Low frequency of bacteremia after endoscopic mucosal resection

Analysis of Predictors and Risk Factors of Postpolypectomy Syndrome

BACKGROUND AND AIMS

Postpolypectomy syndrome (PPS) is a relevant adverse event that can appear after polypectomy. Several publications mention postpolypectomy syndrome using different criteria to define it. The aim of this study is to detect potential risk factors and predictors for developing PPS and to define the main criteria of PPS.

METHODS

In this retrospective monocentric study, 475 out of 966 patients who underwent colonoscopy with polypectomy from October 2015 to June 2020 were included. The main criterion of PPS is defined as the development of postinterventional abdominal pain lasting more than six hours.

RESULTS

A total of 9.7% of the patients developed PPS, which was defined as local abdominal pain around the polypectomy area after six hours. A total of 8.6% of the study population had abdominal pain within six hours postintervention. A total of 3.7% had an isolated triad of fever, leukocytosis, and increased CRP in the absence of abdominal pain. Increased CRP combined with an elevated temperature over 37.5 °C seems to be a positive predictor for developing PPS. Four independent risk factors could be detected: serrated polyp morphology, polypoid configurated adenomas, polyp localization in the cecum, and the absence of intraepithelial neoplasia.

CONCLUSIONS

Four independent risk factors for developing PPS were detected. The combination of increased CRP levels with elevated temperature seems to be a predictor for this pathology. As expected, the increasing use of cold snare polypectomies will reduce the incidence of this syndrome. Key summary: Our monocentric study on 966 patients detected four independent risk factors for developing PPS: pedunculated polyp, resected polyps in the cecum, absence of IEN, and serrated polyp morphology. The combination of increased CRP levels with elevated temperature seems to be a predictor for this pathology.

Pyogenic spondylitis following endoscopic submucosal dissection for early gastric cancer

A man in his 80s who had a history of diabetes mellitus and aortic valve replacement was referred to our hospital for treatment of early gastric cancer and underwent endoscopic submucosal dissection (ESD). Three days after ESD, the patient presented with low back pain and fever (38.7°). We initially considered adverse events associated with gastric ESD such as delayed perforation. Moreover, thromboembolism and infectious endocarditis were suspected because of his medical history. However, there were no remarkable findings suggestive of these diseases. Finally, based on the results of blood cultures and MRI, the diagnosis of pyogenic spondylitis (PS) was made. We administered antibiotics for 12 weeks, and the patient improved without neurological impairments. This case indicates that bacteraemia and subsequent PS can occur following gastric ESD. Physicians should not overlook the patient's physical signs related to various adverse events after ESD.

Antibiotics for fever in patients without perforation after gastric endoscopic submucosal dissection and endoscopic submucosal excavation may be unnecessary: a propensity score-matching analysis

Background

Endoscopic submucosal dissection (ESD) and endoscopic submucosal excavation (ESE) have been widely used and have gradually become the main endoscopic treatment for gastrointestinal mucosal and submucosal lesions. Whether antibiotics are necessary for fever after gastric ESD and ESE remain unclear. The aim of this study was to analyse the value of using antibiotics in patients without perforation after ESD or ESE with fever.

Methods

In this retrospective study, patients with fever without perforation after ESD or ESE from January 2014 to January 2019 were included and divided into 2 groups: the antibiotic group and the non-antibiotic group. Fever and hospitalization time were compared between the 2 groups after propensity score matching.

Results

Overall, 253 patients meeting the inclusion criteria were enrolled in the present study, with 186 patients in the non-antibiotic group and 67 patients in the antibiotic group before matching, 55 patients in the non-antibiotic group and 55 patients in the antibiotic group after matching with all baseline characteristics balanced (p > 0.05). The duration of fever was not significantly different between the 2 groups (p = 0.12). However, the median hospitalization stay in the antibiotic group was longer than that in the non-antibiotic group (8 vs 7, p = 0.007).

Conclusions

Antibiotics may be unnecessary for fever in patients without perforation and without serious co-morbidities after gastric ESD or ESE.

