Accurate and safe diagnosis and treatment of neoplastic biliary lesions using a novel 9F and 11F digital single-operator cholangioscope.

Background and study aims Digital single-operator cholangioscopy (DSOC) allows the diagnosis of biliary duct disorders and treatment for complicated stones. However, these technologies have limitations such as the size of the probe and working channel, excessive cost, and low image resolution. Recently, a novel DSOC system (eyeMAX, Micro-Tech, Nanjing, China) was developed to address these limitations. We aimed to evaluate the usefulness and safety of a novel 9F and 11F DSOC system in terms of neoplastic diagnostic accuracy based on visual examination, ability to evaluate tumor extension and to achieve complete biliary stone clearance, and procedure-related adverse events (AEs). Patients and methods Data from ≥ 18-year-old patients who underwent DSOC from July 2021 to April 2022 were retrospectively recovered and divided into a diagnostic and a therapeutic cohort. Results A total of 80 patients were included. In the diagnostic cohort (n = 49/80), neovascularity was identified in 26 of 49 patients (46.9%). Biopsy was performed in 65.3% patients with adequate tissue sample obtained in 96.8% of cases. Biopsy confirmed neoplasia in 23 of 32 cases. DSOC visual impression achieved 91.6% sensitivity and 87.5% specificity in diagnosing neoplasms. In the therapeutic cohort (n = 43/80), 26 of 43 patients required lithotripsy alone. Total stone removal was achieved in 71% patients in the first session. Neither early nor late AEs were documented in either the diagnostic or therapeutic cohort. Conclusions The novel DSOC device has excellent diagnostic accuracy in distinguishing neoplastic biliary lesions as well as therapeutic benefits in the context of total stone removal, with no documented AEs.

Individual variation of tentorial notch morphometry in a series of neurocritical patients / Variación individual de la morfometría de la hendidura tentorial en una serie de pacientes neurocríticos

Background: Cadaveric studies on humans have shown anatomical variabilities in the morphometric characteristics of the tentorial notch. These anatomical variations could influence the worsening of neurocritical patients. Objectives: 1) To investigate the morphometric characteristics of the tentorial notch in neurocritical patients using computed tomography (CT); 2) To investigate the correlation between tentorial notch measurements by CT and by magnetic resonance imaging (MRI); and 3) To analyze the individual variability of the tentorial notch anatomy seen in neurocritical patients. Methods: Prospective series of neurocritical patients was examined. An imaging protocol for measurements was designed for CT and MRI. The level of the agreement of the measurements from CT and MR images was established. According to the measurements found, patients were divided into different types of tentorial notch. Results: We studied 34 neurocritical patients by CT and MRI. Measurements of the tentorial notch via CT and MRI showed significant agreement: concordance correlation coefficient of 0.96 for notch length and 0.85 for maximum width of tentorial notch. Classification of tentorial notch measurements according to the criteria established by Adler and Milhorat, we found the following: 15 patients (58%) corresponded to a "short" subtype; 7 (21%) to "small"; 3 (9%) to "narrow"; 2 (6%) to "wide"; 2 (6%) to "large"; 1 (3%) to "long"; and 4 (12%) to "typical". Conclusions: The anatomical variability of the tentorial notch could be detected in vivo by means of CT scan and MRI. Good agreement between the measurements made using these two imaging methods was found.

