Comparison of adenoma miss rate and adenoma detection rate between conventional colonoscopy and colonoscopy with second-generation distal attachment cuff: a multicenter, randomized, back-to-back trial

BACKGROUND AND AIMS

Endocuff Vision (Olympus Europe, Hamburg, Germany) has been designed to enhance mucosal visualization, thereby improving detection of (pre-)malignant colorectal lesions. This multicenter, international, back-to-back, randomized colonoscopy trial compared the adenoma detection rate (ADR) and adenoma miss rate (AMR) between Endocuff Vision-assisted colonoscopy (EVC) and conventional colonoscopy (CC).

METHODS

Patients aged 40 to 75 years referred for non-immunochemical fecal occult blood test-based screening, surveillance, or diagnostic colonoscopy were included at 10 hospitals and randomized into 4 groups: group 1, 2 × CC; group 2, CC followed by EVC; group 3, EVC followed by CC; and group 4, 2 × EVC. Primary outcomes included ADR and AMR.

RESULTS

A total of 717 patients were randomized, of whom 661 patients (92.2%) had 1 and 646 (90.1%) patients had 2 completed back-to-back colonoscopies. EVC did not significantly improve ADR compared to CC (41.1%; [95% confidence interval (CI), 36.1-46.3] vs 35.5% [95% CI, 30.7-40.6], respectively; P = .125), but EVC did reduce AMR by 11.7% (29.6% [95% CI, 23.6-36.5] vs 17.9% [95% CI, 12.5-23.5], respectively; P = .049). AMR of 2 × CC compared to 2 × EVC was also not significantly different (25.9% [95% CI, 19.3-33.9] vs 18.8% [95% CI, 13.9-24.8], respectively; P = .172). Only 3.7% of the polyps missed during the first procedures had advanced pathologic features. Factors affecting risk of missing adenomas were age (P = .002), Boston Bowel Preparation Scale (P = .008), and region where colonoscopy was performed (P < .001).

CONCLUSIONS

Our trial shows that EVC reduces the risk of missing adenomas but does not lead to a significantly improved ADR. Remarkably, 25% of adenomas are still missed during conventional colonoscopies, which is not different from miss rates reported 25 years ago; reassuringly, advanced features were only found in 3.7% of these missed lesions. (Clinical trial registration number: NCT03418948.).

Colorectal polypectomy and endoscopic mucosal resection: European Society of Gastrointestinal Endoscopy (ESGE) Guideline - Update 2024

1:  ESGE recommends cold snare polypectomy (CSP), to include a clear margin of normal tissue (1-2 mm) surrounding the polyp, for the removal of diminutive polyps (≤ 5 mm).Strong recommendation, high quality of evidence. 2:  ESGE recommends against the use of cold biopsy forceps excision because of its high rate of incomplete resection.Strong recommendation, moderate quality of evidence. 3:  ESGE recommends CSP, to include a clear margin of normal tissue (1-2 mm) surrounding the polyp, for the removal of small polyps (6-9 mm).Strong recommendation, high quality of evidence. 4:  ESGE recommends hot snare polypectomy for the removal of nonpedunculated adenomatous polyps of 10-19 mm in size.Strong recommendation, high quality of evidence. 5:  ESGE recommends conventional (diathermy-based) endoscopic mucosal resection (EMR) for large (≥ 20 mm) nonpedunculated adenomatous polyps (LNPCPs).Strong recommendation, high quality of evidence. 6:  ESGE suggests that underwater EMR can be considered an alternative to conventional hot EMR for the treatment of adenomatous LNPCPs.Weak recommendation, moderate quality of evidence. 7:  Endoscopic submucosal dissection (ESD) may also be suggested as an alternative for removal of LNPCPs of ≥ 20 mm in selected cases and in high-volume centers.Weak recommendation, low quality evidence. 8:  ESGE recommends that, after piecemeal EMR of LNPCPs by hot snare, the resection margins should be treated by thermal ablation using snare-tip soft coagulation to prevent adenoma recurrence.Strong recommendation, high quality of evidence. 9:  ESGE recommends (piecemeal) cold snare polypectomy or cold EMR for SSLs of all sizes without suspected dysplasia.Strong recommendation, moderate quality of evidence. 10:  ESGE recommends prophylactic endoscopic clip closure of the mucosal defect after EMR of LNPCPs in the right colon to reduce to reduce the risk of delayed bleeding.Strong recommendation, high quality of evidence. 11:  ESGE recommends that en bloc resection techniques, such as en bloc EMR, ESD, endoscopic intermuscular dissection, endoscopic full-thickness resection, or surgery should be the techniques of choice in cases with suspected superficial invasive carcinoma, which otherwise cannot be removed en bloc by standard polypectomy or EMR.Strong recommendation, moderate quality of evidence.

American Society for Gastrointestinal Endoscopy-European Society of Gastrointestinal Endoscopy guideline on primary endoscopic bariatric and metabolic therapies for adults with obesity

This joint ASGE-ESGE guideline provides an evidence-based summary and recommendations regarding the role of endoscopic bariatric and metabolic therapies (EBMTs) in the management of obesity. The document was developed using the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) framework. It evaluates the efficacy and safety of EBMT devices and procedures that currently have CE mark or FDA-clearance/approval, or that had been approved within five years of document development. The guideline suggests the use of EBMTs plus lifestyle modification in patients with a BMI of ≥30 kg/m2, or with a BMI of 27.0-29.9 kg/m2 with at least 1 obesity-related comorbidity. Furthermore, it suggests the utilization of intragastric balloons and devices for endoscopic gastric remodeling (EGR) in conjunction with lifestyle modification for this patient population.

American Society for Gastrointestinal Endoscopy-European Society of Gastrointestinal Endoscopy guideline on primary endoscopic bariatric and metabolic therapies for adults with obesity

This joint ASGE-ESGE guideline provides an evidence-based summary and recommendations regarding the role of endoscopic bariatric and metabolic therapies (EBMTs) in the management of obesity. The document was developed using the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) framework. It evaluates the efficacy and safety of EBMT devices and procedures that currently have CE mark or FDA-clearance/approval, or that had been approved within five years of document development. The guideline suggests the use of EBMTs plus lifestyle modification in patients with a BMI of ≥ 30 kg/m2, or with a BMI of 27.0-29.9 kg/m2 with at least 1 obesity-related comorbidity. Furthermore, it suggests the utilization of intragastric balloons and devices for endoscopic gastric remodeling (EGR) in conjunction with lifestyle modification for this patient population.

Endoscopic Management of Difficult Biliary Stones: An Evergreen Issue

Choledocholithiasis is one of the most common indications for endoscopic retrograde cholangiopancreatography (ERCP) in daily practice. Although the majority of stones are small and can be easily removed in a single endoscopy session, approximately 10-15% of patients have complex biliary stones, requiring additional procedures for an optimum clinical outcome. A plethora of endoscopic methods is available for the removal of difficult biliary stones, including papillary large balloon dilation, mechanical lithotripsy, and electrohydraulic and laser lithotripsy. In-depth knowledge of these techniques and the emerging literature on them is required to yield the most optimal therapeutic effects. This narrative review aims to describe the definition of difficult bile duct stones based on certain characteristics and streamline their endoscopic retrieval using various modalities to achieve higher clearance rates.

Fatal Left Ventricular Free Wall Rupture Complicating Acute Myopericarditis

This is a case of a 59-year-old man presenting with myopericarditis. Over a 2-week period, he developed progressive symptoms and worsening pericardial effusion, leading to cardiac tamponade. Pericardiocentesis revealed hemopericardium, and multidetector computed tomography angiography showed left ventricular free wall rupture. The patient collapsed abruptly, and autopsy confirmed the findings.

Training in basic gastrointestinal endoscopic procedures: a European Society of Gastrointestinal Endoscopy (ESGE) and European Society of Gastroenterology and Endoscopy Nurses and Associates (ESGENA) Position Statement

This ESGE Position Statement provides structured and evidence-based guidance on the essential requirements and processes involved in training in basic gastrointestinal (GI) endoscopic procedures. The document outlines definitions; competencies required, and means to their assessment and maintenance; the structure and requirements of training programs; patient safety and medicolegal issues. 1:  ESGE and ESGENA define basic endoscopic procedures as those procedures that are commonly indicated, generally accessible, and expected to be mastered (technically and cognitively) by the end of any core training program in gastrointestinal endoscopy. 2:  ESGE and ESGENA consider the following as basic endoscopic procedures: diagnostic upper and lower GI endoscopy, as well as a limited range of interventions such as: tissue acquisition via cold biopsy forceps, polypectomy for lesions ≤ 10 mm, hemostasis techniques, enteral feeding tube placement, foreign body retrieval, dilation of simple esophageal strictures, and India ink tattooing of lesion location. 3:  ESGE and ESGENA recommend that training in GI endoscopy should be subject to stringent formal requirements that ensure all ESGE key performance indicators (KPIs) are met. 4:  Training in basic endoscopic procedures is a complex process and includes the development and acquisition of cognitive, technical/motor, and integrative skills. Therefore, ESGE and ESGENA recommend the use of validated tools to track the development of skills and assess competence. 5:  ESGE and ESGENA recommend incorporating a multimodal approach to evaluating competence in basic GI endoscopic procedures, including procedural thresholds and the measurement and documentation of established ESGE KPIs. 7:  ESGE and ESGENA recommend the continuous monitoring of ESGE KPIs during GI endoscopy training to ensure the trainee's maintenance of competence. 9:  ESGE and ESGENA recommend that GI endoscopy training units fulfil the ESGE KPIs for endoscopy units and, furthermore, be capable of providing the dedicated personnel, infrastructure, and sufficient case volume required for successful training within a structured training program. 10:  ESGE and ESGENA recommend that trainers in basic GI endoscopic procedures should be endoscopists with formal educational training in the teaching of endoscopy, which allows them to successfully and safely teach trainees.

Endoscopic Gastrointestinal Placement of Capsule Endoscopy to Investigate the Small Bowel: a Multicentric European Retrospective Series of 630 Procedures in Adult Patients

BACKGROUND AND AIMS

Small bowel (SB) capsule endoscopy (CE) is a first line procedure for exploring the SB. Endoscopic GastroIntestinal PlacemenT (EGIPT) of SB CE is sometimes necessary. While the experience of EGIPT is large in pediatric populations, we aimed to describe the safety, efficacy and outcomes of EGIPT of SB CE in adult patients.

