Endoscopic Biliary Darinage (EBD) versus Percutaneous Transhepatic Biliary Drainage (PTBD) for biliary drainage in patients with Perihilar Cholangiocarcinoma (PCCA): A systematic review and meta-analysis

Abstract Biliary drainage for Perihilar Cholangiocarcinoma (PCCA) can be performed either by endoscopic retrograde cholangiopancreatography or Percutaneous Transhepatic Biliary Drainage (PTBD). To date there is no consensus about which method is preferred. Taking that into account, the aim of this study is to compare Endoscopic Biliary Drainage (EBD) versus percutaneous transhepatic biliary drainage in patients with perihilar cholangiocarcinoma through a systematic review and metanalysis. A comprehensive search of multiple electronic databases was performed. Evaluated outcomes included technical success, clinical success, post drainage complications (cholangitis, pancreatitis, bleeding, and major complications), crossover, hospital length stay, and seeding metastases. Data extracted from the studies were used to calculate Mean Differences (MD). Seventeen studies were included, with a total of 2284 patients (EBD = 1239, PTBD = 1045). Considering resectable PCCA, the PTBD group demonstrated lower rates of crossover (RD = 0.29; 95% CI 0.07-0.51; p = 0.009 I2 = 90%), post-drainage complications (RD = 0.20; 95% CI 0.06-0.33; p < 0.0001; I2 = 78%), and post-drainage pancreatitis (RD = 0.10; 95% CI 0.05-0.16; p < 0.0001; I2 = 64%). The EBD group presented reduced length of hospital stay (RD = -2.89; 95% CI -3.35 - -2,43; p < 0.00001; I2 = 42%). Considering palliative PCCA, the PTBD group demonstrated a higher clinical success (RD = -0.19; 95% CI -0.27 - -0.11; p < 0.00001; I2 = 0%) and less post-drainage cholangitis (RD = 0.08; 95% CI 0.01-0.15; p = 0.02; I2 = 48%) when compared to the EBD group. There was no statistical difference between the groups regarding: technical success, post-drainage bleeding, major post-drainage complications, and seeding metastases.

Eficácia da aplicação endoscópica tópica de mitomicina C em estenoses esofágicas cáusticas na população pediátrica: uma revisão sistemática e meta-análise de ensaios clínicos randomizados / Efficacy of endoscopic topical mitomycin c application in caustic esophageal strictures in the pediatric population: a systematic review and meta-analysis of randomized controlled trials

ABSTRACT BACKGROUND: Caustic ingestion and development of esophageal strictures are recognized major public health problems in childhood. Different therapeutic methods have been proposed in the management of such strictures. OBJECTIVE: To evaluate efficacy and risk of endoscopic topical application of mitomycin C in the treatment of caustic esophageal strictures. METHODS: We searched MEDLINE, EMBASE, Central Cochrane, and LILACS databases. The outcomes evaluated were dysphagia resolution rate, number of dilations performed in resolved cases, and the number of dilations performed in all patients. RESULTS: Three randomized clinical trials were included for final analysis with a total of 190 patients. Topical mitomycin C application group showed a significant increase in dysphagia resolution rate, corresponding to a 42% higher dysphagia resolution as compared to endoscopic dilation alone, with statistical significance between the two groups (RD: 0.42 - [CI: 0.29-0.56]; P-value <0.00001). The mean number of dilations performed in resolved cases were significantly less in the topical mitomycin C application group, compared to endoscopic dilations alone, with statistical significance between the two groups (MD: 2.84 [CI: 1.98-3.69]; P-value <0.00001). When comparing the number of dilations in all patients, there was no statistical difference between the two groups (MD: 1.46 [CI: -1.53-4.44]; P-value =0.34). CONCLUSION: Application of topical mitomycin C with endoscopic dilations in caustic esophageal strictures was more effective in dysphagia resolution than endoscopic therapy alone in the pediatric population. Moreover, topical mitomycin C application also reduced the number of dilation sessions needed to alleviate dysphagia without rising morbidity.

RESUMO CONTEXTO: A ingestão de soda cáustica e o desenvolvimento de estenoses esofágicas são reconhecidos como importantes problemas de saúde pública na infância. Diferentes métodos terapêuticos têm sido propostos no manejo dessas estenoses. OBJETIVO: Avaliar a eficácia e o risco da aplicação endoscópica tópica de mitomicina C no tratamento de estenoses esofágicas cáusticas. MÉTODOS: Buscamos as bases de dados MEDLINE, EMBASE, Central Cochrane e LILACS. Os desfechos avaliados foram taxa de resolução da disfagia, número de dilatações realizadas nos casos resolvidos e número de dilatações realizadas em todos os pacientes. RESULTADOS: Três ensaios clínicos randomizados foram incluídos para análise final com um total de 190 pacientes. O grupo de aplicação de mitomicina C tópica apresentou aumento significativo na taxa de resolução da disfagia, correspondendo a uma resolução da disfagia 42% maior em comparação à dilatação endoscópica isolada, com significância estatística entre os dois grupos (RD: 0,42 - [IC: 0,29-0,56]; P-valor <0,00001). O número médio de dilatações realizadas em casos resolvidos foi significativamente menor no grupo de aplicação tópica de mitomicina C, em comparação com as dilatações endoscópicas isoladas, com significância estatística entre os dois grupos (MD: 2,84 [IC: 1,98-3,69]; P-valor <0,00001). Ao comparar o número de dilatações em todos os pacientes, não houve diferença estatística entre os dois grupos (MD: 1,46 [IC: -1,53-4,44]; valor de P=0,34). CONCLUSÃO: A aplicação de mitomicina C tópica com dilatações endoscópicas em estenoses esofágicas cáusticas foi mais eficaz na resolução da disfagia do que a terapia endoscópica isolada na população pediátrica. Além disso, a aplicação tópica de mitomicina C também reduziu o número de sessões de dilatação necessárias para aliviar a disfagia sem aumentar a morbidade.