The Endoscopy Patient as a Vector and Victim

Patient and procedural factors can increase the risk of infectious adverse events during endoscopy. Prophylactic antibiotic use must be judicious and individualized in the era of antibiotic resistance. New and emerging procedures require high-quality studies to elucidate appropriate risk profiles.

EMR/ESD: Techniques, Complications, and Evidence

PURPOSE OF REVIEW

To discuss endoscopic resection techniques of early gastrointestinal malignancy. The review will focus on the indications and outcomes of endoscopic mucosal resection (EMR) and endoscopic submucosal dissection (ESD).

RECENT FINDINGS

EMR is indicated for upper GI lesions less than 20 mm provided they can be easily lifted and have a low risk of submucosal invasion (SMI). ESD should be considered for esophageal and gastric lesions that are bulky, show intramucosal carcinoma, or have a risk of superficial submucosal invasion. With regard to colonic polyps, EMR is acceptable for the removal of large colonic polyps using a piecemeal technique. ESD can be reserved for rectal neuroendocrine tumors, fibrotic polyps, or polyps harboring early malignancy. In selected cases, particularly in lesions less than 2 cm in size, EMR can be safe and effective. For larger lesions or lesions with submucosal invasion, ESD is effective and curative. Choosing the best approach can be tailored for each patient depending on lesion size, pathology, and availability of local expertise.

Efficacy of a silver colloidal gel against selected oral bacteria in vitro

Background: It is necessary to develop new strategies to protect against bacteria such as S treptococcus mutans, S treptococcus sanguis, and Streptococcus salivarius, which contribute to tooth decay and plaque formation. Our current study investigated the efficacy of a colloidal silver gel in inhibiting biofilm formation by these principal oral bacteria , in vitro. The aim of this study was to assess the efficacy of a colloidal silver gel formulation for inhibiting bacterial biofilm formation (Ag-gel) by the principal bacteria that cause plaque formation and tooth decay.

Methods: The effect of Ag-gel on viability of S. mutans, S. sanguis, and S. salivarius was assessed by quantifying their colony forming units (CFU) in presence or absence of the test gel. The effect of this formulation on biofilm-forming ability of these bacteria was studied through scanning electron microscopy.

Results: Using the CFU assays, over 6 logs of inhibition (100%) were found for S. mutans, S. sanguis, and S. salivarius for the Ag-gel-treated bacteria when compared with the control gel. In addition, the Ag-gel also inhibited biofilm formation by these three bacteria mixed together. These results were confirmed by scanning electron microscopy.

Conclusions: The Ag-gel was effective in preventing biofilm formation by S. mutans, S. sanguis, and S. salivarius. This Ag-gel should be tested for the ability to block plaque formation in the mouth, through its use as a tooth paste.

The low incidence of bacteremia after esophageal endoscopic submucosal dissection (ESD) obviates the need for prophylactic antibiotics in esophageal ESD

BACKGROUND

Although a high incidence of bacteremia after esophageal endoscopic procedures has been reported, the incidence of bacteremia associated with esophageal endoscopic submucosal dissection (ESD) remains unknown. Therefore, we investigated the incidence of bacteremia associated with esophageal ESD.

METHODS

From April 2013 to March 2014, patients who underwent esophageal ESD were enrolled prospectively. Two sets of blood cultures were collected from patients at the following time points: (1) immediately after ESD; (2) the next morning; and (3) when fever ≥38 °C was present after ESD.

RESULTS

A total of 424 blood culture sets were collected from 101 patients. Six patients had positive blood cultures immediately after ESD (4 %, 7/202 sets). Another patient had a positive blood culture the next morning (0.5 %, 1/202 sets). Ten patients (10 %) developed a post-ESD fever ≥38 °C, and blood cultures from these patients were all negative (0/20 sets). The seven patients with positive blood cultures had no post-ESD fever or infectious symptoms. Growth of Bacteroides thetaiotaomicron was only observed in one patient (1 %) with positive blood cultures immediately after ESD, and this patient was diagnosed with transient bacteremia. The other six patients were considered to have contaminants in their blood cultures. Thus, the incidence of bacteremia after esophageal ESD was 1 % [95 % confidence interval (CI) 0-5 %]. No patient had infectious symptoms, and none required antibiotics after ESD.

