EAES), International Society of Digestive Surgery-European Federation (EFISDS) and European Society of Gastrointestinal Endoscopy (ESGE). A targeted literature search was performed to discover recent evidence concerning the management and follow-up of gallbladder polyps. The changes within these updated guidelines were formulated after consideration of the latest evidence by a group of international experts. The Grading of Recommendations Assessment, Development and Evaluation (GRADE) system was adopted to define the strength of recommendations and the quality of evidence. KEY POINT: • These recommendations update the 2017 European guidelines regarding the management and follow-up of gallbladder polyps.

Photoredox-Mediated Net-Neutral Radical/Polar Crossover Reactions.

Radical/Polar Crossover (RPC) chemistry is a rapidly growing subset of photoredox catalysis that is characterized by transformations featuring both radical and ionic modes of reactivity. Net-neutral RPC is particularly interesting in that both the single-electron oxidation and reduction steps occur through interaction with the photocatalyst, thus precluding the need for exogenous oxidants or reductants. As such, these transformations facilitate rapid incorporation of molecular complexity while maintaining mild reaction conditions. This review covers recent advances in photoredox-mediated net-neutral RPC synthetic methods, with a particular emphasis on C-C bond-forming reactions.

Management and follow-up of gallbladder polyps : Joint guidelines between the European Society of Gastrointestinal and Abdominal Radiology (ESGAR), European Association for Endoscopic Surgery and other Interventional Techniques (EAES), International Society of Digestive Surgery - European Federation (EFISDS) and European Society of Gastrointestinal Endoscopy (ESGE).

OBJECTIVES: The management of incidentally detected gallbladder polyps on radiological examinations is contentious. The incidental radiological finding of a gallbladder polyp can therefore be problematic for the radiologist and the clinician who referred the patient for the radiological examination. To address this a joint guideline was created by the European Society of Gastrointestinal and Abdominal Radiology (ESGAR), European Association for Endoscopic Surgery and other Interventional Techniques (EAES), International Society of Digestive Surgery - European Federation (EFISDS) and European Society of Gastrointestinal Endoscopy (ESGE). METHODS: A targeted literature search was performed and consensus guidelines were created using a series of Delphi questionnaires and a seven-point Likert scale. RESULTS: A total of three Delphi rounds were performed. Consensus regarding which patients should have cholecystectomy, which patients should have ultrasound follow-up and the nature and duration of that follow-up was established. The full recommendations as well as a summary algorithm are provided. CONCLUSIONS: These expert consensus recommendations can be used as guidance when a gallbladder polyp is encountered in clinical practice. KEY POINTS: • Management of gallbladder polyps is contentious • Cholecystectomy is recommended for gallbladder polyps >10 mm • Management of polyps <10 mm depends on patient and polyp characteristics • Further research is required to determine optimal management of gallbladder polyps.

Photoredox Generation of Carbon-Centered Radicals Enables the Construction of 1,1-Difluoroalkene Carbonyl Mimics.

Described is a facile, scalable route to access functional-group-rich gem-difluoroalkenes. Using visible-light-activated catalysts in conjunction with an arsenal of carbon-radical precursors, an array of trifluoromethyl-substituted alkenes undergoes radical defluorinative alkylation. Nonstabilized primary, secondary, and tertiary radicals can be used to install functional groups in a convergent manner, which would otherwise be challenging by two-electron pathways. The process readily extends to other perfluoroalkyl-substituted alkenes. In addition, we report the development of an organotrifluoroborate reagent to expedite the synthesis of the requisite trifluoromethyl-substituted alkene starting materials.

Toward a Unified Mechanism for Oxoammonium Salt-Mediated Oxidation Reactions: A Theoretical and Experimental Study Using a Hydride Transfer Model.

A range of oxoammonium salt-based oxidation reactions have been explored computationally using density functional theory (DFT), and the results have been correlated with experimentally derived trends in reactivity. Mechanistically, most reactions involve a formal hydride transfer from an activated C-H bond to the oxygen atom of the oxoammonium cation. Several new potential modes of reactivity have been uncovered and validated experimentally.

Oxidative cleavage of allyl ethers by an oxoammonium salt.

A method to oxidatively cleave allyl ethers to their corresponding aldehydes mediated by an oxoammonium salt is described. Using a biphasic solvent system and mild heating, cleavage proceeds readily, furnishing a variety of α,ß-unsaturated aldehydes and ketones.

Growth rate and malignant potential of small gallbladder polyps--systematic review of evidence.

THE BACKGROUND AND PURPOSE: The overall aim of this systematic review was to determine whether ultrasound (US) follow up for gallbladder polyps (GBPs) measuring less than 10 mms is necessary. METHODS: A search was performed in MEDLINE and EMBASE between January 1976 and January 2012 using keywords: gallbladder, polyps, neoplasm, cancer, tumour, carcinoma, malignant, adenoma. Included were studies involving adult patients, examined with transabdominal US at least twice. The outcomes of included studies were gallbladder polyp growth as demonstrated on US over time, followed where available by histological examination of cholecystectomy specimens. MAIN FINDINGS: Ten studies met the inclusion criteria for the review. Altogether 1958 subjects with mean age between 41.5 and 59 years were followed up with US. The percentage of GBPs which showed growth over the follow up period ranged from 1% to 23%. 43 neoplastic polyps were found in total irrespective of size, 20 of which were malignant and at least 7 of those were >10 mms. At least 7 malignancies were present in polyps <10 mms but it was unknown if they had undergone growth on follow up. CONCLUSIONS: Level II-2 and below evidence on rate of growth of small GBPs <10 mms exists in the literature. It indicates that growth does occur in a significant minority of small GBPs, but it is slow. Due to deficient reporting and small numbers of cases, the correlation between growth of GBP and development of malignancy cannot be established using currently available evidence. Malignancy can be present in polyps <10 mms although it is significantly more frequent in polyps >10 mms. Cholecystectomy for symptomatic GBPs irrespective of their size, alongside the current practice for removal of gall bladders containing asymptomatic polyps >10 mms, is proposed. No evidence based US follow up schedule can be recommended at present for asymptomatic polyps <10 mms, and in its absence an intuitive follow up with US is likely to continue.