METHODS

The international CApsule endoscopy REsearch (iCARE) group set up a retrospective multicenter study. Patients over 18 year-old who underwent EGIPT of SB CE before May 2022 were included. Data were collected from medical records and capsule recordings. The primary endpoint was the technical success rate of the EGIPT procedures.

RESULTS

630 patients were included (mean age 62.5 years old, 55.9% female) from 39,565 patients (1.6%) issued from 29 centers. EGIPT technical success was achieved in 610 procedures (96.8%). Anesthesia (moderate/deep sedation or general anesthesia) and centers with intermediate or high procedure loads were independent factors of technical success. Severe adverse events occurred in three (0.5%) patients. When technically successful, EGIPT was associated with a high SB CE completion rate (84.4%) and with a substantial diagnostic yield (61.1%). Completion rate was significantly higher when the capsule was delivered in the SB compared to when delivered in the stomach.

CONCLUSION

EGIPT of SB CE is highly feasible, safe and comes with high completion rate and diagnostic yield. When indicated, it should rather be performed under anesthesia and the capsule should be delivered in the duodenum rather than in the stomach, for better SB examination outcomes.

Models and scores to predict adequacy of bowel preparation before colonoscopy

Adequate bowel preparation is of paramount importance for the effectiveness of preventive colonoscopy as it allows visualization of the mucosal surface and adenomas detection, the pre-malignant lesions leading to colon cancer. Still, a considerable portion of patients fail to achieve adequate bowel cleansing, with predictors of inadequate bowel preparation being at the focal point of several studies, so far. Incorporation of these factors within predictive models has been implemented in an effort to promptly identify patients at risk for inadequate bowel preparation and thus, timely adopt practices that have the potential to improve bowel cleansing. Ultimately, this could lead to improved procedural outcomes not only in terms of neoplastic detection rate but also interval repeat procedures, expenses, patient convenience and adverse events risk. Aim of this manuscript is to present an up to date overview of all predictive scores/models addressing bowel cleansing adequacy in everyday clinical practice.

Lactated Ringers Use in the First 24 Hours of Hospitalization Is Associated With Improved Outcomes in 999 Patients With Acute Pancreatitis

INTRODUCTION

Recent pilot trials in acute pancreatitis (AP) found that lactated ringers (LR) usage may result in decreased risk of moderately severe/severe AP compared with normal saline, but their small sample sizes limit statistical power. We investigated whether LR usage is associated with improved outcomes in AP in an international multicenter prospective study.

METHODS

Patients directly admitted with the diagnosis of AP were prospectively enrolled at 22 international sites between 2015 and 2018. Demographics, fluid administration, and AP severity data were collected in a standardized prospective manner to examine the association between LR and AP severity outcomes. Mixed-effects logistic regression analysis was performed to determine the direction and magnitude of the relationship between the type of fluid administered during the first 24 hours and the development of moderately severe/severe AP.

RESULTS

Data from 999 patients were analyzed (mean age 51 years, female 52%, moderately severe/severe AP 24%). Usage of LR during the first 24 hours was associated with reduced odds of moderately severe/severe AP (adjusted odds ratio 0.52; P = 0.014) compared with normal saline after adjusting for region of enrollment, etiology, body mass index, and fluid volume and accounting for the variation across centers. Similar results were observed in sensitivity analyses eliminating the effects of admission organ failure, etiology, and excessive total fluid volume.

DISCUSSION

LR administration in the first 24 hours of hospitalization was associated with improved AP severity. A large-scale randomized clinical trial is needed to confirm these findings.

Diagnosis and management of Barrett esophagus: European Society of Gastrointestinal Endoscopy (ESGE) Guideline

MR1 : ESGE recommends the following standards for Barrett esophagus (BE) surveillance:- a minimum of 1-minute inspection time per cm of BE length during a surveillance endoscopy- photodocumentation of landmarks, the BE segment including one picture per cm of BE length, and the esophagogastric junction in retroflexed position, and any visible lesions- use of the Prague and (for visible lesions) Paris classification- collection of biopsies from all visible abnormalities (if present), followed by random four-quadrant biopsies for every 2-cm BE length.Strong recommendation, weak quality of evidence. MR2:  ESGE suggests varying surveillance intervals for different BE lengths. For BE with a maximum extent of ≥ 1 cm and < 3 cm, BE surveillance should be repeated every 5 years. For BE with a maximum extent of ≥ 3 cm and < 10 cm, the interval for endoscopic surveillance should be 3 years. Patients with BE with a maximum extent of ≥ 10 cm should be referred to a BE expert center for surveillance endoscopies. For patients with an irregular Z-line/columnar-lined esophagus of < 1 cm, no routine biopsies or endoscopic surveillance are advised.Weak recommendation, low quality of evidence. MR3:  ESGE suggests that, if a patient has reached 75 years of age at the time of the last surveillance endoscopy and/or the patient's life expectancy is less than 5 years, the discontinuation of further surveillance endoscopies can be considered. Weak recommendation, very low quality of evidence. MR4:  ESGE recommends offering endoscopic eradication therapy using ablation to patients with BE and low grade dysplasia (LGD) on at least two separate endoscopies, both confirmed by a second experienced pathologist.Strong recommendation, high level of evidence. MR5:  ESGE recommends endoscopic ablation treatment for BE with confirmed high grade dysplasia (HGD) without visible lesions, to prevent progression to invasive cancer.Strong recommendation, high level of evidence. MR6:  ESGE recommends offering complete eradication of all remaining Barrett epithelium by ablation after endoscopic resection of visible abnormalities containing any degree of dysplasia or esophageal adenocarcinoma (EAC).Strong recommendation, moderate quality of evidence. MR7:  ESGE recommends endoscopic resection as curative treatment for T1a Barrett's cancer with well/moderate differentiation and no signs of lymphovascular invasion.Strong recommendation, high level of evidence. MR8:  ESGE suggests that low risk submucosal (T1b) EAC (i. e. submucosal invasion depth ≤ 500 µm AND no [lympho]vascular invasion AND no poor tumor differentiation) can be treated by endoscopic resection, provided that adequate follow-up with gastroscopy, endoscopic ultrasound (EUS), and computed tomography (CT)/positrion emission tomography-computed tomography (PET-CT) is performed in expert centers.Weak recommendation, low quality of evidence. MR9:  ESGE suggests that submucosal (T1b) esophageal adenocarcinoma with deep submucosal invasion (tumor invasion > 500 µm into the submucosa), and/or (lympho)vascular invasion, and/or a poor tumor differentiation should be considered high risk. Complete staging and consideration of additional treatments (chemotherapy and/or radiotherapy and/or surgery) or strict endoscopic follow-up should be undertaken on an individual basis in a multidisciplinary discussion.Strong recommendation, low quality of evidence. MR10 A: ESGE recommends that the first endoscopic follow-up after successful endoscopic eradication therapy (EET) of BE is performed in an expert center.Strong recommendation, very low quality of evidence. B:  ESGE recommends careful inspection of the neo-squamocolumnar junction and neo-squamous epithelium with high definition white-light endoscopy and virtual chromoendoscopy during post-EET surveillance, to detect recurrent dysplasia.Strong recommendation, very low level of evidence. C:  ESGE recommends against routine four-quadrant biopsies of neo-squamous epithelium after successful EET of BE.Strong recommendation, low level of evidence. D:  ESGE suggests, after successful EET, obtaining four-quadrant random biopsies just distal to a normal-appearing neo-squamocolumnar junction to detect dysplasia in the absence of visible lesions.Weak recommendation, low level of evidence. E:  ESGE recommends targeted biopsies are obtained where there is a suspicion of recurrent BE in the tubular esophagus, or where there are visible lesions suspicious for dysplasia.Strong recommendation, very low level of evidence. MR11:  After successful EET, ESGE recommends the following surveillance intervals:- For patients with a baseline diagnosis of HGD or EAC:at 1, 2, 3, 4, 5, 7, and 10 years after last treatment, after which surveillance may be stopped.- For patients with a baseline diagnosis of LGD:at 1, 3, and 5 years after last treatment, after which surveillance may be stopped.Strong recommendation, low quality of evidence.

Diagnostic performance of quantitative flow ratio in non-ST elevation acute coronary syndromes in comparison to non-hyperemic pressure ratios: a prospective study

Quantitative flow ratio (QFR) is a new angiography-based coronary physiology tool aimed to evaluate functional relevance of intermediate coronary lesions. Aim of the study is to assess diagnostic performance of QFR in patients with non-ST-elevation acute coronary syndrome (NSTE-ACS) in comparison to currently used non-hyperaemic pressure ratios (NHPRs). In this prospective, single-centre study, coronary physiology of intermediate coronary stenoses of non-culprit vessels in patients presenting with NSTE-ACS was evaluated using NHPRs (iFR, DFR or RFR). Subsequently, QFR was computed offline by a QFR analyst blinded to the NHPR results. Diagnostic performance of QFR was assessed in comparison to NHPRs as reference standard. A total of 60 vessels with intermediate coronary stenoses was investigated. The NHPRs were used as follows: RFR 38%, DFR 47% and iFR 15% of the cases. The NHPR result was positive, showing significant lesion, in 19 cases. A significant correlation was found between NHPR and QFR (r = 0.84, p < 0.001). Classification agreement of the two methods (95%) and diagnostic performance of QFR in comparison to NHPR (AUC: 0.962 [0.914-1.00]) were both high. Sensitivity, specificity, positive and negative predictive value of QFR in comparison to NHPR were 84.2%, 100%, 100% and 93.2% respectively. QFR has high diagnostic performance in detecting functionally significant lesions of non-culprit arteries in patients with NSTE-ACS and multivessel disease. Due to its high negative predictive value, it can be used to safely avoid unnecessary invasive physiological assessment of these lesions.

Risk assessment of post-myocardial infarction patients with preserved ejection fraction using 45-min short resting Holter electrocardiographic recordings

BACKGROUND

Risk stratification for sudden cardiac death in post-myocardial infarction (post-MI) patients remains a challenging task. Several electrocardiographic noninvasive risk factors (NIRFs) have been associated with adverse outcomes and were used to refine risk assessment. This study aimed to evaluate the performance of NIRFs extracted from 45-min short resting Holter ECG recordings (SHR), in predicting ventricular tachycardia inducibility with programmed ventricular stimulation (PVS) in post-MI patients with preserved left ventricular ejection fraction (LVEF).