Acurácia diagnóstica de teste quantitativo imunoquímico fecal com uma amostra ou com duas amostras para detectar neoplasia intestinal / Diagnostic accuracy of one sample or two samples quantitative fecal immunochemical tests for intestinal neoplasia detection

ABSTRACT BACKGROUND: Rectal bleeding is the most important symptom of intestinal neoplasia; thus, tests of occult blood detection in stools are widely used for pre neoplastic lesions and colorectal cancer (CRC) screening. OBJECTIVE: Evaluate the accuracy of OC-Sensor quantitative test (Eiken Chemical, Tokyo, Japan) at cut-off 10 µg Hb/g feces (50 ng/mL) in a cohort of subjects that had to undergo diagnostic colonoscopy, and if more than one sample collected in consecutive days would improve the diagnostic accuracy of the test. METHODS: Patients (mean age 56.3±9.7 years) that underwent colonoscopy prospectively randomly received one (1-sample FIT, FIT 1) or two (2-sample FIT, FIT 2) collection tubes. They collected the stool sample before starting colonoscopy preparation. Samples were analyzed by the OC-Auto Micro 80 (Eiken Chemical, Tokyo, Japan). The performance of FIT 1 and FIT 2 were compared to the colonoscopy findings. RESULTS: Among 289 patients, CRC was diagnosed in 14 (4.8%), advanced adenoma in 37 (12.8%), early adenoma in 71 (24.6%) and no abnormalities in 141 (48.8%). For FIT 1, the sensitivity for CRC was 83.3% (95%CI 36.5-99.1%), for advanced adenoma was 24% (95%CI 10.1-45.5%), with specificity of 86.9% (95%CI 77.3-92.9%). For FIT 2, the sensitivity for CRC was 75% (95%CI 35.6-95.5%), for advanced adenoma was 50% (95%CI 22.3-77.7%), with specificity of 92.9% (95%CI 82.2-97.7%). The positive likelihood ratios were 1.8 (95%CI 0.7-4.4 for FIT 1) and 7.1 (95%CI 2.4-21.4 for FIT 2) for advanced adenoma, and 6.4 (95%CI 3.3-12.3, for FIT 1) and 10.7 (95%CI 3.8-29.8, for FIT 2) for CRC. The negative likelihood ratio were 0.9 (95%CI 0.7-1, for FIT 1) and 0.5 (95%CI 0.3-0.9, for FIT 2) for advanced adenoma, and 0.2 (0.03-1.1, for FIT 1) and 0.3 (0.08-0.9, for FIT 2) for CRC. The differences between FIT 1 and FIT 2 performances were not significant. However, the comparison of the levels of hemoglobin in feces of patients of FIT 1 and FIT 2 showed that the differences between no polyp group and advanced adenoma and CRC were significant. CONCLUSION: The accuracy of OCR Sensor with 10 µg Hb/g feces cut-off was comparable to other reports and two-sample collection improved the detection rate of advanced adenoma, a pre neoplastic condition to prevent CRC incidence.

RESUMO CONTEXTO: Sangramento retal é o sintoma mais importante de neoplasia intestinal; portanto, testes para detecção de sangue oculto nas fezes são amplamente usados para rastreamento de lesões pré-neoplásicas e de câncer colorretal (CCR). OBJETIVO: Avaliar a acurácia do teste quantitativo OC-Sensor (Eiken Chemical, Tokyo, Japan) com o valor de corte de 10 µg Hb/g fezes (50 ng/mL) numa coorte de indivíduos que se submeteram à colonoscopia diagnóstica, e se mais de uma amostra coletada em dias consecutivos melhoraria a acurácia diagnóstica do teste. MÉTODOS: Pacientes (idade média 56,3±9,7 anos) que se submeteram à colonoscopia prospectivamente, randomicamente, receberam tubos de coleta: um (1-amostra FIT, FIT 1), ou dois (2-amostra FIT, FIT 2). Eles coletaram as amostras de fezes antes de iniciar o preparo da colonoscopia. As amostras foram analisadas pelo OC-Auto Micro 80 (Eiken Chemical, Tokyo, Japan). As performances do FIT 1 e do FIT 2 foram comparadas com os achados da colonoscopia. RESULTADOS: Entre 289 pacientes, CCR foi diagnosticado em 14 (4,8%), adenoma avançado em 37 (12,8%), adenoma precoce em 71 (24,6%) e sem anormalidades em 141 (48,8%). Para FIT 1, a sensibilidade para CCR foi 83,3% (95%IC 36,5-99,1%), para adenoma avançado foi 24% (95%IC 10,1-45,5%), com especificidade de 86,9% (95%IC 77,3-92,9%). Para FIT 2, a sensibilidade para CCR foi 75% (95%IC 35,6-95,5%), para adenoma avançado foi 50% (95%IC 22,3-77,7%), com especificidade de 92,9% (95%IC 82,2-97,7%). A razão de verossimilhança positiva foi 1,8 (95%IC 0,7-4,4 para FIT 1) e 7,1 (95%IC 2,4-21,4 para FIT 2) para adenoma avançado, e 6,4 (95%IC 3,3-12,3, para FIT 1) e 10,7 (95%IC 3,8-29,8, para FIT 2) para CCR. A razão de verossimilhança negativa foi 0,9 (95%IC 0,7-1, para FIT 1) e 0,5 (95%IC 0,3-0,9, para FIT 2) para adenoma avançado, e 0,2 (0,03-1,1, para FIT 1) e 0,3 (0,08-0,9, para FIT 2) para CCR. As diferenças de performance entre FIT 1 e FIT 2 não foram significantes. Entretanto, a comparação dos níveis de hemoglobina nas fezes dos pacientes de FIT 1 e FIT 2 mostraram que as diferenças entre sem pólipo e adenoma avançado e CCR foram significantes. CONCLUSÃO: A acurácia do OCR Sensor com valor de corte de 10 µg Hb/g de fezes foi comparável a outras publicações e a coleta de duas amostras melhorou a taxa de detecção de adenoma avançado, lesão pré-neoplásica, para prevenir CCR.