Epigastric anterior abdominal wall hernia: An unusual cause of gastric outlet obstruction.

A 79-year-old female presented with a 3-week history of dysphagia and vomiting, and an upper abdominal mass which had increased in size over the previous 2 weeks. CT scan showed a partial gastric outlet obstruction secondary to an epigastric hernia. This was assessed further on fluoroscopy, showing the distal stomach in the hernial sac and a delay in gastric emptying. We present the CT and fluoroscopic findings of this rare cause of gastric outlet obstruction.

Sensitivity of SARS-CoV-2 RNA polymerase chain reaction using a clinical and radiological reference standard.

OBJECTIVES: Diagnostic tests for SARS-CoV-2 are important for epidemiology, clinical management, and infection control. Limitations of oro-nasopharyngeal real-time PCR sensitivity have been described based on comparisons of single tests with repeated sampling. We assessed SARS-CoV-2 PCR clinical sensitivity using a clinical and radiological reference standard. METHODS: Between March-May 2020, 2060 patients underwent thoracic imaging and SARS-CoV-2 PCR testing. Imaging was independently double- or triple-reported (if discordance) by blinded radiologists according to radiological criteria for COVID-19. We excluded asymptomatic patients and those with alternative diagnoses that could explain imaging findings. Associations with PCR-positivity were assessed with binomial logistic regression. RESULTS: 901 patients had possible/probable imaging features and clinical symptoms of COVID-19 and 429 patients met the clinical and radiological reference case definition. SARS-CoV-2 PCR sensitivity was 68% (95% confidence interval 64-73), was highest 7-8 days after symptom onset (78% (68-88)) and was lower among current smokers (adjusted odds ratio 0.23 (0.12-0.42) p < 0.001). CONCLUSIONS: In patients with clinical and imaging features of COVID-19, PCR test sensitivity was 68%, and was lower among smokers; a finding that could explain observations of lower disease incidence and that warrants further validation. PCR tests should be interpreted considering imaging, symptom duration and smoking status.

Metal-free defluorinative arylation of trifluoromethyl alkenes via photoredox catalysis.

Literature methods to access gem-difluoroalkenes are largely limited to harsh, organometallic-based methods, and known photoredox-mediated processes are not amenable to aryl radical addition to trifluoromethyl alkenes. A metal-free, functional group-tolerant method for the preparation of benzylic gem-difluoroalkenes is described. Halogen atom abstraction from (hetero)aryl halides generates aryl radicals that undergo a defluorinative arylation of α-trifluoromethyl alkenes, tolerating electronically disparate aryl radicals and α-trifluoromethyl alkenes.

Rapid access to diverse, trifluoromethyl-substituted alkenes using complementary strategies.

Two synergistic approaches to the facile assembly of complex α-trifluoromethyl alkenes are described. Using α-trifluoromethyl-ß-silyl alcohols as masked trifluoromethyl alkenes, cross-coupling or related functionalization processes at distal electrophilic sites can be executed without inducing Peterson elimination. Subsequent Lewis acidic activation affords functionalized α-trifluoromethyl alkenes. Likewise, the development of a novel α-trifluoromethylvinyl trifluoroborate reagent complements this approach and allows a one-step cross-coupling of (hetero)aryl halides to access a broad array of complex α-trifluoromethyl alkenes.

Correction: Rapid access to diverse, trifluoromethyl-substituted alkenes using complementary strategies.

[This corrects the article DOI: 10.1039/C7SC05420C.].

Haloselective Cross-Coupling via Ni/Photoredox Dual Catalysis.

The chemoselective functionalization of polyfunctional aryl linchpins is crucial for rapid diversification. Although well-explored for Csp2 and Csp nucleophiles, the chemoselective introduction of Csp3 groups remains notoriously difficult and is virtually undocumented using Ni catalysts. To fill this methodological gap, a "haloselective" cross-coupling process of arenes bearing two halogens, I and Br, using ammonium alkylbis(catecholato)silicates, has been developed. Utilizing Ni/photoredox dual catalysis, Csp3 -Csp2 bonds can be forged selectively at the iodine-bearing carbon of bromo(iodo)arenes. The described high-yielding, base-free strategy accommodates various protic functional groups. Selective electrophile activation enables installation of a second Csp3 center and can be done without the need for purification of the intermediate monoalkylated product.

Oxidative esterification of aldehydes using a recyclable oxoammonium salt.

A simple, high yielding, rapid route for the oxidative esterification of a wide range aldehydes to hexafluoroisopropyl (HFIP) esters using the oxoammonium salt 4-acetylamino-2,2,6,6-tetramethylpiperidine-1-oxoammonium tetrafluoroborate (1a) is reported. These esters can be readily transformed into a variety of other functional groups. The spent oxidant (1b) can be recovered and conveniently reoxidized to regenerate the oxoammonium salt, 1a.