METHODS

We studied 99 post-MI ischemia-free patients (mean age: 60.5 ± 9.5 years, 86.9% men) with LVEF ≥40%, at least 40 days after revascularization. All the patients underwent PVS and a high-resolution SHR. The following parameters were evaluated: mean heart rate, ventricular arrhythmias (premature ventricular complexes, couplets, tachycardias), QTc duration, heart rate variability (HRV), deceleration capacity, heart rate turbulence, late potentials, and T-wave alternans.

RESULTS

PVS was positive in 24 patients (24.2%). HRV, assessed by the standard deviation of normal-to-normal R-R intervals (SDNN), was significantly decreased in the positive PVS group (42 ms vs. 51 ms, p = .039). SDNN values <50 ms were also associated with PVS inducibility (OR 3.081, p = .032 in univariate analysis, and 4.588, p = .013 in multivariate analysis). No significant differences were identified for the other NIRFs. The presence of diabetes, history of ST-elevation MI (STEMI) and LVEF <50% were also important predictors of positive PVS.

CONCLUSIONS

HRV assessed from SHR, combined with other noninvasive clinical and echocardiographic variables (diabetes, STEMI history, LVEF), can provide an initial, practical, and rapid screening tool for arrhythmic risk assessment in post-MI patients with preserved LVEF.

Informed consent for endoscopic procedures: European Society of Gastrointestinal Endoscopy (ESGE) Position Statement

All endoscopic procedures are invasive and carry risk. Accordingly, all endoscopists should involve the patient in the decision-making process about the most appropriate endoscopic procedure for that individual, in keeping with a patient's right to self-determination and autonomy. Recognition of this has led to detailed guidelines on informed consent for endoscopy in some countries, but in many no such guidance exists; this may lead to variations in care and exposure to risk of litigation. In this document, the European Society of Gastrointestinal Endoscopy (ESGE) sets out a series of statements that cover best practice in informed consent for endoscopy. These statements should be seen as a minimum standard of practice, but practitioners must be aware of and adhere to the law in their own country. 1:  Patients should give informed consent for all gastrointestinal endoscopic procedures for which they have capacity to do so. 2:  The healthcare professional seeking consent for an endoscopic procedure should ensure that the patient has the capacity to consent to that procedure. 3:  For patients who lack capacity, healthcare personnel should at all times try to engage with people close to the patient, such as family, friends, or caregivers, to achieve consensus on the appropriateness of performing the procedure. 4:  Where a patient lacks capacity to provide informed consent, the best interest decision should be clearly documented in the medical record. This should include information about the capacity assessment, reason(s) that the decision cannot be delayed for capacity recovery (or if recovery is not expected), who has been consulted, and where relevant the form of authority for the decision. 5:  There should be a systematic and transparent disclosure of the expected benefits and harms that may reasonably affect patient choice on whether or not to undergo any diagnostic or interventional endoscopic procedure. Information about possible alternatives, as well as the consequences of doing nothing, should also be provided when relevant. 6:  The information provided on the benefit and harms of an endoscopic procedure should be adapted to the procedure and patient-specific risk factors, and the preferences of the patient should be central to the consent process. 7:  The consent discussion should be undertaken by an individual who is familiar with the procedure and its risks, and is able to discuss these in the context of the individual patient. 8:  Patients should confirm consent to an endoscopic procedure in a private, unrushed, and non-coercive environment. 9:  If a patient requests that an endoscopic procedure be discontinued, the procedure should be paused and the patient's capacity for decision making assessed. If a competent patient continues to object to the procedure, or if a conclusive determination of capacity is not feasible, the examination should be terminated as soon as it is safe to do so. 10: Informed consent should be sufficiently detailed to cover all findings that can be reasonably anticipated during an endoscopic examination. The scope of this consent should not be expanded, nor a patient's implicit consent for additional interventions assumed, unless failure to proceed with such interventions would result in immediate and predictable harm to the patient.

The Low-FODMAP Diet, IBS, and BCFAs: Exploring the Positive, Negative, and Less Desirable Aspects-A Literature Review

The literature about the association of branched short-chain fatty acids (BCFAs) and irritable bowel syndrome (IBS) is limited. BCFAs, the bacterial products of the catabolism of branched-chain amino acids, are proposed as markers for colonic protein fermentation. IBS is a gastrointestinal disorder characterized by low-grade inflammation and intestinal dysbiosis. The low-FODMAP diet (LFD) has increasingly been applied as first-line therapy for managing IBS symptoms, although it decreases the production of short-chain fatty acids (SCFA), well known for their anti-inflammatory action. In parallel, high protein consumption increases BCFAs. Protein fermentation alters the colonic microbiome through nitrogenous metabolites production, known for their detrimental effects on the intestinal barrier promoting inflammation. Purpose: This review aims to explore the role of BCFAs on gut inflammation in patients with IBS and the impact of LFD in BCFAs production. Methods: A literature search was carried out using a combination of terms in scientific databases. Results: The included studies have contradictory findings about how BCFAs affect the intestinal health of IBS patients. Conclusions: Although evidence suggests that BCFAs may play a protective role in gut inflammation, other metabolites of protein fermentation are associated with gut inflammation. Further research is needed in order to clarify how diet protein composition and, consequently, the BCFAs are implicated in IBS pathogenesis or in symptoms management with LFD+.

Effect of add-on devices with projections on screening colonoscopy: a systematic review and meta-analysis

Background

Add-on devices with projections, e.g., Endocuff, Endocuff Vision, EndoRings, and Wingcap, placed on the distal tip of the colonoscope promise to improve the detection of precancerous lesions. We performed a meta-analysis to evaluate the performance of these devices exclusively among individuals undergoing colonoscopy for screening purpose.

Methods

A computerized literature search was performed across MEDLINE and Cochrane Library databases for randomized controlled trials that compared standard colonoscopy (SC) to procedures using add-on devices. The primary outcome was adenoma detection rate (ADR), while secondary outcomes included polyp detection rate (PDR), advanced ADR (AADR), and sessile serrated lesion detection rate (SSLDR). The effect size on study outcomes was calculated using a random-effects model and presented as the risk ratio (RR) and 95% confidence interval (CI).

Results

Seven studies enrolling a total of 5785 patients were included. The use of add-on-devices with projections was associated with a higher ADR compared to SC: 45.9% vs. 41.1%; RR 1.18, 95%CI 1.02-1.37; P=0.03; I2=79%. Although PDR was higher in screening colonoscopies assisted by add-on devices as compared to SC, the difference failed to reach significance: 55.1% vs. 50.8%; RR 1.10, 95%CI 0.96-1.26; P=0.17; I2=75%. No difference was found between procedures assisted by add-on devices with projections and SC colonoscopies in terms of AADR (18.5% vs. 17.6%; RR 1.00, 95%CI 0.79-1.27; P=0.98; I2=56%) or SSLDR (6.8% vs. 5.8%; RR 1.17, 95%CI 0.95-1.44; P=0.15; I2=0%).

Conclusion

Colonoscopy assisted by add-on devices with projections achieves a better ADR compared to SC among individuals undergoing screening for bowel cancer.

Real-Time Computer-Aided Detection of Colorectal Neoplasia During Colonoscopy : A Systematic Review and Meta-analysis

BACKGROUND

Artificial intelligence computer-aided detection (CADe) of colorectal neoplasia during colonoscopy may increase adenoma detection rates (ADRs) and reduce adenoma miss rates, but it may increase overdiagnosis and overtreatment of nonneoplastic polyps.

PURPOSE

To quantify the benefits and harms of CADe in randomized trials.

DESIGN

Systematic review and meta-analysis. (PROSPERO: CRD42022293181).

DATA SOURCES

Medline, Embase, and Scopus databases through February 2023.

STUDY SELECTION

Randomized trials comparing CADe-assisted with standard colonoscopy for polyp and cancer detection.

DATA EXTRACTION

Adenoma detection rate (proportion of patients with ≥1 adenoma), number of adenomas detected per colonoscopy, advanced adenoma (≥10 mm with high-grade dysplasia and villous histology), number of serrated lesions per colonoscopy, and adenoma miss rate were extracted as benefit outcomes. Number of polypectomies for nonneoplastic lesions and withdrawal time were extracted as harm outcomes. For each outcome, studies were pooled using a random-effects model. Certainty of evidence was assessed using the GRADE (Grading of Recommendations Assessment, Development and Evaluation) framework.

DATA SYNTHESIS

Twenty-one randomized trials on 18 232 patients were included. The ADR was higher in the CADe group than in the standard colonoscopy group (44.0% vs. 35.9%; relative risk, 1.24 [95% CI, 1.16 to 1.33]; low-certainty evidence), corresponding to a 55% (risk ratio, 0.45 [CI, 0.35 to 0.58]) relative reduction in miss rate (moderate-certainty evidence). More nonneoplastic polyps were removed in the CADe than the standard group (0.52 vs. 0.34 per colonoscopy; mean difference [MD], 0.18 polypectomy [CI, 0.11 to 0.26 polypectomy]; low-certainty evidence). Mean inspection time increased only marginally with CADe (MD, 0.47 minute [CI, 0.23 to 0.72 minute]; moderate-certainty evidence).

LIMITATIONS

This review focused on surrogates of patient-important outcomes. Most patients, however, may consider cancer incidence and cancer-related mortality important outcomes. The effect of CADe on such patient-important outcomes remains unclear.

CONCLUSION

The use of CADe for polyp detection during colonoscopy results in increased detection of adenomas but not advanced adenomas and in higher rates of unnecessary removal of nonneoplastic polyps.

PRIMARY FUNDING SOURCE

European Commission Horizon 2020 Marie Skłodowska-Curie Individual Fellowship.

EUS-Guided Diagnosis of Gastric Subepithelial Lesions, What Is New?

Gastric subepithelial lesions (SELs) are intramural lesions that arise underneath the gastric mucosa. SELs can be benign, but can also be malignant or have malignant potential. Therefore, correct diagnosis is crucial. Endosonography has been established as the diagnostic gold standard. Although the identification of some of these lesions can be carried out immediately, solely based on their echo characteristics, for certain lesions histological examination is necessary. Sometimes histology can be inconclusive, especially for smaller lesions. Therefore, new methods have been developed in recent years to assist decision making, such as contrast enhanced endosonography, EUS elastography, and artificial intelligence systems. In this narrative review we provide a complete overview of the gastric SELs and summarize the new data of the last ten years concerning the diagnostic advances of endosonography on this topic.