Acurácia diagnóstica do painel gástrico para gastrite atrófica em brasileiros e o efeito dos inibidores de bomba de prótons / Diagnostic accuracy of gastropanel® for atrophic gastritis in brazilian subjects and the effect of proton pump inhibitors

ABSTRACT BACKGROUND: It has been proposed that the combination of gastrin-17 (G-17), pepsinogens I and II (PGI and PGII), and anti-Helicobacter pylori (H. pylori) antibodies (GastroPanel®, BIOHIT HealthCare, Helsinki, Finland) could serve as biomarkers of atrophic gastritis. OBJECTIVE: This study aimed to ensure the diagnostic accuracy of GastroPanel® and evaluate the effect of proton pump inhibitors (PPIs) on these biomarkers. METHODS: Dyspeptic patients who underwent gastrointestinal endoscopy were enrolled in the present study. Histological findings, which were the gold standard to stratify groups, were as follows: no atrophy (controls); antrum atrophy; corpus atrophy; multifocal atrophy; and neoplasia. G-17, PGI, PGII, and anti-H. pylori immunoglobulin (Ig)G antibodies were assayed using commercially available kits. The ratio of PGI/PGII was calculated. RESULTS: Among 308 patients, 159 (51.6%) were PPI users. The overall prevalence of atrophy was 43.8% (n=135). Ninety-two (29.9%) patients were H. pylori positive according to anti-H. pylori IgG levels. G-17 levels were not low in those with antrum atrophy but were high in those with corpus and multifocal atrophies. PGI levels were significantly lower in those with corpus and multifocal atrophies. The sensitivity of PGI <30 µg/L to detect corpus atrophy was 50% (95% CI 27.8-72.1%), with a specificity of 93.2% (95% CI 84.3-97.5%), a positive likelihood ratio of 7.4 (95% CI 2.9-19.2), and a negative likelihood ratio of 0.5 (95% CI 0.3-0.8). A small number of subjects (n=6) exhibited moderate to intense atrophy (4%), among whom 66.7% exhibited decreased PGI levels. PPI significantly increased the levels of G-17 and PGI, except in those with corpus and multifocal atrophies, in whom PGI levels were not increased by PPIs. CONCLUSION: GastroPanel® (Gastrin-17, PGI, and PGI/PGII ratio) did not demonstrate high sensitivity for detecting gastric atrophy.

RESUMO CONTEXTO: Foi proposto que a combinação de gastrina 17 (G-17), pepsinogênios I e II (PGI e PGII), e anticorpos anti-Helicobacter pylori (H. pylori) (GastroPanel®, BIOHIT HealthCare), poderiam indicar gastrite atrófica. OBJETIVO: Portanto, o objetivo foi averiguar a acurácia diagnóstica do painel gástrico e avaliar o efeito dos inibidores de bomba de prótons (IBP) nesses marcadores. MÉTODOS: Pacientes dispépticos que se submeteram à endoscopia gastrointestinal entraram no estudo. Os achados histológicos foram o padrão ouro para estratificar os grupos: sem atrofia (controles), atrofia de antro, atrofia de corpo, atrofia multifocal e neoplasia. G-17, PGI, PGII, e anticorpos IgG anti-H. pylori foram determinados por kits comerciais. A razão PGI/PGII foi calculada. RESULTADOS: Entre 308 pacientes que foram incluídos, 159 estavam usando IBP (51,6%). A prevalência de atrofia foi de 43,8% (135 pacientes). H. pylori foi positivo em 92 (29,9%) pacientes por IgG anti-H. pylori. G-17 não estava diminuída na atrofia do antro, mas estava elevada nas atrofias do corpo e multifocal. PGI estava significantemente menor nas atrofias de corpo e multifocal. A sensibilidade da PGI <30 µg/L de indicar atrofia do corpo foi 50% (95%IC 27,8-72,1%) com especificidade de 93,2% (95%IC 84,3-97,5%), razão de verossimilhança positiva de 7,4 (95%IC 2,9-19,2) e razão de verossimilhança negativa de 0,5 (95%IC 0,3-0,8). O número de indivíduos com atrofia moderada para intensa foi pequeno (n=6;4%), dos quais 66,7% tinham diminuição dos níveis de PGI. IBP significantemente aumentou os níveis de G-17 e PGI, exceto nas atrofias de corpo e multifocal que não apresentaram aumento de PGI. CONCLUSÃO: O painel gástrico não teve alta sensibilidade de indicar gastrite atrófica.

Miotomia peroral (POEM) ou cirúrgica para o tratamento da acalasia: revisão sistemática e metanálise / Peroral (poem) or surgical myotomy for the treatment of achalasia: a systematic review and meta-analysis

ABSTRACT BACKGROUND: Achalasia is a neurodegenerative motility esophageal disorder characterized by failure of lower esophageal sphincter relaxation. The conventional treatment option for achalasia has been laparoscopic Heller myotomy (LHM). However, in 2010, Inoue et al. described peroral endoscopic myotomy (POEM), a minimally invasive procedure, as an alternative therapy. To date, some studies with small sample sizes have aimed to compare outcomes of LHM vs POEM. OBJECTIVE: Thus, the aim of this study is to perform a systematic review and meta-analysis to better evaluate the efficacy and safety of these two techniques. METHODS: Individualized search strategies were developed from inception through April 2019 in accordance with PRISMA guidelines. Variables analyzed included operative time, overall adverse events rate, post-procedure gastroesophageal reflux disease (GERD), hospitalization length, post-procedure pain score, and Eckardt Score reduction. RESULTS: Twelve cohort trials were selected, consisting of 893 patients (359 in POEM group and 534 in LHM.) No randomized clinical trials were available. There was no difference in operative time (MD= -10,26, 95% CI (-5,6 to 8,2), P<0.001) or Post-Operative Gastroesophageal Reflux (RD: -0.00, 95%CI: (-0.09, 0.09), I2: 0%). There was decreased length of hospital stay for POEM (MD: -0.6, 95% CI (-1.11, -0.09), P=0.02), and an increased mean reduction in Eckardt score in POEM patients (MD = -0.257, 95% CI: (-0.512 to -0.002), P=0.048), with similar rates of adverse events. CONCLUSION: POEM demonstrated similar results compared to laparoscopic Heller myotomy with regards to improvement of dysphagia, post-procedure reflux, and surgical time, with the benefit of shorter length of hospital stay. Therefore, POEM can be considered an option for patients with achalasia.