CONCLUSIONS

The incidence of bacteremia after esophageal ESD was low and post-ESD fever was not associated with bacteremia. We conclude that use of routine prophylactic antibiotics to patients undergoing esophageal ESD is unnecessary.

CLINICAL TRIAL REGISTRY NUMBER

UMIN000012908.

Changes in Gut and Plasma Microbiome following Exercise Challenge in Myalgic Encephalomyelitis/Chronic Fatigue Syndrome (ME/CFS)

Myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS) is a disease characterized by intense and debilitating fatigue not due to physical activity that has persisted for at least 6 months, post-exertional malaise, unrefreshing sleep, and accompanied by a number of secondary symptoms, including sore throat, memory and concentration impairment, headache, and muscle/joint pain. In patients with post-exertional malaise, significant worsening of symptoms occurs following physical exertion and exercise challenge serves as a useful method for identifying biomarkers for exertion intolerance. Evidence suggests that intestinal dysbiosis and systemic responses to gut microorganisms may play a role in the symptomology of ME/CFS. As such, we hypothesized that post-exertion worsening of ME/CFS symptoms could be due to increased bacterial translocation from the intestine into the systemic circulation. To test this hypothesis, we collected symptom reports and blood and stool samples from ten clinically characterized ME/CFS patients and ten matched healthy controls before and 15 minutes, 48 hours, and 72 hours after a maximal exercise challenge. Microbiomes of blood and stool samples were examined. Stool sample microbiomes differed between ME/CFS patients and healthy controls in the abundance of several major bacterial phyla. Following maximal exercise challenge, there was an increase in relative abundance of 6 of the 9 major bacterial phyla/genera in ME/CFS patients from baseline to 72 hours post-exercise compared to only 2 of the 9 phyla/genera in controls (p = 0.005). There was also a significant difference in clearance of specific bacterial phyla from blood following exercise with high levels of bacterial sequences maintained at 72 hours post-exercise in ME/CFS patients versus clearance in the controls. These results provide evidence for a systemic effect of an altered gut microbiome in ME/CFS patients compared to controls. Upon exercise challenge, there were significant changes in the abundance of major bacterial phyla in the gut in ME/CFS patients not observed in healthy controls. In addition, compared to controls clearance of bacteria from the blood was delayed in ME/CFS patients following exercise. These findings suggest a role for an altered gut microbiome and increased bacterial translocation following exercise in ME/CFS patients that may account for the profound post-exertional malaise experienced by ME/CFS patients.

Antimicrobial prophylaxis in patients with colorectal lesions undergoing endoscopic resection

AIM: To investigate the effect of prophylaxis with antibiotics on clinical adverse events in patients who underwent endoscopic submucosal dissection (ESD) or endoscopic mucosal resection (EMR) for colorectal lesions.

METHODS: From June 2011 to December 2013, a total of 428 patients were enrolled into the study, of which 214 patients admitted to hospital underwent EMR or ESD procedures. These patients were randomized to an antibiotic group, in which patients were given cefuroxime 1.5 g iv half an hour before and 6 h after surgery respectively, and a control group, in which patients were not given any antibiotic. A further 214 outpatients with small polyps treated by polypectomy were compared with controls that were matched by age and gender, and operations were performed as outpatient surgery. Recorded patient parameters were demographics, characteristics of lesions and treatment modality, and the size of the wound area. The primary outcome measures were clinical adverse events, including abdominal pain, diarrhea, hemotachezia, and fever. Secondary outcome measures were white blood cell count, C-reactive protein and blood culture. Additionlly, the relationship between the size of the wound area and clinical adverse events was analyzed.