Antecedentes: Estudios cadavéricos en humanos han mostrado variabilidad anatómica en las características morfométricas de la hendidura tentorial (HT). Estas variaciones anatómicas podrían influir en el neurodeterioro agudo de los pacientes neurocríticos. Objetivos: 1) Investigar las características morfométricas de la HT en pacientes neurocríticos mediante tomografía computarizada (TC); 2) Investigar la correlación de las mediciones de la HT realizadas por TC y resonancia magnética (RM); 3) Analizar la variabilidad individual de la anatomía de la HT observada en pacientes neurocríticos. Métodos: Se examinó una serie prospectiva de pacientes neurocríticos. Se diseñó un protocolo de imágenes para mediciones por TC y RM. Se estableció la concordancia de las mediciones realizadas mediante TC y RM. Según las mediciones encontradas, los pacientes se dividieron en diferentes tipos de HT. Resultados: Estudiamos 34 pacientes neurocríticos por TC y RM. Las mediciones de la HT por TC y RM mostraron una concordancia significativa: coeficiente de correlación de concordancia de 0,96 para la longitud de la HT y 0,85 para el ancho máximo de la HT. Clasificando las medidas de la HT de acuerdo con los criterios establecidos por Adler y Milhorat, encontramos: 15 pacientes (58%) correspondieron al subtipo "corto", 7 (21%) al "pequeño", 3 (9%) al "estrecho" ", 2 (6%) a "ancho ", 2 (6%) al "grande ", 1 (3%) al "largo" y 4 (12%) al "típico". Conclusiones: Se pudo detectar variabilidad anatómica de la HT in vivo, mediante TC y RM. Se encontró una buena concordancia en las medidas obtenidas con ambos métodos imagenológicos.

Determinants of HIV-1 Late Presentation in a Cohort of Portuguese HIV-1 Patients.

Undiagnosed HIV-1 patients still account for 25% of worldwide HIV patients. Studying late presenters (LPs) for HIV care may help to identify characteristics of such patients. The present study aims to identify factors associated with late presentation and late presentation with advanced disease based on a population of patients followed in a Portuguese hospital between 1984 and 2017. Sociodemographic and clinical data from infected patients with HIV-1 aged 18 years and older, followed in Egas Moniz Hospital, in Portugal were collected. Of the 907 patients included in this study, 68.7% were males and the median age was 37 years (interquartile range 30-47). Four hundred fifty-nine patients (50.6%) were LP and, of these, 284 patients (61.9%) were LPAD. The LP population mostly originated from Portugal and sub-Saharan Africa (64.4% and 28.8%; p = .004) and the HIV exposure category, mainly heterosexuals and men have sex with men (57.0% and 24.9%; p < .001). The stage of disease and viral load at diagnosis were significantly associated with both LP and LPAD (p < .001). Factors associated with LP in the logistic regression included age at diagnosis lower than 30 years (adjusted odds ratio [aOR] 0.34; 0.17-0.68; p = .002) and origin from sub-Saharan Africa (aOR 2.24; 1.44-3.50; p < .001). Late presentation is a major obstacle to halt the HIV epidemic. In this population, the majority of newly diagnosed HIV-infected individuals were LPs. Our results characterize vulnerable populations that should be frequently tested for HIV.

Assessment of tolerance and acceptability between mannitol solution and polyethylene glycol as bowel preparation for colonoscopy: a three-center study.

INTRODUCTION: Adequate bowel preparation is one of the most important factors related to the yield of colonoscopy. Lowquality bowel preparation has been associated with lower adenoma detection rates and increased healthcare expenses. Bowel preparation is a major impediment to undergo colonoscopy since it is perceived as an unpleasant experience by patients. OBJECTIVE: This study was aimed to assess tolerance and acceptability of the bowel preparation using either polyethylene glycol (PEG) or mannitol solution. MATERIALS AND METHODS: We enrolled 140 patients with indications of screening for colorectal cancer or with suspected large bowel diseases. They received either mannitol solution or PEG as bowel preparation. Patients were asked to fill a questionnaire about the bowel preparation experience. RESULTS: Patients perceived more burdensome the preparation with PEG than mannitol for the variables nausea overall experience, post-procedure discomfort, disagreeable flavor, volume ingested and cost (p<0.05). A similar tolerance was reported for abdominal pain, bloating and anal irritation (p>0.05). The acceptability was 82.9% and 71.4% in the Mannitol group and in the PEG group, respectively (p=0.10). CONCLUSION: Acceptance of the bowel preparation between mannitol solution and PEG was comparable. However, mannitol was better tolerated by the patients in regard to most of the evaluated items.

Novel Endoscopic Management of a Chronic Gastro-Gastric Fistula Using a Cardiac Septal Defect Occluder.