RESUMO CONTEXTO: A acalasia é um distúrbio esofágico da motilidade neurodegenerativa caracterizado por falha no relaxamento do esfíncter esofágico inferior (EEI). A opção de tratamento convencional para acalasia tem sido a miotomia laparoscópica de Heller (LHM). No entanto, em 2010, Inoue et al. descreveram a miotomia endoscópica peroral (POEM), um procedimento minimamente invasivo, como uma terapia alternativa. Até o momento, poucos estudos com amostras pequenas tiveram como objetivo comparar os resultados do LHM versus POEM. OBJETIVO: Assim, o objetivo deste estudo é realizar uma revisão sistemática e metanálise para melhor avaliar a eficácia e segurança dessas duas técnicas. MÉTODOS: Estratégias de busca individualizadas foram desenvolvidas desde o início até abril de 2019, de acordo com as diretrizes do PRISMA. As variáveis analisadas incluíram tempo operatório, taxa global de eventos adversos, doença de refluxo gastroesofágico (DRGE) pós-procedimento, tempo de internação, escore de dor pós-procedimento e redução do escore de Eckardt. RESULTADOS: Doze estudos de coorte foram selecionados, consistindo em 893 pacientes (359 no grupo POEM e 524 no LHM). Nenhum ensaio clínico randomizado estava disponível. Não houve diferença no tempo operatório (MD = -10,26, IC 95% (-5,6 a 8,2), P<0,001) ou refluxo gastroesofágico pós-operatório (RD: -0,00, 95% IC: (-0,09, 0,09), I2: 0%). Houve diminuição do tempo de permanência hospitalar para POEM (MD: -0,6, 95% CI (-1,11, -0,09), P=0,02) e um aumento da redução média no escore de Eckardt em pacientes POEM (MD= -0,257, IC95%: (-0,512 a -0,002), P=0,048), com taxas similares de eventos adversos. CONCLUSÃO: O POEM demonstrou resultados semelhantes aos da miotomia a Heller por videolaparoscopia, com melhora da disfagia, do refluxo pós-procedimento e tempo cirúrgico, com o benefício de menor tempo de internação hospitalar. Portanto, o POEM pode ser considerado uma opção para pacientes com acalasia.

Cholangioscopy-guided lithotripsy vs. conventional therapy for complex bile duct stones: a systematic review and meta-analysis / Litotripsia guiada por colangioscopia vs. terapias convencionais no tratamento da litíase biliar complexa: revisão sistemática e metanálise

ABSTRACT Introduction: Endoscopic removal of common bile duct stones has a high success rate ranging from 85% to 95%. Bile duct stones >15 mm are difficult and frequently require lithotripsy. Peroral cholangioscopy (POC) allows lithotripsy with similar success rates. Aim: To determine the efficacy and safety of cholangioscopy-guided lithotripsy used in the treatment of difficult to remove bile duct stones vs. conventional therapy. Methods: Search was based in Medline, Embase, Cochrane Central, Lilacs/Bireme. Studies enrolling patients referred for the removal of difficult bile duct stones via POC were considered eligible. Two analyses were carried out separately, one included randomized controlled trials (RCTs) and another observational studies. Results: Forty-six studies were selected (3 RTC and 43 observational). In the analysis there was no statistical significant difference between successful endoscopic clearance (RD=-0.02 CI: -0.17, 0.12/I²=0%), mean fluoroscopy time (MD=-0.14 CI -1.60, 1.32/I²=21%) and adverse events rates (RD=-0.06 CI: -0.14, 0.02/I²=0%), by contrast, the mean procedure time favored conventional therapy with statistical significance (MD=27.89 CI: 16.68, 39.10/I²=0%). In observational studies, the successful endoscopic clearance rate was 88.29% (CI95: 86.9%-90.7%), the first session successful endoscopic clearance rate was 72.7 % (CI95: 69.9%-75.3%), the mean procedure time was 47.50±6 min for session and the number of sessions to clear bile duct was 1.5±0.18. The adverse event rate was 8.7% (CI95: 7%-10.9%). Conclusions: For complex common bile duct stones, cholangioscopy-guided lithotripsy has a success rate that is similar to traditional ERCP techniques in terms of therapeutic success, adverse event rate and means fluoroscopy time. Conventional ERCP methods have a shorter mean procedure time.

RESUMO Introdução: A remoção endoscópica das litíases do ducto biliar comum tem alta taxa de sucesso variando de 85% a 95%. Litíases do ducto biliar >15 mm são difíceis e frequentemente requerem litotripsia. A colangioscopia peroral permite litotripsia com taxas de sucesso semelhantes. Objetivo: Determinar a eficácia e segurança da litotripsia guiada por colangioscopia no tratamento de litíases biliares difíceis em comparação à terapias convencionais guiadas por colangiopancreatografia retrógrada endoscópica. Método: Pesquisa na Medline, Embase, Cochrane Central, Lilacs/Bireme de estudos avaliando a eficácia da colangioscopia na remoção de cálculos biliares difíceis. Duas análises foram realizadas separadamente, uma incluiu ensaios clínicos randomizados (ECR) e outros estudos observacionais. Resultados: Quarenta e seis estudos foram selecionados (3 ECR e 43 observacionais). Na análise, não houve diferença estatisticamente significativa na taxa de extração litiásica total (RD=-0,02 IC: -0,17,0,12/I²=0%), tempo médio de fluoroscopia (MD=-0,14 CI -1,60, 1,32/I²=21%) e na taxa de eventos adversos (RD=-0,06 IC: -0,14, 0,02/I²=0%).Por outro lado, o tempo médio do procedimento favoreceu terapêuticas convencionais guiadas por CPRE com significância estatística (MD=27,89 IC: 16,68, 39,10/I²=0%). Nos estudos observacionais, a taxa do tratamento completo por endoscopia foi de 88,29% (IC95: 86,9% a 90,7%), a taxa de sucesso na primeira sessão foi de 72,7% (IC95: 69,9% a 75,3%), o tempo médio do procedimento foi de 47,50±6 min por sessão e o número de procedimentos necessários para remoção total da litíase foi de 1,5±0,18. A taxa de eventos adversos foi de 8,7% (IC95: 7% a 10,9%), com 0,5% considerado como severo. Conclusão: Para litíases biliares difíceis, a litotripsia guiada por colangioscopia tem taxa de sucesso semelhante às terapêuticas convencionais guiadas CPRE em termos de sucesso terapêutico, taxa de eventos adversos e tempo de fluoroscopia. As terapêuticas convencionais guiadas por CPRE têm tempo médio de procedimento menor.