Diagnosis and management of small-bowel bleeding

Small-bowel (SB) bleeding is a challenging problem for the clinician, presenting many pitfalls in both diagnosis and subsequent treatment. Videocapsule endoscopy (VCE) and device-assisted enteroscopy (DAE) have revolutionized the approach to the patient with SB bleeding, allowing for the endoscopic diagnosis and management of what was previously only a surgical matter. The patients' assessment in SB bleeding is of foremost importance, as treatment success relies on a detailed evaluation of clinical history, suspicion for underlying lesions, and a careful selection and timing of diagnostic and therapeutic tools. This review will summarize current state-of-the-art evidence and practice points, to provide the clinician with a comprehensive guide towards the management of SB bleeding.

Endoscopic ultrasound-guided tissue acquisition beyond the pancreas

Endoscopic ultrasound (EUS) offers the ability to obtain tissue material via a fine needle under direct visualization for cytological or pathological examination. Prior studies have looked at EUS tissue acquisition; however, most reports have been centered around lesions of the pancreas. This paper aims to review the literature on EUS tissue acquisition in other organs (beyond the pancreas) such as the liver, biliary tree, lymph nodes, and upper and lower gastrointestinal tracts. Furthermore, techniques for obtaining tissue samples under EUS guidance continue to evolve. Specifically, some of the techniques that endoscopists employ are suction techniques (i.e., dry heparin, dry suction technique, wet suction technique), the slow pull technique, and the fanning technique. Apart from acquisition techniques, the type and size of the needle utilized play a major role in the quality of samples. This review describes the indications for tissue acquisition for each organ, and also describes and compares the various tissue acquisition techniques, as well as the different needles used according to their shape and size.

Obesity and alcoholic etiology as risk factors for multisystem organ failure in acute pancreatitis: Multinational study

BACKGROUND

Multisystem organ failure (MSOF) is the most important determinant of mortality in acute pancreatitis (AP). Obesity and alcoholic etiology have been examined as potential risk factors for MSOF, but prior studies have not adequately elucidated their independent effects on the risk of MSOF.

OBJECTIVE

We aimed to determine the adjusted effects of body mass index (BMI) and alcoholic etiology on the risk of MSOF in subjects with AP.

METHODS

A prospective observational study of 22 centers from 10 countries was conducted. Patients admitted to an APPRENTICE consortium center with AP between August 2015 and January 2018 were enrolled. Multivariable logistic regression was used to estimate the adjusted effects of BMI, etiology, and other relevant covariates on the risk of MSOF. Models were stratified by sex.

RESULTS

Among 1544 AP subjects, there was a sex-dependent association between BMI and the risk of MSOF. Increasing BMI was associated with increased odds of MSOF in males (OR 1.10, 95% confidence interval [CI] 1.04-1.15) but not in females (OR 0.98, 95% CI 0.90-1.1). Male subjects with AP, whose BMIs were 30-34 and >35 kg/m² , had odds ratios of 3.78 (95% CI 1.62-8.83) and 3.44 (95% CI 1.08-9.99), respectively. In females, neither higher grades of obesity nor increasing age increased the risk of MSOF. Alcoholic etiology was independently associated with increased odds of MSOF compared with non-alcohol etiologies (OR 4.17, 95% CI 2.16-8.05).

CONCLUSION

Patients with alcoholic etiology and obese men (but not women) are at substantially increased risk of MSOF in AP.

Prevalence of Small Intestinal Bacterial Overgrowth Syndrome in Patients with Non-Alcoholic Fatty Liver Disease/Non-Alcoholic Steatohepatitis: A Cross-Sectional Study

INTRODUCTION

Non-alcoholic fatty liver disease (NAFLD) is a multifactorial, wide-spectrum liver disorder. Small intestinal bacterial overgrowth (SIBO) is characterized by an increase in the number and/or type of colonic bacteria in the upper gastrointestinal tract. SIBO, through energy salvage and induction of inflammation, may be a pathophysiological factor for NAFLD development and progression.

AIM/METHODS

Consecutive patients with histological, biochemical, or radiological diagnosis of any stage of NAFLD (non-alcoholic fatty liver [NAFL], non-alcoholic steatohepatitis [NASH], cirrhosis) underwent upper gastrointestinal endoscopy. Duodenal fluid (2cc) was aspirated from the 3rd-4th part of duodenum into sterile containers. SIBO was defined as ≥103 aerobic colony-forming units (CFU)/mL of duodenal aspirate and/or the presence of colonic-type bacteria. Patients without any liver disease undergoing gastroscopy due to gastroesophageal reflux disease (GERD) comprised the healthy control (HC) group. Concentrations (pg/mL) of tumor necrosis factor alpha (TNFα), interleukin (IL)-1β, and IL-6 were also measured in the duodenal fluid. The primary endpoint was to evaluate the prevalence of SIBO in NAFLD patients, while the comparison of SIBO prevalence among NAFLD patients and healthy controls was a secondary endpoint.

RESULTS

We enrolled 125 patients (51 NAFL, 27 NASH, 17 cirrhosis, and 30 HC) aged 54 ± 11.9 years and with a weight of 88.3 ± 19.6 kg (NAFLD vs. HC 90.7 ± 19.1 vs. 80.8 ± 19.6 kg, p = 0.02). Overall, SIBO was diagnosed in 23/125 (18.4%) patients, with Gram-negative bacteria being the predominant species (19/23; 82.6%). SIBO prevalence was higher in the NAFLD cohort compared to HC (22/95; 23.2% vs. 1/30; 3.3%, p = 0.014). Patients with NASH had higher SIBO prevalence (6/27; 22.2%) compared to NAFL individuals (8/51; 15.7%), but this difference did not reach statistical significance (p = 0.11). Patients with NASH-associated cirrhosis had a higher SIBO prevalence compared to patients with NAFL (8/17; 47.1% vs. 8/51; 15.7%, p = 0.02), while SIBO prevalence between patients with NASH-associated cirrhosis and NASH was not statistically different (8/17; 47.1% vs. 6/27; 22.2%, p = 0.11). Mean concentration of TNF-α, IL-1β, and IL-6 did not differ among the different groups.

CONCLUSION

The prevalence of SIBO is significantly higher in a cohort of patients with NAFLD compared to healthy controls. Moreover, SIBO is more prevalent in patients with NASH-associated cirrhosis compared to patients with NAFL.

Anemia in Celiac Disease: Multiple Aspects of the Same Coin

Extraintestinal manifestations of celiac disease (CD) are an integral part of the disease's clinical profile and, frequently, appear as the presenting feature. Given that anemia in CD may be multifactorial, increased awareness is needed on the part of treating physicians, and especially hematologists, to screen for CD. In this study, we highlight anemia as the presenting feature of CD which has remained undiagnosed for several years. In patients with a positive antibody testing or high suspicion of CD, endoscopy with a biopsy of the small intestine is performed, as it is considered the "gold standard" for diagnosing CD. Since most of the manifestations of CD are preventable or treatable with a gluten-free diet, an early diagnosis is vital for the prevention of serious and potentially lethal complications.

Performance and safety of motorized spiral enteroscopy: a systematic review and meta-analysis

BACKGROUND AND AIMS

The introduction of motorized spiral enteroscopy (mSe) into clinical practice holds diagnostic and therapeutic potential for small bowel investigation. This systematic review with meta-analysis aims to evaluate the performance of this modality in diagnosing and treating small bowel lesions.

METHODS

A systematic search in Medline and Cochrane databases were performed through September 2022. The primary outcome was diagnostic success, defined as the identification of a lesion relative to the indication. Secondary outcomes included successful therapeutic manipulations, total enteroscopy rate (examination from the duodenojejunal flexion to the cecum), technical success (passage from the ligament of Treitz or ileocecal valve for anterograde and retrograde approach, respectively) and complication rates. We performed meta-analyses using a random effects model and the results were reported as percentages with 95% Confidence Intervals (95%CIs).

RESULTS

From 2016 to 2022 nine studies [959 patients; 42% females; mean age>45 years; 474 (49.4%) investigated for mid GI bleeding/anemia) were considered eligible and included in analysis. The diagnostic success rate of mSE was 78% (95%CI:72-84; I²=78.3%). Considering secondary outcomes, total enteroscopy was attempted in 460 cases, and completed with a rate of 51% (95%CI:30-72; I²=96.2%), whereas therapeutic interventions were successful in 98% (95%CI:96-100; I²=79.8%) of cases where attempted. Technical success rates were 96% (95%CI:94-97; I²=1.5%) for anterograde and 97% (95%CI:94-100; I²=38.6%) for retrograde approaches, respectively. Finally, the incidence of complications was 17% (95%CI:13-21; I²=65.1%), albeit the vast majority included minor adverse events [16% (95%CI: 11-20; I²=67.2%) vs major= 1% (95%CI:0-1; I²=0%)].

CONCLUSIONS

Motorized spiral enteroscopy provides high rates of diagnostic and therapeutic success with a low prevalence of severe adverse events.

Probiotics in Functional Dyspepsia

Functional dyspepsia (FD) is a common disorder in everyday clinical practice identified nowadays as a multi-factorial, difficult to treat condition with a significant burden on patients' quality of life (QoL) and healthcare systems worldwide. Despite its high prevalence in the general population, the precise etiology of the disorder remains elusive, with its pathophysiological spectrum evolving over time, including variable potential mechanisms, i.e., impaired gastric accommodation, gastric motor disorders, hypersensitivity to gastric distention, disorders of the brain-gut axis, as well as less evident ones, i.e., altered duodenal microbiota composition and genetic susceptibility. In light of these implications, a definitive, universal treatment that could be beneficial for all FD patients is not available yet. Recently, probiotics have been suggested to be an effective therapeutic option that could alleviate gastrointestinal symptoms in patients with Irritable Bowel Syndrome (IBS), potentially due to anti-inflammatory properties or by modulating the complex bidirectional interactions between gastrointestinal microbiota and host crosstalk; however, their impact on the multiple aspects of FD remains ambiguous. In this review, we aim to summarize all currently available evidence for the efficacy of probiotics as a novel therapeutic approach for FD.

Clinical value of alarm features for colorectal cancer: a meta-analysis

BACKGROUND

Colorectal cancer (CRC) is a common neoplasm in Western countries. Prioritizing access to colonoscopy appears of critical relevance. Alarm features are considered to increase the likelihood of CRC. Our aim was to assess the diagnostic performance of alarm features for CRC diagnosis.

