Advanced skills for general surgeons and carving out a niche: Endoscopic retrograde cholangiopancreatography in regional Australia.

BACKGROUND: The provision of high-quality healthcare in rural Australian hospitals has necessitated general surgeons to take up the challenge and expand their expertise to advanced endoscopy techniques including endoscopic retrograde cholangiopancreatography (ERCP). This study examines the utility of ERCP in a regional setting especially in decreasing patient transfers and associated costs while achieving exceptional safety by measuring key indicators of safety and efficacy. METHODS: A single-centre retrospective cross-sectional cohort review in a rural Queensland hospital of patients who underwent ERCP (emergent and elective) from January 2019 until July 2022. Standardized international ERCP performance indicators were collected and compared to benchmark literature values including the rate of cannulation, stone extraction, successful stent placement, and post-ERCP pancreatitis. RESULTS: The majority of the ERCP performance indicator benchmarks were met. 100% of patients had an appropriate indication for the procedure and consent. 98.95% successful CBD cannulation with only 14.14% requiring multiple attempts. 92.22% successful stone retrieval with 100% stent placement, well above guideline targets. The post-procedural complication rate was 6.81% (2.09% pancreatitis; 1.05% pancreatitis; 1.05% duodenal perforation). Antibiotic prophylaxis adherence was identified to require improvement (12.57%). CONCLUSION: High-quality ERCP procedures can be performed in a regional hospital by general surgeons in a safe and cost-effective manner, significantly decreasing the costs associated with patient transfer. This study reflects strong evidence for consistently achieving international ERCP performance benchmarks and the provision of high-quality healthcare by a regional hospital and provides a strong argument for increasing access to ERCP in rural and remote hospitals.

Upper GI bleeding in rural Australia: general surgery still alive and well!

BACKGROUND: The complex and critically unwell upper gastrointestinal bleeding (UGIB) patient is a common emergency presentation in Australia. Managed medically and endoscopically by rural general surgeons in rural and remote Australian hospitals which lack a gastroenterology service, this can be ameliorated by clear evidence-based guidelines. METHODS: A single-centre retrospective review of adult patients who underwent emergency gastroscopy for UGIB at the Mackay Base Hospital, January 2019 to January 2022. Detailed patient data from the assessment, resuscitation, time to endoscopy, endoscopic intervention, and outcomes were compared against key international gastroenterology society safety and quality standards for UGIB. RESULTS: Two hundred patients had a comprehensive initial assessment and resuscitation with PRBC (39%), anticoagulation reversal (18%), pantoprazole infusion (81%), tranexamic acid (10.50%) and octreotide (16.50%). Risk scores were calculated retrospectively as none were documented. Time-to-endoscopy targets were achieved in over 70% of variceal or non-variceal UGIB patients. Bleeding was found in 59.50% of patients but 63% of patients did not require a manoeuvre to stop the bleeding. Post-operative complications were scarce. CONCLUSION: This study reflects on the need for a local multidisciplinary protocol to help expedite the current high-quality healthcare delivered by rural general surgeons in managing patients with UGIB. Implementing risk assessment scores would shorten the time to endoscopy in the initial assessment Guidelines would optimize resuscitation ensuring appropriate replacement, medication administration, anticoagulation reversal, and preventing unnecessary therapy. Despite these nuisances, the time to endoscopy, endoscopic intervention, and patient outcomes were largely in line with international quality assurance and safety targets.

Orally administered Bifidobacterium triggers immune responses following capture by CD11c(+) cells in Peyer's patches and cecal patches.

We have investigated the immunomodulatory mechanisms of Bifidobacterium pseudocatenulatum JCM7041 (Bp) as model of probiotics following oral administration to mice. This study was conducted with the aim of clarifying the mechanism of immunomodulation induced by oral administration of probiotic bacteria through elucidation of the detailed mechanism of transfer of orally administered bacterial cells within the body and the interaction between bacterial cells and cells of the immune tissues. We observed the localization of Bp in mice following oral administration, showing that Bp was surrounded by CD11c(+) cells in Peyer's patches (PP) and cecal patches (CP). These results indicated that Bp might induce CD11c(+) cell-mediated immune responses directly. Furthermore, IL-10 and IL-12p40 production by Thy1.2(-) cells, including CD11c(+) cells, increased significantly. Production of IL-10 and IL-12p40 by bone marrow-derived dendritic cells (BMDC) was significantly increased by Bp stimulation. These results suggest that oral administration of Bp induces immune responses directly following capture by CD11c(+) dendritic cells (DCs). Subsequently, we observed oral administration of Bp for 1 week induced IgA and IgA-associated cytokine production by CP and PP cells, suggesting that Bp induced DC-mediated immune responses on CP as well as PP.