Gastrointestinal manifestations and associated health outcomes of COVID-19: a brazilian experience from the largest south american public hospital

OBJECTIVES: Brazil has rapidly developed the second-highest number of COVID-19 cases in the world. As such, proper symptom identification, including gastrointestinal manifestations, and relationship to health outcomes remains key. We aimed to assess the prevalence and impact of gastrointestinal symptoms associated with COVID-19 in a large quaternary referral center in South America. METHODS: This was a single-center cohort study in a COVID-19 specific hospital in São Paulo, Brazil. Consecutive adult patients with laboratory confirmed SARS-CoV-2 were included. Baseline patient history, presenting symptoms, laboratory results, and clinically relevant outcomes were recorded. Regression analyses were performed to determine significant predictors of the gastrointestinal manifestations of COVID-19 and hospitalization outcomes. RESULTS: Four-hundred patients with COVID-19 were included. Of these, 33.25% of patients reported ≥1 gastrointestinal symptom. Diarrhea was the most common gastrointestinal symptom (17.25%). Patients with gastrointestinal symptoms had higher rates of concomitant constitutional symptoms, notably fatigue and myalgia (p<0.05). Gastrointestinal symptoms were also more prevalent among patients on chronic immunosuppressants, ACE/ARB medications, and patient with chronic kidney disease (p<0.05). Laboratory results, length of hospitalization, ICU admission, ICU length of stay, need for mechanical ventilation, vasopressor support, and in-hospital mortality did not differ based upon gastrointestinal symptoms (p>0.05). Regression analyses showed older age [OR 1.04 (95% CI, 1.02-1.06)], male gender [OR 1.94 (95% CI, 1.12-3.36)], and immunosuppression [OR 2.60 (95% CI, 1.20-5.63)], were associated with increased mortality. CONCLUSION: Based upon this Brazilian study, gastrointestinal manifestations of COVID-19 are common but do not appear to impact clinically relevant hospitalization outcomes including the need for ICU admission, mechanical ventilation, or mortality.

Diagnostic characteristics of serological-based COVID-19 testing: a systematic review and meta-analysis

Serologic testing for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) promises to assist in assessing exposure to and confirming the diagnosis of coronavirus disease 2019 (COVID-19), and to provide a roadmap for reopening countries worldwide. Considering this, a proper understanding of serologic-based diagnostic testing characteristics is critical. The aim of this study was to perform a structured systematic review and meta-analysis to evaluate the diagnostic characteristics of serological-based COVID-19 testing. Electronic searches were performed using Medline (PubMed), EMBASE, and Cochrane Library. Full-text observational studies that reported IgG or IgM diagnostic yield and used nucleic acid amplification tests (NAATs) of respiratory tract specimens, as a the reference standard in English language were included. A bivariate model was used to compute pooled sensitivity, specificity, positive/negative likelihood ratio (LR), diagnostic odds ratio (OR), and summary receiver operating characteristic curve (SROC) with corresponding 95% confidence intervals (CIs). Five studies (n=1,166 individual tests) met inclusion criteria. The pooled sensitivity, specificity, and diagnostic accuracy for IgG was 81% [(95% CI, 61-92);I2=95.28], 97% [(95% CI, 78-100);I2=97.80], and 93% (95% CI, 91-95), respectively. The sensitivity, specificity, and accuracy for IgM antibodies was 80% [(95% CI, 57-92);I2=94.63], 96% [(95% CI, 81-99);I2=92.96] and 95% (95% CI, 92-96). This meta-analysis demonstrates suboptimal sensitivity and specificity of serologic-based diagnostic testing for SARS-CoV-2 and suggests that antibody testing alone, in its current form, is unlikely to be an adequate solution to the difficulties posed by COVID-19 and in guiding future policy decisions regarding social distancing and reopening of the economy worldwide.

Approach to endoscopic procedures: a routine protocol from a quaternary university referral center exclusively for coronavirus disease 2019 patients

OBJECTIVES: The present coronavirus disease (COVID-19) pandemic has ushered in an unprecedented era of quality control that has necessitated advanced safety precautions and the need to ensure the adequate protection of healthcare professionals (HCPs). Endoscopy units, endoscopists, and other HCP may be at a significant risk for transmission of the virus. Given the immense burden on the healthcare system and surge in the number of patients with COVID-19, well-designed protocols and recommendations are needed. We aimed to systematically characterize our approach to endoscopic procedures in a quaternary university hospital setting and provide summary protocol recommendations. METHOD: This descriptive study details a COVID-19-specific protocol designed to minimize infection risks to patients and healthcare workers in the endoscopy unit. RESULTS: Our institution, located in São Paulo, Brazil, includes a 900-bed hospital, with a 200-bed-specific intensive care unit exclusively designed for patients with moderate and severe COVID-19. We highlighted recommendations for infection prevention and control during endoscopic procedures, including appropriate triage and screening, outpatient management and procedural recommendations, role and usage of personal protective equipment (PPE), and role and procedural logistics involving COVID-19-positive patients. We also detailed hospital protocols for reprocessing endoscopes and cleaning rooms and also provided recommendations to minimize severe acute respiratory syndrome coronavirus 2 transmission. CONCLUSION: This COVID-19-specific administrative and clinical protocol can be replicated or adapted in multiple institutions and endoscopy units worldwide. Furthermore, the recommendations and summary protocol may improve patient and HCP safety in these trying times.