RESULTS: A total of 409 patients were enrolled in this study, with 107 patients in the control group, 107 patients in the antibiotic group, and another 195 cases in the follow-up outpatient group. The patients’ demographic characteristics, including age, gender, characteristics of lesions, treatment modality, and the size of the wound area were similar between the 2 groups. The rates of adverse events in the antibiotic group were significantly lower than in the control group: abdominal pain (2.8% vs 14.9%, P < 0.01), diarrhea (2.0% vs 9.3%, P < 0.05), and fever (0.9% vs 8.4%, P < 0.05) respectively. The levels of inflammatory markers also decreased significantly in the antibiotic group compared with the control group: leukocytosis (2.0% vs 11.2%, P < 0.01), and C-reactive protein (2.0% vs 10.7%, P < 0.05). Additionally, clinical adverse events were related to the size of the surgical wound area. When the surgical wound area was larger than 10 mm × 10 mm, there were more clinical adverse events.

CONCLUSION: Clinical adverse events are not uncommon after EMR or ESD procedures. Prophylactic antibiotics can reduce the incidence of clinical adverse events. This should be further explored.

Pneumonia after endoscopic resection for gastric neoplasm

BACKGROUND

Pneumonia following endoscopic procedures may affect the clinical course and prolong hospital stay.

AIM

To investigate the incidence and risk factors for pneumonia after endoscopic resection (ER) for gastric neoplasm.

METHODS

Subjects who underwent ER for gastric neoplasm at the Asan Medical Center from January 1997 to March 2013 were included. To investigate risk factors, control patients were randomly selected from these subjects.

RESULTS

Of the 7,149 subjects who underwent ER for gastric neoplasm, 44 (0.62 %) developed pneumonia. The median age of these 44 patients was 68 years (range 31-82 years), and the male to female ratio was 3:1. Twenty-five of the pneumonia patients (56.8 %) were smokers, and 8 (18.2 %) had underlying pulmonary diseases. The median procedure time was 23 min (range 2-126 min), and pathologic diagnoses included adenocarcinoma (n = 29), dysplasia (n = 10), and hyperplastic polyp (n = 5). Compared with the control group, smoking (current smoker vs. never smoker, odds ratio [OR] 2.366, p = 0.021), total procedure time (OR 1.011, p = 0.048), and hemostasis time (OR 1.026, p = 0.028) were risk factors for the development of pneumonia. In multivariate analysis, age >65 years (OR 2.073, p = 0.031), smoking (current smoker vs. never smoker, OR 2.324, p = 0.023), and hemostasis time (OR 1.025, p = 0.038) were independent risk factors. All patients recovered from pneumonia, and the duration of hospital stay did not differ between patients with pneumonia and the control group (p = 0.077).

CONCLUSIONS

Whereas old age, smoking, and longer hemostasis time are risk factors for pneumonia, its incidence after ER is not associated with clinically significant adverse outcomes.

The feasibility and safety of the endoscopic submucosal dissection of superficial gastric neoplastic lesions in patients with compensated liver cirrhosis: a retrospective study

Background/Aims

When undergoing endoscopic submucosal dissection (ESD), patients with liver cirrhosis (LC) may suffer from a high risk of bleeding, bacteremia and tissue vulnerability. There have been few reports evaluating the efficacy and safety of ESD in patients with LC.

Methods

From January 2004 to March 2010, 23 patients with LC (cirrhosis group) underwent ESD for superficial gastric neoplastic lesions. The number of patients with a liver function in the Child-Pugh classes A and B were 20 and 3, respectively. The clinical outcomes and complications were compared with 69 patients without LC (control group) that were matched for age and sex.

Results

The en bloc resection, R0 resection and en bloc plus R0 resection rates of the cirrhosis group were 82.6%, 91.3%, and 82.6%, respectively, and did not show significant differences from the rates of the control group. No local recurrence was found in either group during the follow-up period. The procedure length of time (41.0 vs 39.0 minutes), rate of bleeding (4.3% vs 7.2%) and rate of perforation (0.0% vs 1.4%) in the cirrhosis group were also comparable to the results from the control group.

Conclusions

ESD was safely performed in patients with LC, and satisfactory outcomes were achieved with high en bloc and R0 resection rates for superficial gastric neoplastic lesions.