PURPOSE: Closure of GG fistulas after RYGB is challenging due to epithelialization of the tract. Common endoscopic therapies are less efficacious than surgical revision, which is unfortunately fraught with high morbidity and mortality. Cardiac septal defect occluders (CSDO) have been successfully used for the management of gastrointestinal fistulas, but use has never been reported in management of GG fistulas. Thus, we describe the first off-label use of CSDO for the treatment of a GG fistula. MATERIALS AND METHODS: Endoscopy and fluoroscopic examination determined the appropriate size of CSDO for closure. A guidewire was placed in the remnant stomach followed by placement of the delivery system. Then, under fluoroscopy, we deployed the first flange of the CSDO in the remnant stomach. Then, under fluoroscopy and endoscopic visualization, the second flange is deployed in the gastric pouch. RESULTS: A 51-year-old woman, status-post RYGB in 2008, presented with a 6-month history of weight regain and reflux. She had regained weight to 84 kg (BMI = 32 kg/m2) when she was found to have a GG fistula. She underwent successful CSDO placement and, 3 months later, had lost 10 kg with significant improvement in her reflux. Repeat evaluation confirmed successful fistula closure. CONCLUSION: The use of CSDO was technically feasible and appeared to be effective and safe. Future studies should continue to investigate the role of CSDO in management of this challenging condition.

Assessment of tolerance and acceptability between mannitol solution and polyethylene glycol as bowel preparation for colonoscopy: a three-center study / Evaluación de tolerancia y aceptabilidad entre la solución de manitol y el polietilenglicol como preparación intestinal para la colonoscopía: un estudio de tres centros

ABSTRACT Introduction: Adequate bowel preparation is one of the most important factors related to the yield of colonoscopy. Low quality bowel preparation has been associated with lower adenoma detection rates and increased healthcare expenses. Bowel preparation is a major impediment to undergo colonoscopy since it is perceived as an unpleasant experience by patients. Objective: This study was aimed to assess tolerance and acceptability of the bowel preparation using either polyethylene glycol (PEG) or mannitol solution. Materials and methods: We enrolled 140 patients with indications of screening for colorectal cancer or with suspected large bowel diseases. They received either mannitol solution or PEG as bowel preparation. Patients were asked to fill a questionnaire about the bowel preparation experience. Results: Patients perceived more burdensome the preparation with PEG than mannitol for the variables nausea overall experience, post-procedure discomfort, disagreeable flavor, volume ingested and cost (p<0.05). A similar tolerance was reported for abdominal pain, bloating and anal irritation (p>0.05). The acceptability was 82.9% and 71.4% in the Mannitol group and in the PEG group, respectively (p=0.10). Conclusion: Acceptance of the bowel preparation between mannitol solution and PEG was comparable. However, mannitol was better tolerated by the patients in regard to most of the evaluated items.

RESUMEN Introducción: La preparación intestinal adecuada es uno de los factores más importantes relacionados con el rendimiento de la colonoscopía. La preparación intestinal de baja calidad se ha asociado con tasas de detección de adenoma más bajas y mayores gastos de atención sanitaria. La preparación intestinal es un impedimento importante para someterse a una colonoscopía, ya que los pacientes la perciben como una experiencia desagradable. Objetivo: Este estudio tuvo como objetivo evaluar la tolerancia y la aceptabilidad de la preparación intestinal utilizando polietilenglicol (PEG) o solución de manitol. Materiales y métodos: Fueron incluidos 140 pacientes con indicación de pesquisa de cáncer colorrectal o con sospecha de enfermedades del intestino grueso. Los pacientes recibieron solución de manitol o PEG como preparación intestinal. Se pidió a los pacientes que completaran un cuestionario sobre la experiencia de preparación intestinal. Resultados: Los pacientes percibieron más agobiante la preparación con PEG que el manitol para las variables náuseas, experiencia general, molestias posteriores al procedimiento, sabor desagradable, volumen ingerido y costo (p<0,05). Se informó una tolerancia similar para el dolor abdominal, distensión abdominal e irritación anal (p>0,05). La aceptabilidad fue de 82,9% y 71,4% en el grupo de manitol y en el grupo de PEG, respectivamente (p=0,10). Conclusión: La aceptación de la preparación intestinal entre la solución de manitol y el PEG fue comparable. Sin embargo, el manitol fue mejor tolerado por los pacientes con respecto a la mayoría de las variables evaluadas.