Segurança e eficácia do uso de cianoacrilato + coil guiado por ultrassom endoscópico versus técnica convencional de cianoacrilato no tratamento de varizes gástricas: um ensaio clínico randomizado / Safety and efficacy of eus-guided coil plus cyanoacrylate versus conventional cyanoacrylate technique in the treatment of gastric varices: a randomized controlled trial

ABSTRACT BACKGROUND: One of the most feared complications with the use of cyanoacrylate for treatment of gastric varices is the occurrence of potentially life-threatening systemic embolism. Thus, endoscopists are turning towards new techniques, including endoscopic coiling, as a potentially safer and more effective treatment option. However, no studies have been performed comparing the two techniques. OBJECTIVE: This study aims to compare the safety and efficacy of endoscopic ultrasound guided coil and cyanoacrylate injection versus the conventional technique of injection of cyanoacrylate alone. DESIGN: A pilot randomized controlled trial. METHODS: Patients randomized into group I were treated with coil and cyanoacrylate, and those in group II with cyanoacrylate alone. Flow within the varix was evaluated immediately after the treatment session and one month following initial treatment. If thrombosis was confirmed, additional follow-up was performed 4 and 10 months following initial treatment. All patients underwent a thoracic computerized tomography scan after the procedure. RESULTS: A total of 32 patients, 16 in each group, were followed for an average of 9.9 months (range 1-26 months). Immediately after the procedure, 6 (37.5%) group-I patients and 8 (50%) group-II patients presented total flow reduction in the treated vessel (P=0.476). After 30 days, 11 (73.3%) group-I patients and 12 (75%) group-II patients were found to have varix thrombosis. In both groups, the majority of patients required only one single session for varix obliteration (73.3% in group I versus 80% in group II). Asymptomatic pulmonary embolism occurred in 4 (25%) group-I patients and 8 (50%) group-II patients (P=0.144). No significant difference between the groups was observed. CONCLUSION: There is no statistical difference between endoscopic ultrasound guided coils plus cyanoacrylate versus conventional cyanoacrylate technique in relation to the incidence of embolism. However, a greater tendency towards embolism was observed in the group treated using the conventional technique. Both techniques have similar efficacy in the obliteration of varices. Given the small sample size of our pilot data, our results are insufficient to prove the clinical benefit of the combined technique, and do not yet justify its use, especially in light of higher cost. Further studies with larger sample size are warranted.

RESUMO CONTEXTO: Uma das complicações mais temidas com o uso de cianoacrilato para tratamento de varizes gástricas é a ocorrência de embolia sistêmica potencialmente fatal. Assim, os endoscopistas estão se aprimorando com novas técnicas, incluindo o uso de coils endoscópico, como uma opção de tratamento potencialmente mais segura e eficaz. No entanto, nenhum estudo foi realizado comparando as duas técnicas. OBJETIVO: Este estudo tem como objetivo comparar a segurança e eficácia da injeção de coil com cianoacrilato guiados por ultrassom endoscópico versus a técnica convencional de injeção de cianoacrilato. DESIGN: Um ensaio piloto controlado aleatoriamente. MÉTODOS: Os pacientes randomizados para o grupo I foram tratados com coil + cianoacrilato e os do grupo II apenas com cianoacrilato. O fluxo dentro da variz foi avaliado imediatamente após a sessão de tratamento e um mês após o tratamento inicial. Se a trombose foi confirmada, o acompanhamento adicional era realizado em 4 e 10 meses após o tratamento inicial. Todos os pacientes foram submetidos a uma tomografia computadorizada torácica após o procedimento. RESULTADOS: Um total de 32 pacientes, 16 em cada grupo, foram acompanhados por uma média de 9,9 meses (variação de 1-26 meses). Imediatamente após o procedimento, 6 (37,5%) pacientes do grupo I e 8 (50%) pacientes do grupo II apresentaram redução total do fluxo no vaso tratado (P=0,476). Após 30 dias, 11 (73,3%) pacientes do grupo I e 12 (75%) pacientes do grupo II apresentaram trombose da variz. Em ambos os grupos, a maioria dos pacientes necessitou de apenas uma única sessão para obliteração da variz (73,3% no grupo I versus 80% no grupo II). Embolia pulmonar assintomática ocorreu em 4 (25%) pacientes do grupo I e em 8 (50%) pacientes no grupo II (P=0,144). Nenhuma diferença significativa entre os grupos foi observada. CONCLUSÃO Apesar de não haver diferença estatística entre os dois grupos em relação à incidência de embolia neste estudo piloto, observou-se maior tendência de embolia no grupo tratado pela técnica convencional.

Revisão sistemática e meta-análise sobre técnicas de polipectomia de pólipos colorretais pequenos e diminutos / Best polypectomy technique for small and diminutive colorectal polyps: a systematic review and meta-analysis

ABSTRACT BACKGROUND: Polypectomy of colorectal polyps is the mainstay of colorectal cancer prevention. Identification of the best polypectomy technique is imperative. OBJECTIVE: This review aims at comparing efficacy of nine different resection methods for small colorectal polyps (<10 mm). METHODS: We searched and selected only randomized controlled trials. Primary outcome was complete resection rates of small polyps by histological eradication. Secondary outcomes were: adverse events, retrieval tissue failures rates and duration of procedure. RESULTS: Eighteen trials including 3215 patients and 5223 polyps were analysed. Overall, cold polypectomy had a significantly shorter time of procedure than hot polypectomy (RD -5.92, 95%CI -9.90 to -1.94, P<0.05), with no statistical difference on complete histological eradication (RD 0.08, 95%CI -0.03 to 0.19, P>0.05). Regarding cold polypectomy techniques, cold snare was found superior to cold forceps on complete and en-bloc resection rates and less time consuming. When comparing endoscopic mucosal resection (EMR) with hot-snare and cold-snare, the latter showed no-inferiority on histological eradication, adverse events or retrieval tissue failure rates. CONCLUSION: Cold polypectomy is the best technique for resection of small colorectal polyps. Among cold methods, dedicated cold snare was found superior on histological eradication. Cold snare endoscopic mucosal resection might be considered an option for polyps from 5 to 9 mm.