Bacteremia and endotoxemia after endoscopic submucosal dissection for gastric neoplasia: pilot study

BACKGROUND

Because the invasive procedure of endoscopic submucosal dissection (ESD) entails a large mucosal defect which is left open, with extensive submucosal exposure to the indigenous bacterial flora, the procedure may have a substantial risk for bacteremia. Our aim was to examine gastric ESD-related bacteremia and endotoxemia in gastric neoplasia patients.

METHODS

In patients who underwent ESD for superficial gastric neoplasia, blood cultures and plasma endotoxin measurements were done before, immediately after, and on day 2 after ESD. Clinically manifest infections and inflammatory markers, including C-reactive protein (CRP) and white blood cells, were monitored.

RESULTS

Fifty patients (aged 69 ± 8 years; mean ± SD) were enrolled. The diameter of the resected specimens was 38 ± 18 mm and the procedure time of ESD was 66 ± 53 min. Two percent (2/100) of blood cultures after ESD were positive, with findings as follows: Propionibacterium species immediately after ESD, and Enterobacter aerogenes on day 2 after ESD, but no clinically manifest infection was observed. In 30% of the enrolled patients, CRP on day 2 after ESD had increased to levels higher than 1.0 mg/l. Plasma endotoxin levels, immediately after and on day 2 after ESD were correlated with CRP levels on day 2 after ESD.

CONCLUSIONS

In spite of the invasive procedure with massive submucosal exposure to the indigenous bacterial flora, gastric ESD has a low risk for bacteremia. Gastric ESD-related endotoxemia may be linked to inflammatory reactions such as those shown by the increase of CRP or fever observed after ESD.

Low-frequency of bacteremia after endoscopic submucosal dissection of the stomach

BACKGROUND

Mainstream therapy for early gastric cancer in Japan has now shifted from endoscopic mucosal resection (EMR) to endoscopic submucosal dissection (ESD). Although bacteremia is reported as being infrequent and transient in gastric EMR, there are no reports of it being investigated in gastric ESD. This study aimed to determine the frequency of bacteremia in gastric ESD.

PATIENTS AND METHODS

A prospective study, in 46 consecutive patients who underwent gastric ESD, investigated the frequency of bacteremia before and after the procedure.

RESULTS

  The median time for the total ESD procedure was 105min (range 30-400). The median volume of the submucosal injection was 80ml (range 20-260). The mean size of the resected specimen was 40±9.7mm. Blood cultures obtained before ESD were positive in 4.4% (2/45) of cases. Bacillus subtilis and Bacillus spp. were the isolated microorganisms. Blood cultures obtained 10min after ESD were positive in 4.3% (2/46) of cases; with the same microorganisms being isolated. Blood cultures obtained 3h after ESD were all negative. No signs of sepsis were seen in the two patients with a positive blood culture 10min after ESD.

CONCLUSIONS

The frequency of bacteremia after gastric ESD was low and transient. ESD for gastric lesions is thought to have a low risk of infectious complications; therefore, prophylactic administration of antibiotics may not be warranted.

Clinical outcomes of endoscopic submucosal dissection in elderly patients with early gastric cancer

OBJECTIVES

Endoscopic submucosal dissection (ESD) has advantages over conventional endoscopic mucosa resection. The number of elderly patients (more than 75 years old) with early gastric cancer (EGC) has been steadily increasing. We sought to assess clinical outcomes of ESD for EGC in elderly.

METHODS

ESD was performed for patients with EGC, who fulfilled the criteria for ESD: mucosal cancer without ulcer findings irrespective of tumor size; mucosal cancer with ulcer findings 3 cm or less in diameter; and minute submucosal invasive cancer 3 cm or less in size. Two hundred and sixty elderly patients (> or =75 years old) with 279 lesions, and 401 non-elderly patients with 434 lesions were enrolled to this study. The patients underwent ESD and then received periodic endoscopic follow-up and metastatic surveys for 6-89 months (median: 30 months). Resectability (en-bloc or piecemeal resection), curability (curative or noncurative resection), completeness (complete or incomplete resection), complications, and survival rates were assessed.