Role of Cardiac Septal Occluders in the Treatment of Gastrointestinal Fistulas: A Systematic Review.

Treating gastrointestinal (GI) fistulas endoscopically is challenging owing to an established epithelial tract. The variety of endoscopic approaches is transforming endoscopy into a first-line therapy. However, many sessions are often required, with variable success rates. Owing to these limitations, the off-label use of cardiac septal occluders (CSOs) has been reported. We searched for articles related to CSOs in the MEDLINE, EMBASE, Cochrane Library, and LILACS databases and gray literature. The primary outcomes included technical success, clinical success, and safety of CSOs in GI fistula management. A total of 25,574 records were identified, and 19 studies ultimately satisfied the inclusion criteria. Technical success was achieved in all cases. Of the 22 fistulas, 77.27% had successful closure, with a mean follow-up period of 32.02 weeks. The adverse event rate was 22.72%, with no associated mortality. Univariable and multivariable regression analyses showed no significant difference in the success of closure and adverse events in relation to several variables among the subgroups. The use of CSOs appeared to be technically feasible, effective, and safe in the treatment of GI fistulas. The satisfactory results derived from this sparse literature suggest that it can be an option in the management of GI fistulas.

POEM in Latin America: The Rise of a New Standard.

BACKGROUND: Per-oral endoscopic myotomy (POEM) has become the preferred alternative treatment to standard Heller myotomy for patients with esophageal achalasia, in Latin American countries. The aim of our study was to evaluate the efficacy and safety of a POEM in the management of achalasia with and without Chagas disease in patients receiving POEM. METHODS: Patients who underwent POEM from tertiary centers in Latin America were included in a dedicated registry. Countries included Brazil, Colombia, Ecuador, Mexico, Nicaragua, and Venezuela. Patients enrolled needed to have a preoperative manometry and swallow contrast study confirming achalasia. Clinical success was defined as significant improvement in Eckardt score after therapy. RESULTS: POEM was technically successful in 81/89 (91%) patients (mean age, 44 y). There was a significant decrease in preprocedure and postprocedure Eckardt score from 8.7 (range, 3 to 12) to 2.15 (0 to 10) (P<0.001), preprocedure and postprocedure barium swallow evaluation (98% vs. 89%; P=0.017), and preprocedure and postprocedure lower esophageal sphincter pressure measurement (from 35 to 13.8 mm Hg; P<0.001). Clinical success was achieved in 93% of patients. Patients with Chagas disease (n=58) were 9.5 times more likely to respond to POEM (P=0.0020; odds ratio, 9.5). CONCLUSIONS: POEM is an efficacious and safe therapeutic modality for treatment of achalasia in Latin America. Chagas disease-related achalasia seems to particularly respond better to POEM when it is performed by experienced endoscopists.

Efficacy of the cardiac septal occluder in the treatment of post-bariatric surgery leaks and fistulas.