RESUMO CONTEXTO: A polipectomia de pólipos colorretais é a base da prevenção do câncer colorretal. A identificação da melhor técnica de polipectomia é imperativa. OBJETIVO: Esta revisão tem como objetivo comparar a eficácia de nove diferentes métodos de ressecção para pólipos colorretais pequenos (<10 mm). MÉTODOS: Pesquisamos e selecionamos apenas ensaios clínicos randomizados. O desfecho primário foi taxas de ressecção completa de pólipos pequenos por confirmação histológica. Os desfechos secundários foram: eventos adversos, taxas de falha de recuperação do espécime e duração do procedimento. RESULTADOS: Dezoito estudos, incluindo 3215 pacientes e 5223 pólipos foram analisados. No geral, a polipectomia a frio teve um tempo de procedimento significativamente menor do que a polipectomia a quente (RD -5,92; IC 95% -9,90 a -1,94; P<0,05), sem diferença estatística na erradicação histológica (RD 0,08; IC 95% -0,03 a 0,19; P>0,05). Em relação às técnicas de polipectomia a frio, a alça fria foi considerada superior ao uso de pinça fria nas taxas de ressecção completa e em bloco, além de um menor tempo de procedimento. Ao comparar a ressecção endoscópica da mucosa utilizando alça quente ou alça fria, esta última mostrou não-inferioridade na erradicação histológica, eventos adversos ou taxas de falha do tecido de recuperação. CONCLUSÃO: A polipectomia a frio mostrou ser a melhor técnica para ressecção de pequenos pólipos colorretais. Entre os métodos frios, a alça fria dedicada foi considerada superior na erradicação histológica. ressecção endoscópica da mucosa com alça fria pode ser considerado uma opção para pólipos de 5 a 9 mm.

A eficácia dos diferentes tratamentos endoscópicos versus métodos sham, farmacológicos ou cirúrgicos para o refluxo gastroesofágico crônico: uma revisão sistemática e meta-análise / The efficacy of the different endoscopic treatments versus sham, pharmacologic or surgical methods for chronic gastroesophageal reflux disease: a systematic review and meta-analysis

ABSTRACT BACKGROUND: Endoscopic antireflux treatments for gastroesophageal reflux disease (GERD) are still evolving, and most of the published studies address symptom relief in the short-term. Objective - We aimed to perform a systematic review and meta-analysis focused on evaluating the efficacy of the different endoscopic procedures. METHODS: Search was restricted to randomized controlled trials (RCTs) on MedLine, Cochrane, SciELO, and EMBASE for patients with chronic GERD (>6 months), over 18 years old and available follow up of at least 3 months. The main outcome was to evaluate the efficacy of the different endoscopic treatments compared to sham, pharmacological or surgical treatment. Efficacy was measured by different subjective and objective outcomes. RESULTS: We analyzed data from 16 RCT, totaling 1085 patients. The efficacy of endoscopic treatments compared to sham and proton pump inhibitors (PPIs) treatment showed a significant difference up to 6 months in favor of endoscopy with no heterogeneity (P<0.00001) (I2: 0%). The subgroup analysis showed a statistically significant difference up to 6 months in favor of endoscopy: endoscopy vs PPI (P<0.00001) (I2: 39%). Endoscopy vs sham (P<0.00001) (I2: 0%). Most subjective and objective outcomes were statistically significant in favor of endoscopy up to 6 and 12 months follow up. CONCLUSION: This systematic review and meta-analysis shows a good short-term efficacy in favor of endoscopic procedures when comparing them to a sham and pharmacological or surgical treatment. Data on long-term follow up is lacking and this should be explored in future studies.

RESUMO CONTEXTO: Os tratamentos endoscópicos para a doença do refluxo gastroesofágico (DRGE) ainda estão em evolução e a maioria dos estudos publicados abordam o alívio dos sintomas em curto prazo. OBJETIVO: Pretendemos realizar uma revisão sistemática e meta-análise focada na avaliação da eficácia dos diferentes procedimentos endoscópicos. MÉTODOS: A pesquisa foi restrita a ensaios clínicos randomizados em MedLine, Cochrane, SciELO e EMBASE para pacientes com DRGE crônica (>6 meses), com mais de 18 anos e acompanhamento disponível por pelo menos 3 meses. O principal desfecho foi avaliar a eficácia dos diferentes tratamentos endoscópicos em comparação com o tratamento sham, farmacológico ou cirúrgico. A eficácia foi medida por diferentes resultados subjetivos e objetivos. RESULTADOS: Analisamos dados de 16 ensaios clínicos randomizados, totalizando 1085 pacientes. A eficácia dos tratamentos endoscópicos em comparação com o tratamento com sham e inibidores da bomba de prótons mostrou uma diferença significativa até 6 meses a favor da endoscopia sem heterogeneidade (P<0,00001) (I2: 0%). A análise do subgrupo mostrou diferença estatisticamente significativa até 6 meses a favor da endoscopia: endoscopia vs inibidores da bomba de prótons (P<0,00001) (I2: 39%). Endoscopia vs sham (P<0,00001) (I2: 0%). A maioria dos resultados subjetivos e objetivos foram estatisticamente significativos em favor da endoscopia até 6 e 12 meses de acompanhamento. CONCLUSÃO: Esta revisão sistemática e meta-análise mostrou uma boa eficácia a curto prazo em favor dos procedimentos endoscópicos ao compará-los a tratamento sham, farmacológico ou cirúrgico. Não existem dados sobre o acompanhamento a longo prazo e isso deve ser explorado em estudos futuros.