RESULTS

The one-piece resection rate was significantly lower in elderly patients (93.9%) than in non-elderly patients (97.9%). The complete resection rate was significantly lower in elderly patients (87.4%) than in non-elderly patients (96.6%). Pneumonia, but not bleeding or perforation, developed in association with ESD more frequently in the elderly patients by 2.2%. Local tumor recurrence was quite rare, and the overall and disease-free survival rates were acceptable irrespective of age.

CONCLUSION

En-bloc and complete resections were achieved less frequently in elderly patients, but the long-term outcomes in elderly EGC patients may be excellent, and ESD is a feasible treatment in the elderly.

Low frequency of bacteremia after an endoscopic resection for large colorectal tumors in spite of extensive submucosal exposure

BACKGROUND

During an EMR or endoscopic submucosal dissection (ESD) for colorectal tumors, an injection needle catheter is passed through the contaminated endoscopic channel and may directly inoculate bacteria into the blood stream during submucosal injection. In addition, extensively exposed submucosa, especially with an ESD, directly contacts colonic luminal bacteria after the procedure, which may increase the risk of bacteremia. However, the incidence of bacteremia after an EMR or ESD for colorectal tumors has not been reported.

OBJECTIVE

To evaluate the frequency of bacteremia associated with an EMR or ESD for colon lesions.

DESIGN

A prospective study.

PATIENTS

A total of 40 patients who underwent a conventional EMR (n = 30), an EMR after circumferential pre-cutting (n = 3), or ESD (n = 7) for colorectal tumors.

INTERVENTIONS AND MAIN OUTCOME MEASUREMENTS

Blood cultures were obtained immediately before, 5 minutes after, and 30 minutes after the procedure. Patients were closely monitored for 24 hours after the procedure to detect the development of infectious complications.

RESULTS

Blood cultures at baseline and 5 minutes after the procedure were all negative. However, a blood culture at 30 minutes after the procedure showed a positive result in 1 of 40 patients (2.5%). This patient underwent a conventional EMR, and the isolated microorganism was coagulase-negative Staphylococcus, which might be regarded as a contaminant. None of the 40 patients showed any signs or symptoms associated with infection.

LIMITATION

The small sample size.

CONCLUSIONS

An EMR, or even an ESD, for colon lesions may be considered a low-risk procedure for infectious complications that does not warrant prophylactic administration of antibiotics.

Endoscopic mucosal resection of colonic lesions: current applications and future prospects

The introduction of submucosal fluid injection has remarkably extended the range of endoscopically resectable polyps. The limiting factor for endoscopic resection is not polyp size, but polyp depth. Endoscopic ultrasound is a useful adjunctive diagnostic tool to assess the depth of invasion. The success of are section ultimately depends on pathologic confirmation of a benign nature of this lesion or of a cancer limited to the mucosa. Selected well-differentiated cancers without lymphovascular invasion of the superficial submucosa can be successfully resected endoscopically.

Endoscopic submucosal dissection for early gastric cancers: experience from a new endoscopic center in Taiwan

GOAL

To evaluate the efficacy of endoscopic submucosal dissection (ESD) for early gastric cancers (EGCs) at a new endoscopic center.

BACKGROUND

ESD is a novel technique that can facilitate en-bloc resection of EGCs, but seldom reported outside Japan.

STUDY

A total of 25 consecutive patients (25 lesions) underwent ESD from June 2004 to March 2006. Patients were divided into 2 groups: group A underwent ESD from June 2004 to May 2005 (introduction stage) and group B from June 2005 to March 2006. The following data were obtained: tumor size, tumor location, operative time, and major complication.

RESULTS

The complete resection was achieved in 20 lesions (success rate 80%). Four out of 10 lesions from group A were removed by conventional endoscopic mucosal resection (EMR) piecemeally after ESD failure. Conversely, 14 patients from group B (n=15) were resected by ESD en-bloc (success rate 93.3%). One patient with microscopic residual tumor after ESD was further treated by surgical resection. The time required for resection was significantly longer in group A when compared with group B (130.5 min vs. 81.5 min, P<0.05). Postoperative complication rate between the 2 groups were similar. One patient with piecemeal EMR recurred in follow-up, and was further treated successfully by EMR.