METHODS

We performed a systematic review and meta-analysis of studies reporting the diagnostic accuracy of alarm features (rectal bleeding, anemia, change in bowel habit, and weight loss) for CRC, published up to September 2021. Colonoscopy was required as the reference diagnostic test. Diagnostic accuracy measures were pooled by a bivariate mixed-effects regression model. The number needed to scope (NNS; i. e. the number of patients who need to undergo colonoscopy to diagnose one CRC) according to each alarm feature was calculated.

RESULTS

31 studies with 45 100 patients (mean age 31-88 years; men 36 %-63 %) were included. The prevalence of CRC ranged from 0.2 % to 22 %. Sensitivity was suboptimal, ranging from 12.4 % for weight loss to 49 % for rectal bleeding, whereas specificity ranged from 69.8 % for rectal bleeding to 91.9 % for weight loss. Taken individually, rectal bleeding and anemia would be the only practical alarm features mandating colonoscopy (NNS 5.3 and 6.7, respectively).

CONCLUSIONS

When considered independently, alarm features have variable accuracy for CRC, given the high heterogeneity of study populations reflected by wide variability in CRC prevalence. Rectal bleeding and anemia are the most practical to select patients for colonoscopy. Integration of alarm features in a comprehensive evaluation of patients should be considered.

Endoscopic Treatment of Large Bile Duct Stones: A Systematic Review and Network Meta-Analysis

BACKGROUND & AIMS

Several endoscopic methods have been proposed for the treatment of large biliary stones. We assessed the comparative efficacy of these treatments through a network meta-analysis.

METHODS

Nineteen randomized controlled trials (2752 patients) comparing different treatments for management of large bile stones (>10 mm) (endoscopic sphincterotomy, balloon sphincteroplasty, sphincterotomy followed by endoscopic papillary large balloon dilation [S+EPLBD], mechanical lithotripsy, single-operator cholangioscopy [SOC]) with each other were identified. Study outcomes were the success rate of stone removal and the incidence of adverse events. We performed pairwise and network meta-analysis for all treatments, and used Grading of Recommendations, Assessment, Development, and Evaluation criteria to appraise the quality of evidence.

RESULTS

All treatments except mechanical lithotripsy significantly outperformed sphincterotomy in terms of stone removal rate (risk ratio [RR], 1.03-1.29). SOC was superior to other adjunctive interventions (vs balloon sphincteroplasty [RR, 1.24; 95% CIs, 1.07-1.45], vs S+EPLBD [RR, 1.23; range, 1.06-1.42] and vs mechanical lithotripsy [RR, 1.34; range, 1.14-1.58]). Cholangioscopy ranked the highest in increasing the success rate of stone removal (surface under the cumulative ranking [SUCRA] score, 0.99) followed by S+EPLBD (SUCRA score, 0.68). SOC and S+EPLBD outperformed the other modalities when only studies reporting on stones greater than 15 mm were taken into consideration (SUCRA scores, 0.97 and 0.71, respectively). None of the assessed interventions was significantly different in terms of adverse event rate compared with endoscopic sphincterotomy or with other treatments. Post-ERCP pancreatitis and bleeding were the most frequent adverse events.

CONCLUSIONS

Among patients with large bile stones, cholangioscopy represents the most effective method, in particular in patients with larger (>15 mm) stones, whereas S+EPLBD could represent a less expensive and more widely available alternative.

Comparative performance and external validation of three different scores in predicting inadequate bowel preparation among Greek inpatients undergoing colonoscopy

Background

Predictive scores aim to predict bowel preparation adequacy among hospitalized patients undergoing colonoscopy. We evaluated the comparative efficacy of these scores in predicting inadequate bowel cleansing in a cohort of Greek inpatients.

Methods

We performed a post hoc analysis of data generated from a cohort of inpatients undergoing colonoscopy in 4 tertiary Greek centers to validate the 3 models currently available (models A, B and C). We used the Akaike information criterion to quantify the performance of each model, while Harrell's C-index, as the area under the receiver operating characteristics curve (AUC), verified the discriminative ability to predict inadequate bowel prep. Primary endpoint was the comparison of performance among models for predicting inadequate bowel cleansing.

Results

Overall, 261 patients-121 (46.4%) female, 100 (38.3%) bedridden, mean age 70.7±15.4 years-were included in the analysis. Model B showed the highest performance (Harrell's C-index: AUC 77.2% vs. 72.6% and 57.5%, compared to models A and C, respectively). It also achieved higher performance for the subgroup of mobilized inpatients (Harrell's C-index: AUC 72.21% vs. 64.97% and 59.66%, compared to models A and C, respectively). Model B also performed better in predicting patients with incomplete colonoscopy due to inadequate bowel preparation (Harrell's C-index: AUC 74.23% vs. 69.07% and 52.76%, compared to models A and C, respectively).

Conclusions

Predictive model B outperforms its comparators in the prediction of inpatients with inadequate bowel preparation. This model is particularly advantageous when used to evaluate mobilized inpatients.

Small-bowel capsule endoscopy and device-assisted enteroscopy for diagnosis and treatment of small-bowel disorders: European Society of Gastrointestinal Endoscopy (ESGE) Guideline - Update 2022

MR1: ESGE recommends small-bowel capsule endoscopy as the first-line examination, before consideration of other endoscopic and radiological diagnostic tests for suspected small-bowel bleeding, given the excellent safety profile of capsule endoscopy, its patient tolerability, and its potential to visualize the entire small-bowel mucosa.Strong recommendation, moderate quality evidence. MR2: ESGE recommends small-bowel capsule endoscopy in patients with overt suspected small-bowel bleeding as soon as possible after the bleeding episode, ideally within 48 hours, to maximize the diagnostic and subsequent therapeutic yield.Strong recommendation, high quality evidence. MR3: ESGE does not recommend routine second-look endoscopy prior to small-bowel capsule endoscopy in patients with suspected small-bowel bleeding or iron-deficiency anemia.Strong recommendation, low quality evidence. MR4: ESGE recommends conservative management in those patients with suspected small-bowel bleeding and high quality negative small-bowel capsule endoscopy.Strong recommendation, moderate quality evidence. MR5: ESGE recommends device-assisted enteroscopy to confirm and possibly treat lesions identified by small-bowel capsule endoscopy.Strong recommendation, high quality evidence. MR6: ESGE recommends the performance of small-bowel capsule endoscopy as a first-line examination in patients with iron-deficiency anemia when small bowel evaluation is indicated.Strong recommendation, high quality evidence. MR7: ESGE recommends small-bowel capsule endoscopy in patients with suspected Crohn's disease and negative ileocolonoscopy findings as the initial diagnostic modality for investigating the small bowel, in the absence of obstructive symptoms or known bowel stenosis.Strong recommendation, high quality evidence. MR8: ESGE recommends, in patients with unremarkable or nondiagnostic findings from dedicated small-bowel cross-sectional imaging, small-bowel capsule endoscopy as a subsequent investigation if deemed likely to influence patient management.Strong recommendation, low quality evidence. MR9: ESGE recommends, in patients with established Crohn's disease, the use of a patency capsule before small-bowel capsule endoscopy to decrease the capsule retention rate.Strong recommendation, moderate quality evidence. MR10: ESGE recommends device-assisted enteroscopy (DAE) as an alternative to surgery for foreign bodies retained in the small bowel requiring retrieval in patients without acute intestinal obstruction.Strong recommendation, moderate quality evidence. MR11: ESGE recommends DAE-endoscopic retrograde cholangiopancreatography (DAE-ERCP) as a first-line endoscopic approach to treat pancreaticobiliary diseases in patients with surgically altered anatomy (except for Billroth II patients).Strong recommendation, moderate quality evidence.

Cold Reactive Proteins in Cardiovascular Surgery

Background

According to the literature, Cryoglobins, Cold Agglutinins, Donath-Landsteiner antibodies, and Cryofibrinogen arethe 4 types of Cold-Reactive proteins described.

Objective

The aim of the study was to show the role of these proteins cardiovascular surgery.

Case presentation

A 57-year-old male patient with a history of myocardial infarction 6 years ago, heavy smoker until 1 year ago, with diabetes, was admitted to the hospital for a surgical confrontation of coronary disease. He reports that for1-month symptoms are deteriorating (NYHA III). The history of the patient does not include either hematopoietic system or connective tissue diseases or recent viral infection. Angiographic control showed total obstruction of the small branch. The patient underwent median sternotomy. Suspension of the left sternum. Mobilization of the left internal mammary artery. Concomitant reception of left great saphenous vein. Intubation of ascending aorta and right atrium - vena cava with acatheter of two steps. He was extubated at the 10th post-surgical hour. Smooth post-surgical progression, with no signs of brain, myocardial or renal failure. The patient was discharged on the 5th post-surgical day.

Conclusion

Independently of the technique that is used, the systemic temperature must be maintained duringthe cardiopulmonary bypass above the temperature threshold activity of the cold-reactiveproteins.

Comparison between EUS-guided fine-needle biopsy with or without rapid on-site evaluation for tissue sampling of solid pancreatic lesions: A systematic review and meta-analysis

The benefit of rapid on-site evaluation (ROSE) on the diagnostic accuracy of EUS-guided fine-needle biopsy (EUS-FNB) in patients with pancreatic masses is still matter of debate. Aim of our meta-analysis is to compare the diagnostic outcomes of these two tissue acquisition strategies. Computerized bibliographic search on the main databases was performed through December 2021 and 8 studies were identified (2147 patients). The primary outcome was sample adequacy. Pooled effects were calculated using a random-effects model by means of DerSimonian and Laird test and summary estimates were expressed in terms of odds ratio (OR) or mean difference and 95% confidence Interval (CI). There was no difference in terms of baseline variables between the two groups. Pooled sample adequacy was 95.5% (95% CI 93.2%-97.8%) and 88.9% (83.4%-94.5%) in the EUS-FNB + ROSE and EUS-FNB groups, respectively (OR = 2.05, 0.94-4.49; P = 0.07). Diagnostic accuracy resulted significantly superior in the EUS-FNB + ROSE group (OR = 2.49, 1.08-5.73; P = 0.03), particularly when the analysis was restricted to reverse bevel needle (OR = 3.24, 1.19-8.82, P = 0.02), whereas no statistical difference was observed when newer end-cutting needles were used (OR = 0.71, 0.29-3.61, P = 0.56). Diagnostic sensitivity was not significantly different between the two groups (OR = 1.94, 0.84-4.49; P = 0.12), whereas pooled specificity was 100% with both approaches. The number of needle passes needed to obtain diagnostic samples was not significantly different (mean difference 0.07,-0.22 to 0.37; P = 0.62). Our meta-analysis stands for a non-superiority of EUS-FNB + ROSE over EUS-FNB with newer end-cutting needles, whereas ROSE could have still a role when reverse bevel needles are used.