A aplicação da profundidade de dissecção da submucosa gástrica na avaliação do aprendizado em ESD: um estudo experimental / Usefulness of gastric submucosal dissection depth to evaluate skill acquirement in short term training courses in esd: an experimental study

ABSTRACT BACKGROUND: Endoscopic submucosal dissection (ESD) is a complex endoscopic procedure, with high rates of adverse events and technical difficulties. To overcome that problem, many training centers published the importance of animal models for skill acquirement in ESD. However, no study has used the submucosal dissection depth (DSUB) as a parameter to evaluate the learning curve in ESD, which might be a relevant factor since an optimal resection plane is important to achieve a curative resection and avoid intraoperative complications. OBJECTIVE: This study aimed to assess ESD skill acquirement after short-term training sessions by evaluating the submucosal dissection depth (DSUB) and the association with adverse events. METHODS: This experimental study included 25 experienced endoscopists in therapeuthic procedures (>5years) and 75 specimens resected by ESD (three resections / endoscopist). Learning parameters (resection time, size, en bloc resection rate, bleeding, perforation and submucosal dissection depth) were prospectively evaluated. The percentages of DSUB of all specimens resected were calculated. RESULTS: All specimens were resected from the gastric body (n=75). The mean size of the resected specimens was 23.97±7.2 mm. The number of adverse events, including bleeding, perforation, and death, were 17 (22.67%), 3 (4%), and 0 cases, respectively. The average mean time by the third dissection decreased from 28.44±9.73 to 18.72±8.81 min (P<0.001). The proportion of DSUB in the bleeding and non-bleeding group were respectively 37.97%±21.13% and 68.66%±23.99%, indicating a significant association between DSUB and bleeding incidence (P<0.001). The ROC curve analysis indicated a cut-off point of 61% (sensitivity, 64%; specificity, 94%) of submucosal dissection depth associated with bleeding. Therefore, when ESD was performed at a depth of >61% of the submucosal layer, the risk for bleeding during the procedure decreased (PPV, 0.97; 95% CI, 0.85-0.99). CONCLUSION: Improvement in the learning curve in ESD and a better cognitive ability were seen by the third dissection in these short term training courses. And a significant association between DSUB and the risk of bleeding.

RESUMO CONTEXTO: A técnica de ESD (Endoscopic Submucosal Dissection) é um procedimento endoscópico de grande complexidade, com alto índice de complicações e dificuldades técnicas. Para superar este problema, muitos centros de treinamento em endoscopia vêm publicando a aplicabilidade dos modelos animais para a aquisição de competência em ESD. Entretanto, a profundidade de ressecção nunca foi utilizada como parâmetro de aprendizagem, o que pode ser um fator relevante a ser ensinado, dado que atingir o plano de dissecção ideal é de suma importância para uma ressecção curativa e na prevenção de complicações intraoperatórias. OBJETIVO: Analisar o aprendizado em ESD em treinamentos de curta duração através da avaliação da profundidade de submucosa ressecada; e sua associação com complicações. MÉTODOS: Estudo experimental; incluídos 25 endoscopistas com experiência em procedimentos terapêuticos (> 5anos) e 75 peças ressecadas por ESD sendo uma média de três resseções por endoscopista. Os parâmetros de aprendizagem (tempo de ressecção, tamanho, taxa de ressecção em bloco, sangramento, perfuração e análise histológica da camada submucosa) foram prospectivamente avaliados. A percentagem de profundidade de submucosa ressecada foi calculada. RESULTADOS: Todas as ressecções foram realizadas no corpo gástrico (n=75). O tamanho médio das peças ressecadas foi de 23,97±7,2 mm. O número de complicações como sangramento, perfuração e morte foram respectivamente, 17 (22,67%), 3 (4%) e 0 casos. Na terceira dissecção, tempo médio do procedimento diminuiu de 28,44±9,73 para 18,72±8,81 minutos (P<0,001). O grupo que teve sangramento durante o procedimento ressecou 37,97%±21,13% da camada submucosa e o grupo sem sangramento ressecou 68,66%±23,99%, demonstrando uma associação significante entre a profundidade de dissecção submucosa e a incidência de sangramento (P<0,001). De acordo com a análise de curva ROC, o valor de corte da profundidade de submucosa ressecada para a ocorrência de sangramento é de 61% (64% sensibilidade, 94% especificidade), logo quando o ESD é realizado em uma profundidade maior do que 61% da camada submucosa o risco de sangramento durante o procedimento diminui (VPP=0,97; IC95%:0,85-0,99). CONCLUSÃO: O modelo de treinamento de curta duração possibilitou um aprendizado da técnica de ESD mostrando uma melhora cognitiva dos alunos já na terceira dissecção. Existe uma associação significativa entre a profundidade de ressecção da submucosa com o risco de sangramento.

A comparison of the efficiency of 22G versus 25G needles in EUS-FNA for solid pancreatic mass assessment: A systematic review and meta-analysis

Our aim in this study was to compare the efficiency of 25G versus 22G needles in diagnosing solid pancreatic lesions by EUS-FNA. We performed a systematic review and meta-analysis. Studies were identified in five databases using an extensive search strategy. Only randomized trials comparing 22G and 25G needles were included. The results were analyzed by fixed and random effects. A total of 504 studies were found in the search, among which 4 randomized studies were selected for inclusion in the analysis. A total of 462 patients were evaluated (233: 25G needle/229: 22G needle). The diagnostic sensitivity was 93% for the 25G needle and 91% for the 22G needle. The specificity of the 25G needle was 87%, and that of the 22G needle was 83%. The positive likelihood ratio was 4.57 for the 25G needle and 4.26 for the 22G needle. The area under the sROC curve for the 25G needle was 0.9705, and it was 0.9795 for the 22G needle, with no statistically significant difference between them (p=0.497). Based on randomized studies, this meta-analysis did not demonstrate a significant difference between the 22G and 25G needles used during EUS-FNA in the diagnosis of solid pancreatic lesions.