BACKGROUND: Endoscopy has evolved to become first-line therapy for the treatment of post-bariatric leaks; however, many sessions are often required with variable success rates. Due to these limitations, the use of the cardiac septal defect occluder (CSDO) has recently been reported in this population. METHODS: The study population was a multicenter retrospective series of patients with post-bariatric surgical leaks who underwent treatment with CSDO placement. Data on the type of surgery, previous treatment details, fistula dimensions, success rate, and adverse events were collected. Leaks were grouped according to the International Sleeve Gastrectomy Expert Panel Consensus. Outcomes included technical and clinical success and safety of the CSDO. Regression analysis was performed to determine the predictors of response. RESULTS: Forty-three patients with leaks were included (31 sleeve gastrectomy and 12 Roux-en-Y gastric bypass). They were divided into acute (n = 3), early (n = 5), late (n = 23), and chronic (n = 12). Forty patients had failed previous endoscopic treatment and 3 patients had CSDO as the primary treatment. Median follow-up was 34 weeks. Technical success was achieved in all patients and clinical success in 39 patients (90.7%). All chronic, late, and early leaks were successfully closed, except one undrained late leak. The 5 patients with early leaks had an initial satisfactory response, but within 30 days, drainage recurred. The CSDOs were removed and replaced with larger-diameter devices leading to permanent defect closure. Acute leaks were not successfully closed in all 3 patients. Regression analysis showed that chronicity and previous treatment were associated with fistula closure; success rates for late/chronic leaks versus acute/early leaks were 97.1% and 62.5%, respectively (P = .0023). CONCLUSION: This observational study found that the CSDO had a high efficacy rate in patients with non-acute leaks, with no adverse events. All early, late, and chronic leaks were successfully closed, except for one undrained late leak. However, early leaks required a second placement of a larger CSDO in all cases. These results suggest that the CSDO should be considered for non-acute fistula and that traditional closure methods are likely preferred in the acute and early settings.

Sedación con propofol en endoscopia digestiva administrado por gastroenterólogos. Experiencia en un hospital de Venezuela / Sedation with propofol in digestive endoscopy administered by gastroenterologists. Experience in a Venezuelan hospital

Objetivos: el propofol es un hipnótico de acción rápida que está convirtiéndose a nivel mundial en el fármaco de elección para la sedación en endoscopia digestiva. Hay cierta controversia en relación a su uso por médicos que no son anestesiólogos. Presentamos nuestra experiencia en la administración de propofol por endoscopistas y su personal de enfermería. Métodos: estudio retrospectivo. Para la sedación en endoscopia se utilizó exclusivamente propofol, administrado por el endoscopista que realizaba el procedimiento y su personal de enfermería. Todos los pacientes incluidos eran de bajo y moderado riesgo quirúrgico (ASA I, II y III). No se utilizó medicación complementaria como benzodiacepinas u opiáceos. Resultados: se incluyeron un total de 70.696 procedimientos de endoscopia digestiva realizados entre los años 2002 y 2017. Se administró propofol en un bolus de inducción de 10 a 50 mg continuando con bolus intermitentes de 10 a 20 mg, de acuerdo a la respuesta del paciente. La incidencia de complicaciones fue muy baja, requiriéndose ventilación asistida con máscara en 78 (0,11%) ocasiones. Solo un caso requirió intubación endotraqueal y dos pacientes presentaron hipotensión importante, por lo que precisaron la administración de efedrina. El tiempo de recuperación promedio de todas las funciones neuropsicomotoras posterior al procedimiento fue de 15 minutos. El 98% de los pacientes refirieron como bueno o excelente el nivel de tolerancia y recordaron con claridad los detalles de la entrevista realizada una hora después del procedimiento. Conclusiones: el uso del propofol como sedante en endoscopia digestiva administrado y controlado por el endoscopista y su personal de enfermería, en pacientes debidamente seleccionados, es una técnica segura y eficaz que permite a los gastroenterólogos lograr sedaciones adecuadas

Objectives: propofol is a rapid acting hypnotic that is becoming the drug of choice for sedation in digestive endoscopy worldwide. There is some controversy with regard to the use of propofol by physicians who are not anesthesiologists. We present our experience of the administration of propofol by endoscopist and nursing personnel. Methods: this was a retrospective study of sedation in endoscopy. Propofol was exclusively used and administered by the endoscopist who performed the procedure and the nursing staff. All patients included were of a low and moderate surgical risk (ASA I, II and III). No complementary medication was used such as benzodiazepines or opiates. Results: a total of 70,696 digestive endoscopy procedures performed between 2002 and 2017 were included in the study. Propofol was administered in an induction bolus of 10 to 50 mg, continuing with intermittent boluses of 10 to 20 mg, according to the patients’ response. The incidence of complications was very low, assisted ventilation with a mask was required on 78 (0.11%) occasions. Only one case required endotracheal intubation and two patients had significant hypotension that required the administration of ephedrine. The average recovery time of all neuropsychomotor functions after the procedure was 15 minutes; 98% of patients reported a good or excellent level of tolerance and clearly remembered the details of the interview one hour after the procedure. Conclusions: the use of propofol as a sedative in digestive endoscopy is a safe and effective technique, provided that it is administered and controlled by the endoscopist and nursing staff in properly selected patients. This allows gastroenterologists to achieve adequate sedation