Comparative efficacy and safety of resection techniques for treating 6 to 20mm, nonpedunculated colorectal polyps: A systematic review and network meta-analysis

INTRODUCTION

Various endoscopic resection techniques have been proposed for the treatment of nonpedunculated colorectal polyps sized 6-20 mm, however the optimal technique still remains unclear.

METHODS

A comprehensive literature review was conducted for randomized controlled trials (RCTs), investigating the efficacy of endoscopic treatments for the management of 6-20 mm nonpedunculated colorectal polyps. Primary outcomes were complete and en bloc resection rates and adverse event rate was the secondary. Effect size on outcomes is presented as risk ratio (RR; 95% confidence interval [CI]).

RESULTS

Fourteen RCTs (5219 polypectomies) were included. Endoscopic mucosal resection(EMR) significantly outperformed cold snare polypectomy(CSP) in terms of complete [(RR 95%CI): 1.04(1.00-1.07)] and en bloc resection rate [RR:1.12(1.04-1.21)]. EMR was superior to hot snare polypectomy (HSP) [RR:1.04(1.00-1.08)] regarding complete resection, while underwater EMR (U-EMR) achieved significantly higher rate of en bloc resection compared to CSP [RR:1.15(1.01-1.30)]. EMR yielded the highest ranking for complete resection(SUCRA-score 0.81), followed by cold-snare EMR(CS-EMR,SUCRA-score 0.76). None of the modalities was different regarding adverse event rate compared to CSP, however EMR and CS-EMR resulted in fewer adverse events compared to HSP [RR:0.44(0.26-0.77) and 0.43(0.21-0.87),respectively].

CONCLUSION

EMR achieved the highest performance in resecting 6-20 mm nonpedunculated colorectal polyps, with this effect being consistent for polyps 6-9 and ≥10 mm; findings supported by very low quality of evidence.

Endoscopic diagnosis and management of esophagogastric variceal hemorrhage: European Society of Gastrointestinal Endoscopy (ESGE) Guideline

1: ESGE recommends that patients with compensated advanced chronic liver disease (ACLD; due to viruses, alcohol, and/or nonobese [BMI < 30 kg/m²] nonalcoholic steatohepatitis) and clinically significant portal hypertension (hepatic venous pressure gradient [HVPG] > 10 mmHg and/or liver stiffness by transient elastography > 25 kPa) should receive, if no contraindications, nonselective beta blocker (NSBB) therapy (preferably carvedilol) to prevent the development of variceal bleeding.Strong recommendation, moderate quality evidence. 2: ESGE recommends that in those patients unable to receive NSBB therapy with a screening upper gastrointestinal (GI) endoscopy that demonstrates high risk esophageal varices, endoscopic band ligation (EBL) is the endoscopic prophylactic treatment of choice. EBL should be repeated every 2-4 weeks until variceal eradication is achieved. Thereafter, surveillance EGD should be performed every 3-6 months in the first year following eradication.Strong recommendation, moderate quality evidence. 3: ESGE recommends, in hemodynamically stable patients with acute upper GI hemorrhage (UGIH) and no history of cardiovascular disease, a restrictive red blood cell (RBC) transfusion strategy, with a hemoglobin threshold of ≤ 70 g/L prompting RBC transfusion. A post-transfusion target hemoglobin of 70-90 g/L is desired.Strong recommendation, moderate quality evidence. 4 : ESGE recommends that patients with ACLD presenting with suspected acute variceal bleeding be risk stratified according to the Child-Pugh score and MELD score, and by documentation of active/inactive bleeding at the time of upper GI endoscopy.Strong recommendation, high quality of evidence. 5 : ESGE recommends the vasoactive agents terlipressin, octreotide, or somatostatin be initiated at the time of presentation in patients with suspected acute variceal bleeding and be continued for a duration of up to 5 days.Strong recommendation, high quality evidence. 6 : ESGE recommends antibiotic prophylaxis using ceftriaxone 1 g/day for up to 7 days for all patients with ACLD presenting with acute variceal hemorrhage, or in accordance with local antibiotic resistance and patient allergies.Strong recommendation, high quality evidence. 7 : ESGE recommends, in the absence of contraindications, intravenous erythromycin 250 mg be given 30-120 minutes prior to upper GI endoscopy in patients with suspected acute variceal hemorrhage.Strong recommendation, high quality evidence. 8 : ESGE recommends that, in patients with suspected variceal hemorrhage, endoscopic evaluation should take place within 12 hours from the time of patient presentation provided the patient has been hemodynamically resuscitated.Strong recommendation, moderate quality evidence. 9 : ESGE recommends EBL for the treatment of acute esophageal variceal hemorrhage (EVH).Strong recommendation, high quality evidence. 10 : ESGE recommends that, in patients at high risk for recurrent esophageal variceal bleeding following successful endoscopic hemostasis (Child-Pugh C  ≤ 13 or Child-Pugh B > 7 with active EVH at the time of endoscopy despite vasoactive agents, or HVPG > 20 mmHg), pre-emptive transjugular intrahepatic portosystemic shunt (TIPS) within 72 hours (preferably within 24 hours) must be considered.Strong recommendation, high quality evidence. 11 : ESGE recommends that, for persistent esophageal variceal bleeding despite vasoactive pharmacological and endoscopic hemostasis therapy, urgent rescue TIPS should be considered (where available).Strong recommendation, moderate quality evidence. 12 : ESGE recommends endoscopic cyanoacrylate injection for acute gastric (cardiofundal) variceal (GOV2, IGV1) hemorrhage.Strong recommendation, high quality evidence. 13: ESGE recommends endoscopic cyanoacrylate injection or EBL in patients with GOV1-specific bleeding.Strong recommendations, moderate quality evidence. 14: ESGE suggests urgent rescue TIPS or balloon-occluded retrograde transvenous obliteration (BRTO) for gastric variceal bleeding when there is a failure of endoscopic hemostasis or early recurrent bleeding.Weak recommendation, low quality evidence. 15: ESGE recommends that patients who have undergone EBL for acute EVH should be scheduled for follow-up EBLs at 1- to 4-weekly intervals to eradicate esophageal varices (secondary prophylaxis).Strong recommendation, moderate quality evidence. 16: ESGE recommends the use of NSBBs (propranolol or carvedilol) in combination with endoscopic therapy for secondary prophylaxis in EVH in patients with ACLD.Strong recommendation, high quality evidence.

Comparison between Enteroscopy-, Laparoscopy- and Endoscopic Ultrasound-Assisted Endoscopic Retrograde Cholangio-Pancreatography in Patients with Surgically Altered Anatomy: A Systematic Review and Meta-Analysis

Background and Aims: Endoscopic retrograde cholangiopancreatography (ERCP), in surgically altered anatomy (SAA), can be challenging and the optimal technique selection remains debatable. Most common foregut interventions resulting to this burden consist of Billroth II gastrectomy, Whipple surgery and Roux-en-Y anastomoses, including gastric by-pass. This systematic review, with meta-analysis, aimed to compare the rates of successful enteroscope-assisted (EA)-, endosonography-directed transgastric- (EDGE), and laparoscopy-assisted (LA)-ERCP. Methods: A systematic research (Medline) was performed for relative studies, through January 2022. The primary outcome was technical success, defined as approaching the ampulla site. Secondary outcomes included the desired duct cannulation, successful therapeutic manipulations, and complication rates. We performed meta-analyses of pooled data, and subgroup analysis considering the EA-ERCP subtypes (spiral-, double and single balloon-enteroscope). Pooled rates are reported as percentages with 95% Confidence Intervals (95%CIs). Results: Seventy-six studies were included (3569 procedures). Regarding primary outcome, EA-ERCP was the least effective [87.3% (95%CI: 85.3–89.4); I2: 91.0%], whereas EDGE and LA-ERCP succeeded in 97.9% (95%CI: 96.4–99.4; I2: 0%) and 99.1% (95%CI: 98.6–99.7; I2: 0%), respectively. Similarly, duct cannulation and therapeutic success rates were 74.7% (95%CI: 71.3–78.0; I2: 86.9%) and 69.1% (95%CI: 65.3–72.9; I2: 91.8%) after EA-ERCP, 98% (95%CI: 96.5–99.6; I2: 0%) and 97.9% (95%CI: 96.3–99.4) after EDGE, and 98.6% (95%CI: 97.9–99.2; I2: 0%) and 98.5% (95%CI: 97.8–99.2; I2: 0%) after LA-ERCP, respectively. The noticed high heterogeneity in EA-ERCP results probably reflects the larger number of included studies, the different enteroscopy modalities and the variety of surgical interventions. Comparisons revealed the superiority of LA-ERCP and EDGE over EA-ERCP (p ≤ 0.001) for all success-related outcomes, though LA-ERCP and EDGE were comparable (p ≥ 0.43). ERCP with spiral-enteroscope was inferior to balloon-enteroscope, while the type of the balloon-enteroscope did not affect the results. Most adverse events were recorded after LA-ERCP [15.1% (95%CI: 9.40–20.8); I2: 87.1%], and EDGE [13.1% (95%CI: 7.50–18.8); I2: 48.2%], significantly differing from EA-ERCP [5.7% (95%CI: 4.50–6.80); p ≤ 0.04; I2: 64.2%]. Conclusions: LA-ERCP and EDGE were associated with higher technical, cannulation, and therapeutic success compared to EA-ERCP, though accompanied with more adverse events.

P-wave beat-to-beat analysis to predict atrial fibrillation recurrence after catheter ablation

Introduction

Identification of patients prone to atrial fibrillation (AF) relapse after catheter ablation is essential for better patient selection and risk stratification.

Purpose

The current prospective cohort study aims to validate a novel P-wave index based on beat-to-beat (B2B) P-wave morphological and wavelet analysis designed to detect patients with low burden AF, as a predictor of AF recurrence within a year after successful catheter ablation.

Methods

12-lead ECG and 10-minute vectorcardiogram (VCG) recordings were obtained from 138 consecutive patients scheduled for AF ablation. Pre-ablation B2B P-wave index, along with standard P-wave indices, clinical scores and patients history and physical examination parameters were evaluated as AF recurrence predictors.