CONCLUSIONS

ESD is an ideal method for EGC treatment, but it may result in a risk of complication. The complete resection rate can be improved by endoscopist's experience. Sophisticated endoscopic hemostasis and clipping skills are essential prior ESD procedures. Conventional EMR techniques are also obligatory during the beginning period.

Prospective study of bacteremia and complications With EUS FNA of rectal and perirectal lesions

BACKGROUND & AIMS

Recent studies showed that endoscopic ultrasound (EUS)-guided fine-needle aspiration (FNA) is a low-risk procedure for causing bacteremia and infectious complications when sampling solid lesions of the upper gastrointestinal (GI) tract. As a result, antibiotics are not recommended for prophylaxis against endocarditis. Our aim was to prospectively evaluate the risk of bacteremia and other infectious complications in patients undergoing EUS FNA of lower GI tract lesions.

METHODS

Patients referred for EUS FNA of lower GI tract lesions were considered for enrollment. Patients were excluded if there was an indication for preprocedure antibiotic administration based on American Society for Gastrointestinal Endoscopy guidelines, had taken antibiotics within the prior 7 days, or if they had a cystic lesion. Blood cultures were obtained immediately before the procedure, after flexible sigmoidoscopy/radial EUS, and 15 minutes after EUS FNA.

RESULTS

One hundred patients underwent a total of 471 FNAs (mean, 4.7 FNAs/patient; range, 1-10 FNAs/patient). Blood cultures were positive in 6 patients. Cultures from 4 patients (4.0%, 95% confidence interval, 1.6%-9.8%) grew coagulase-negative Staphylococcus (n = 2), Peptostreptococcus stomatis (n = 1), or Moraxella (n = 1), which were considered contaminants. Two patients (2.0%, 95% confidence interval, 0.6%-7%) developed bacteremia: Bacteroides fragilis (n = 1) and Gemella morbillorum (n = 1). No signs or symptoms of infection developed in any patient.

CONCLUSIONS

EUS FNA of solid lesions in the lower GI tract should be considered a low-risk procedure for infectious complications that does not warrant prophylactic administration of antibiotics for the prevention of bacterial endocarditis.

Bacteremia after diagnostic conventional laparoscopy and minilaparoscopy: a prospective study in 100 patients

BACKGROUND/GOALS

Diagnostic laparoscopy under sedoanalgesia is a valuable tool in the work-up of liver diseases and is helpful as a staging procedure. The rate of bacteremia caused by this procedure is unknown, in particular when performed as minilaparoscopy.

STUDY

A 100 consecutive patients having undergone diagnostic laparoscopy carried out either conventionally (group I, n=50) or as minilaparoscopy (group II, n=50) were prospectively enrolled in this study. Blood cultures were drawn before and within 5 minutes after the procedure. Risk factors for bacteremia were evaluated.

RESULTS

Bacterial growth occurred in 4 blood cultures drawn immediately after laparoscopy. No patient developed fever or other signs of infection in the follow-up. Risk factors predisposing to bacteremia could not be identified.

CONCLUSIONS

Conventional diagnostic laparoscopy under sedoanalgesia and minilaparoscopy are associated with a low rate of bacteremia as in diagnostic upper endoscopy.

Effusive-constrictive calcific pericarditis associated with Streptococcus salivarius. Case report and review of the literature

We report the case of a 40-year-old patient presenting with a 6-month history of dyspnea and edema, with significant worsening of his clinical manifestations for the 2 weeks before admission to our department. During this 14-day preadmission period, continuous positive airway pressure (CPAP) was prescribed elsewhere for management of a working diagnosis of obstructive sleep apnea. The patient presented to us hemodynamically compromised. Management of the patient included emergency cardiac surgery for tamponade caused by effusive-constrictive, calcific pericarditis in addition to antimicrobial treatment as a result of the growth of Streptococcus salivarius from the pericardial fluid. This is the first report in the literature of association of this microorganism with pericarditis. The use of CPAP made the patient's symptoms worse as a result of an increase of the intrathoracic pressure, which was a pathophysiological mechanism, added to the interference of the localized pericardial effusion and the effect of the pericardial constriction. In an era of rapidly increasing use of CPAP systems, clinicians should be aware of their possible detrimental effects on patients with some types of cardiopulmonary diseases.