Sedation with propofol in digestive endoscopy administered by gastroenterologists. Experience in a Venezuelan hospital.

OBJECTIVES: propofol is a rapid acting hypnotic that is becoming the drug of choice for sedation in digestive endoscopy worldwide. There is some controversy with regard to the use of propofol by physicians who are not anesthesiologists. We present our experience of the administration of propofol by endoscopist and nursing personnel. METHODS: this was a retrospective study of sedation in endoscopy. Propofol was exclusively used and administered by the endoscopist who performed the procedure and the nursing staff. All patients included were of a low and moderate surgical risk (ASA I, II and III). No complementary medication was used such as benzodiazepines or opiates. RESULTS: a total of 70,696 digestive endoscopy procedures performed between 2002 and 2017 were included in the study. Propofol was administered in an induction bolus of 10 to 50 mg, continuing with intermittent boluses of 10 to 20 mg, according to the patients' response. The incidence of complications was very low, assisted ventilation with a mask was required on 78 (0.11%) occasions. Only one case required endotracheal intubation and two patients had significant hypotension that required the administration of ephedrine. The average recovery time of all neuropsychomotor functions after the procedure was 15 minutes; 98% of patients reported a good or excellent level of tolerance and clearly remembered the details of the interview one hour after the procedure. CONCLUSIONS: the use of propofol as a sedative in digestive endoscopy is a safe and effective technique, provided that it is administered and controlled by the endoscopist and nursing staff in properly selected patients. This allows gastroenterologists to achieve adequate sedation.

Implementation of cervical cancer screening using visual inspection with acetic acid in rural Mozambique: successes and challenges using HIV care and treatment programme investments in Zambézia Province.

BACKGROUND: In order to maximize the benefits of HIV care and treatment investments in sub-Saharan Africa, programs can broaden to target other diseases amenable to screening and efficient management. We nested cervical cancer screening into family planning clinics at select sites also receiving PEPFAR support for antiretroviral therapy (ART) rollout. This was done using visual inspection with acetic acid (VIA) by maternal child health nurses. We report on achievements and obstacles in the first year of the program in rural Mozambique. METHODS: VIA was taught to clinic nurses and hospital physicians, with a regular clinical feedback loop for quality evaluation and retraining. Cryotherapy using carbon dioxide as the refrigerant was provided at clinics; loop electrosurgical excision procedure (LEEP) and surgery were provided at the provincial hospital for serious cases. No pathology services were available. RESULTS: Nurses screened 4651 women using VIA in Zambézia Province in year one of the program, more than double the Ministry of Health service target. VIA was judged positive for squamous intraepithelial lesions in 8% (n=380) of the women (9% if age ≥ 30 years (n=3154) and 7% if age <30 years (n=1497); p=0.02). Of the 380 VIA-positive women, 4% (n=16) had lesions (0.3% of 4651 total screened) requiring referral to Quelimane Provincial Hospital. Fourteen (88%) of these 16 women were seen at the hospital, but records were inadequate to judge outcomes. Of women screened, 2714 (58%) either had knowledge of their HIV status prior to VIA or were subsequently sent for HIV testing, of which 583 (21%) were HIV positive. CONCLUSIONS: Screening and clinical services were successfully provided on a large scale for the first time ever in these rural clinics. However, health manpower shortages, equipment problems, poor paper record systems and a limited ability to follow-up patients inhibited the quality of the cervical cancer screening services. Using prior HIV investments, chronic disease screening and management for cervical cancer is feasible even in severely resource-constrained rural Africa.