Results

Univariate analysis revealed that patients with higher B2B P-wave index had a two-fold risk for AF recurrence (HR: 2.35, 95% CI: 1.24–4.44, p: 0.010). Prolonged P-wave, interatrial block, early AF recurrence, female gender, heart failure history, previous stroke, and CHA2DS2-VASc score ≥2 were also found to be related to higher recurrence rate. Multivariate analysis of predictors that can be assessed before ablation revealed that B2B P-wave index, along with heart failure history and history of previous stroke or transient ischemic attack are independent predicting factors of AF relapse.

Conclusion

B2B P-wave morphology and wavelet analysis, is a promising, non-invasive technique, able to identify patients prone to AF recurrence after pulmonary veins ablation. Further studies are needed to assess the predictive value of B2B index with greater accuracy and evaluate a possible relationship with atrial substrate analysis.

Funding Acknowledgement

Type of funding sources: Public Institution(s). Main funding source(s): Hellenic Society of Cardiology

Syncopal patients without prodromes exhibit a diverse pattern of adenosine release during head-up tilt test

Background/Introduction

In a significant proportion of patients with neurally-mediated syncope (NMS), the mechanism of syncope remains largely undetermined. Adenosine has been proposed as a central humoral factor in various forms of NMS: high Adenosine Plasma Levels (ADP) are encountered in patients with vasovagal syncope (VVS), low ADP in non-prodromes syncope (NPS), while ADP in patients with situational syncope SS are less well determined.

Purpose

We sought to assess ADP in patients with different clinical forms of syncope, with an emphasis on the presence or absence of prodromal symptoms, as well as the relation between ADP and the outcomes of Head-Up Tilt Table Test (HUTT) and Adenosine test (ADT).

Methods

Patients with different clinical types of NMS (n=124), i.e., VVS, NPS, or SS, were investigated using a standard protocol including HUTT and ADT. During HUTT, ADP was measured in the supine position, at table tilting, and in syncope.

Results

Baseline ADP did not differ among groups. ADP at syncope were higher in NPS compared to VVS (1.55±1.29 vs 0.16±0.05 μM, p=0.03) and SS (0.15±0.05 μM, p=0.02). In NPS, ADP increased from the supine position to the time of syncope (0.47±0.25 to 1.55±1.29 μM, p=0.04). In VVS, ADP increased only from the supine to the tilt position (0.23±0.04 to 0.35±0.10 μMu, p=0.02), while in SS ADP did not change in any stage of HUTT. SS was associated with cardioinhibitory HUTT (OR 3.40, 95% CI 1.05 to 9.56, p=0.04) and positive ADT (OR 4.22, 95% CI 1.47 to 11.46, p=0.012).

Conclusion(s)

A distinct pattern of ADP increase is noted during HUTT in NPS, suggesting that an excessive increase of ADP may play the key role in triggering this type of clinical presentation of syncope independently of the baseline ADP. Cardioinhibition prevails in patients with SS without clear adenosine involvement. Such observations contribute to an enhanced understanding of the pathophysiology of different clinical forms of syncope which may offer the possibility to tailor the management approach appropriately.

Funding Acknowledgement

Type of funding sources: None.

The usability and effect of an mHealth disease management platform on the quality of life of patients with paroxysmal atrial fibrillation – The emPOWERD-AF study

Atrial fibrillation (AF) is the most common arrhythmia. myAlgos is an mHealth disease management system consisting of physician-oriented platform and patient-oriented smartphone app. Our purpose was to assess the usability of myAlgos by physicians and patients and the effect of myAlgos on the quality of life (QoL) in patients with paroxysmal AF (PAF). Physicians rated the platform with the Post-Study System Usability Questionnaire (PSSUQ). Patients rated the app with the mHealth App Usability Questionnaire (MAUQ). The e-medicine Platform for Optimizing the Workflow in hEaRt Diseases (emPOWERD-AF) study investigated the effect of myAlgos in PAF patients randomized to full/control version. QoL was measured by the Atrial Fibrillation Effect on QualiTy-of-life (AFEQT) and 5-level EQ-5D (EQ-5D-5L) questionnaires. myAlgos got a PSSUQ score of 2.52 ± 0.36 by five physicians and a MAUQ score of 79.9% by 33 patients. In emPOWERD-AF, 80 patients were randomized 1:1 (58.1 ± 8.7 years, 66% male). The median AFEQT change at 6 months was +2.63% in full version users and −1.63% in controls ( p < .001). The myAlgos platform and app were easy-to-use and improved QoL in patients.

Reducing the environmental footprint of gastrointestinal endoscopy: European Society of Gastrointestinal Endoscopy (ESGE) and European Society of Gastroenterology and Endoscopy Nurses and Associates (ESGENA) Position Statement

Climate change and the destruction of ecosystems by human activities are among the greatest challenges of the 21st century and require urgent action. Health care activities significantly contribute to the emission of greenhouse gases and waste production, with gastrointestinal (GI) endoscopy being one of the largest contributors. This Position Statement aims to raise awareness of the ecological footprint of GI endoscopy and provides guidance to reduce its environmental impact. The European Society of Gastrointestinal Endoscopy (ESGE) and the European Society of Gastroenterology and Endoscopy Nurses and Associates (ESGENA) outline suggestions and recommendations for health care providers, patients, governments, and industry. MAIN STATEMENTS 1: GI endoscopy is a resource-intensive activity with a significant yet poorly assessed environmental impact. 2: ESGE-ESGENA recommend adopting immediate actions to reduce the environmental impact of GI endoscopy. 3: ESGE-ESGENA recommend adherence to guidelines and implementation of audit strategies on the appropriateness of GI endoscopy to avoid the environmental impact of unnecessary procedures. 4: ESGE-ESGENA recommend the embedding of reduce, reuse, and recycle programs in the GI endoscopy unit. 5: ESGE-ESGENA suggest that there is an urgent need to reassess and reduce the environmental and economic impact of single-use GI endoscopic devices. 6: ESGE-ESGENA suggest against routine use of single-use GI endoscopes. However, their use could be considered in highly selected patients on a case-by-case basis. 7: ESGE-ESGENA recommend inclusion of sustainability in the training curricula of GI endoscopy and as a quality domain. 8: ESGE-ESGENA recommend conducting high quality research to quantify and minimize the environmental impact of GI endoscopy. 9: ESGE-ESGENA recommend that GI endoscopy companies assess, disclose, and audit the environmental impact of their value chain. 10:  ESGE-ESGENA recommend that GI endoscopy should become a net-zero greenhouse gas emissions practice by 2050.

Nomenclature and Definition of Atrophic Lesions in Small Bowel Capsule Endoscopy: A Delphi Consensus Statement of the International CApsule endoscopy REsearch (I-CARE) Group

(1) Background: Villous atrophy is an indication for small bowel capsule endoscopy (SBCE). However, SBCE findings are not described uniformly and atrophic features are sometimes not recognized; (2) Methods: The Delphi technique was employed to reach agreement among a panel of SBCE experts. The nomenclature and definitions of SBCE lesions suggesting the presence of atrophy were decided in a core group of 10 experts. Four images of each lesion were chosen from a large SBCE database and agreement on the correspondence between the picture and the definition was evaluated using the Delphi method in a broadened group of 36 experts. All images corresponded to histologically proven mucosal atrophy; (3) Results: Four types of atrophic lesions were identified: mosaicism, scalloping, folds reduction, and granular mucosa. The core group succeeded in reaching agreement on the nomenclature and the descriptions of these items. Consensus in matching the agreed definitions for the proposed set of images was met for mosaicism (88.9% in the first round), scalloping (97.2% in the first round), and folds reduction (94.4% in the first round), but granular mucosa failed to achieve consensus (75.0% in the third round); (4) Conclusions: Consensus among SBCE experts on atrophic lesions was met for the first time. Mosaicism, scalloping, and folds reduction are the most reliable signs, while the description of granular mucosa remains uncertain.

Association of non-invasive electrocardiographic risk factors with left ventricular systolic function in post-myocardial infarction patients with mildly reduced or preserved ejection fraction: Insights from the PRESERVE-EF study

Background

Electrocardiographic non‐invasive risk factors (NIRFs) have an important role in the arrhythmic risk stratification of post‐myocardial infarction (post‐MI) patients with preserved or mildly reduced left ventricular ejection fraction (LVEF). However, their specific relation to left ventricular systolic function remains unclear. We aimed to evaluate the association between NIRFs and LVEF in the patients included in the PRESERVE‐EF trial.

Methods

We studied 575 post‐MI ischemia‐free patients with LVEF≥40% (mean age: 57.0 ± 10.4 years, 86.2% men). The following NIRFs were evaluated: premature ventricular complexes, non‐sustained ventricular tachycardia (NSVT), late potentials (LPs), prolonged QTc, increased T‐wave alternans, reduced heart rate variability, and abnormal deceleration capacity with abnormal turbulence.

Results

There was a statistically significant relationship between LPs (Chi‐squared = 4.975; p < .05), nsVT (Chi‐squared = 5.749, p < .05), PVCs (r= −.136; p < .01), and the LVEF. The multivariate linear regression analysis showed that LPs (p = .001) and NSVT (p < .001) were significant predictors of the LVEF. The results of the multivariate logistic regression analysis indicated that LPs (OR: 1.76; 95% CI: 1.02–3.05; p = .004) and NSVT (OR: 2.44; 95% CI: 1.18–5.04; p = .001) were independent predictors of the mildly reduced LVEF: 40%–49% versus the preserved LVEF: ≥50%.

Conclusion

Late potentials and NSVT are independently related to reduced LVEF while they are independent predictors of mildly reduced LVEF versus the preserved LVEF. These findings may have important implications for the arrhythmic risk stratification of post‐MI patients with mildly reduced or preserved LVEF.

The Modified Pancreatitis Activity Scoring System Shows Distinct Trajectories in Acute Pancreatitis: An International Study

BACKGROUND & AIMS

The aims of this study were to: (1) assess the performance of the Pancreatitis Activity Scoring System (PASS) in a large intercontinental cohort of patients with acute pancreatitis (AP); and (2) investigate whether a modified PASS (mPASS) yields a similar predictive accuracy and produces distinct early trajectories between severity subgroups.