Novel endoscopic therapies for gastrointestinal malignancies: endoscopic mucosal resection and endoscopic ablation

Gastrointestinal malignancies are often detected at advanced stages when the prognosis is poor. Screening guidelines that vary accord-ing to the regional disease prevalence are needed. High-resolution endoscopy, magnification endoscopy, chromoendoscopy, light autofluorescence endoscopy, and optical coherence tomography are new technologies designed to improve endoscopic detection. Once detected, lesions must be accurately staged, including depth of mucosal penetration and lymph node involvement, to determine endoscopic resectability. Widely applicable, relatively safe, and minimally invasive alternatives to surgery are needed. Endoscopic mucosal resection and endoscopic ablation are potentially curative for malignancies limited to the mucosa, obviating the need for surgery in these patients.

Bacteremia in cirrhotic patients submitted to endoscopic band ligation of esophageal varices

BACKGROUND

Endoscopic procedures can develop bacteremia. Patients with chronic liver disease are more predisposed to undergo bacteremia and infections because they are immunocompromised.

AIMS

The purpose of this study was to determine the incidence of bacteremia in cirrhotics submitted to endoscopic variceal ligation.

METHODS

Three groups of 40 patients each were studied. One group was made up of patients with cirrhosis who were submitted to ligation, a second group was composed of cirrhotics who underwent esophagogastroduodenoscopy only, and a third group was composed of patients without liver disease who underwent esophagogastroduodenoscopy. Blood was sampled from all patients for culture, both in aerobic and in anaerobic mediums, immediately before endoscopy and at 5 and 30 minutes after its completion.

RESULTS

Blood culture was positive in 6 samples. In 4 of these, the bacteria (Staphylococcus hominis hominis, Staphylococcus auricularis, Acinetobacter lwoffii, and coagulase-negative staphylococcus) were isolated before the endoscopic procedure and thus were considered as contamination. In the ligation group, a streptococcus of the viridans group was isolated 5 minutes after the procedure, and in the cirrhosis without ligation group, a Staphylococcus epidermidis was isolated at 30 minutes. None of the patients showed clinical evidence of infection.

CONCLUSIONS

The bacteremia incidence in cirrhotic patients submitted to variceal ligation was 2.5%, showing no difference from the control groups.

Prospective risk assessment of bacteremia and other infectious complications in patients undergoing EUS-guided FNA

BACKGROUND

There are few data regarding the risk of bacteremia with EUS-guided FNA. This study prospectively evaluated the frequency of bacteremia and other infectious complications after EUS-guided FNA.

METHODS

Patients referred for EUS-guided FNA of the upper GI tract lesions were considered for enrollment. Patients were excluded if there was an indication for preprocedure administration of antibiotics based on ASGE guidelines, had taken antibiotics within the prior 7 days, or if they had a pancreatic cystic lesion. Blood cultures were obtained immediately before the procedure, after routine endoscopy/radial EUS, and 15 minutes after EUS-guided FNA.

RESULTS

Fifty-two patients underwent EUS-guided FNA at 74 sites (mean 1.4 sites/patient) totaling 266 passes of the fine needle (mean 5.1 FNA/patient). Coagulase negative Staphylococcus was grown in cultures from 3 patients (5.8%; 95% CI [1%, 15%]) and was considered a contaminant. Three patients (5.8%; 95% CI [1%, 15%]) developed bacteremia: Streptococcus viridans (n = 2), unidentified gram-negative bacillus (n = 1). No signs or symptoms of infection developed in any patient.

CONCLUSION

EUS-guided FNA of solid lesions in the upper GI tract should be considered a low-risk procedure for infectious complications that does not warrant prophylactic administration of antibiotics for prevention of bacterial endocarditis.