METHODS

Data was prospectively collected through the Acute Pancreatitis Patient Registry to Examine Novel Therapies In Clinical Experience (APPRENTICE) consortium (2015-2018) involving 22 centers from 4 continents. AP severity was categorized per the revised Atlanta classification. PASS trajectories were compared between the three severity groups using the generalized estimating equations model. Four mPASS models were generated by modifying the morphine equivalent dose (MED), and their trajectories were compared.

RESULTS

A total of 1393 subjects were enrolled (median age, 49 years; 51% males). The study cohort included 950 mild (68.2%), 315 (22.6%) moderately severe, and 128 (9.2%) severe AP. Mild cases had the lowest PASS at each study time point (all P < .001). A subset of patients with outlier admission PASS values was identified. In the outlier group, 70% of the PASS variation was attributed to the MED, and 66% of these patients were from the United States centers. Among the 4 modified models, the mPASS-1 (excluding MED from PASS) demonstrated high performance in predicting severe AP with an area under the receiver operating characteristic curve of 0.88 (vs area under the receiver operating characteristic of 0.83 in conventional PASS) and produced distinct trajectories with distinct slopes between severity subgroups (all P < .001).

CONCLUSION

We propose a modified model by removing the MED component, which is easier to calculate, predicts accurately severe AP, and maintains significantly distinct early trajectories.

Comparative diagnostic performance of end-cutting fine-needle biopsy needles for EUS tissue sampling of solid pancreatic masses: a network meta-analysis

BACKGROUND AND AIMS

Evidence is limited on the comparative diagnostic performance of newer end-cutting fine-needle biopsy (FNB) needles for tissue sampling of pancreatic masses. We performed a systematic review with network meta-analysis to compare the diagnostic accuracy of available FNB needles for sampling of solid pancreatic lesions.

METHODS

A systematic literature review (Medline and Cochrane Database) was conducted for studies evaluating the accuracy of newer FNB needles in adults undergoing EUS-guided sampling of solid pancreatic masses. The primary outcome was diagnostic accuracy. Secondary outcomes were sample adequacy, diagnostic sensitivity, specificity, and adverse event rate. We performed pairwise and network meta-analyses and appraised the quality of evidence using Grading of Recommendations Assessment, Development and Evaluation methodology.

RESULTS

Overall, 16 RCTs (1934 patients) were identified. On network meta-analysis, Franseen needles (Acquire; Boston Scientific, Marlborough, Mass, USA) significantly outperformed reverse-bevel needles (risk ratio [RR], 1.21 [95% confidence interval {CI}, 1.05-1.40] for accuracy and 1.31 [95% CI, 1.05-1.22] for adequacy) and FNA needles (RR, 1.21 [95% CI, 1.01-1.25] for accuracy and 1.07 [95% CI, 1.02-1.13] for adequacy). Likewise, the Fork-tip needle (SharkCore; Medtronic, Dublin, Ireland) was significantly superior to the reverse-bevel needle (RR, 1.17 [95% CI, 1.03-1.33] for accuracy and 1.09 [95% CI, 1.02-1.16] for adequacy) and to the FNA needle (RR, 1.09 [95% CI, 1.01-1.19] for accuracy and 1.03 [95% CI, 1.01-1.07] for adequacy). Other comparisons did not achieve statistical significance. As a consequence, Franseen (surface under the cumulative ranking score, .89 for accuracy and .94 for adequacy) and Fork-tip needles (surface under the cumulative ranking score, .76 for accuracy and .73 for adequacy) ranked as the 2 highest-performing FNB needles. When considering different needle sizes, 25-gauge Franseen and 25-gauge Fork-tip needles were not superior to 22-gauge reverse-bevel needles (RR, 1.18 [95% CI, .96-1.46] and 1.04 [95% CI, .62-1.52]). None of the tested needles was significantly superior to the other FNB devices or to FNA needles when rapid onsite cytologic evaluation was available.

CONCLUSIONS

Franseen and Fork-tip needles, particularly 22-gauge size, showed the highest performance for tissue sampling of pancreatic masses, with low confidence in estimates.

Gut Microbiome: A Brief Review on Its Role in Schizophrenia and First Episode of Psychosis

There is a growing body of evidence highlighting the role of gut microbiota as a biological basis of psychiatric disorders. The existing literature suggest that cognitive and emotional activities can be influenced by microbes through the microbiota–gut–brain axis and implies an association between alterations in the gut microbiome and several psychiatric conditions, such as autism, depression, bipolar disorder and psychosis. The aim of this review is to summarise recent findings and provide concise updates on the latest progress of the role of gut microbiota in the development and maintenance of psychiatric symptoms in schizophrenia and the first episode of psychosis. Despite the lack of consistent findings in regard to specific microbiome changes related to psychosis, the emerging literature reports significant differences in the gut microbiome of schizophrenic subjects compared to healthy controls and increasingly outlines the significance of an altered microbiome composition in the pathogenesis, development, symptom severity and prognosis of psychosis. Further human studies are, however, required, which should focus on identifying the drivers of microbiota changes in psychosis and establish the direction of causality between psychosis and microbiome alterations.

Small Intestine Bacterial Overgrowth Can Form an Indigenous Proinflammatory Environment in the Duodenum: A Prospective Study

Small intestinal bacterial overgrowth (SIBO) contributes to the formation of an inflammatory environment in various intestinal and extraintestinal diseases. Cytokines that participate in these mechanisms are yet to be examined. Upper gastrointestinal endoscopy with duodenal aspiration was performed in 224 patients. Quantitative cultures of aerobic species were performed, concentrations of interleukin 1β (IL-1β), interleukin 6 (IL-6), and tumor necrosis factor alpha (TNF-α) were measured, and loads of Escherichia coli, Klebsiella pneumoniae, Methanobevibacter smithii, and Aeromonas spp. were detected via real-time PCR in the duodenal fluid. Analysis showed that the odds ratio (OR) for elevated IL-1β levels was 2.61 (1.06–6.43, p = 0.037) among patients with SIBO compared to patients without SIBO, while there was no significant difference at elevated IL-6 and TNF-α levels between patients with and without SIBO, using ≥10³ cfu/mL as a cut-off. The presence of all three elevated cytokine levels has OR 3.47 (1.06–11.34, p = 0.030) among patients with SIBO. Klebsiella pneumoniae detection was positively related with IL-6 and TNF-α levels, when Methanobevibacter smithii was positively related with IL-1β levels. The presence of SIBO is associated with elevated IL-1β levels in the duodenal fluid. There is a high prevalence of all three proinflammatory cytokine levels elevated (IL-1β, IL-6, and TNF-α) in the duodenal fluid among patients with SIBO.

The Effects of Stevia Consumption on Gut Bacteria: Friend or Foe?

Stevia, a zero-calorie sugar substitute, is recognized as safe by the Food and Drug Administration (FDA) and the European Food Safety Authority (EFSA). In vitro and in vivo studies showed that stevia has antiglycemic action and antioxidant effects in adipose tissue and the vascular wall, reduces blood pressure levels and hepatic steatosis, stabilizes the atherosclerotic plaque, and ameliorates liver and kidney damage. The metabolism of steviol glycosides is dependent upon gut microbiota, which breaks down glycosides into steviol that can be absorbed by the host. In this review, we elucidated the effects of stevia’s consumption on the host’s gut microbiota. Due to the lack of randomized clinical trials in humans, we included in vitro using certain microbial strains and in vivo in laboratory animal studies. Results indicated that stevia consumption has a potential benefit on the microbiome’s alpha diversity. Alterations in the colonic microenvironment may depend on the amount and frequency of stevia intake, as well as on the simultaneous consumption of other dietary components. The anti-inflammatory properties of stevioside were confirmed in vitro by decreasing TNF-α, IL-1β, IL-6 synthesis and inhibiting of NF-κB transcription factor, and in vivo by inhibiting NF-κB and MAPK in laboratory animals.

P-Wave Beat-to-Beat Analysis to Predict Atrial Fibrillation Recurrence after Catheter Ablation

The identification of patients prone to atrial fibrillation (AF) relapse after catheter ablation is essential for better patient selection and risk stratification. The current prospective cohort study aims to validate a novel P-wave index based on beat-to-beat (B2B) P-wave morphological and wavelet analysis designed to detect patients with low burden AF as a predictor of AF recurrence within a year after successful catheter ablation. From a total of 138 consecutive patients scheduled for AF ablation, 12-lead ECG and 10 min vectorcardiogram (VCG) recordings were obtained. Univariate analysis revealed that patients with higher B2B P-wave index had a two-fold risk for AF recurrence (HR: 2.35, 95% CI: 1.24–4.44, p: 0.010), along with prolonged P-wave, interatrial block, early AF recurrence, female gender, heart failure history, previous stroke, and CHA₂DS₂-VASc score. Multivariate analysis of assessable predictors before ablation revealed that B2B P-wave index, along with heart failure history and a history of previous stroke or transient ischemic attack, are independent predicting factors of atrial fibrillation recurrence. Further studies are needed to assess the predictive value of the B2B index with greater accuracy and evaluate a possible relationship with atrial substrate analysis.

Perceval S, sutureless aortic valve: cost-consequence analysis

INTRODUCTION

Sutureless aortic valve prostheses have the potential of shortening ischemic time.

AIM

We conducted the present study to assess the clinical and economic impact of the biological, sutureless, self-expanding Perceval S valve since the effect of shortened operative times on hospital costs remains unclear.

MATERIAL AND METHODS

This is a retrospective analysis. From January 2018 to January 2019, 29 patients underwent isolated aortic valve replacement with the Crown PRT bioprosthetic Aortic Valve, whereas 35 patients underwent aortic valve replacement with Perceval S (auto-expanded, sutureless, bioprosthesis). Preoperative data, hospital outcome, and health care resource consumption were compared, using χ² and t-test.

RESULTS

Aortic cross-clamp, cardiopulmonary bypass, and operation times were significantly shorter in the Perceval S group (p < 0.001). Patients in the sutureless group required blood transfusion less frequently (p = 0.03) and had a shorter intensive care unit (ICU) stay (p = 0.01). Hospital stay (p = 0.57) and pacemaker implantation were similar between groups. The reduction of aortic cross-clamp, extracorporeal circulation times, and ICU stay resulted in reduced resource consumption in the sutureless group.

CONCLUSIONS

The use of the Perceval S valve is clinically safe and effective. A shorter procedural time in the sutureless group is associated with better clinical outcomes and reduced hospital costs.

Ultrasound-guided versus anatomic landmark-guided vascular access in cardiac electrophysiology procedures: A systematic review and meta-analysis

Introduction

Methods

Results

Conclusion