Performance of biliary stents in malignant biliary strictures.

INTRODUCTION: Endoscopic stenting is a commonly applied method of treatment in patients with malignant biliary strictures. It involves the use of self­expandable metal stents (SEMSs) or plastic stents (PSs). OBJECTIVES: The aim of the study was to compare the effectiveness of SEMSs and PSs in the endoscopic drainage of malignant strictures of the biliary tree and its sequels for future optimalization of this treatment method. PATIENTS AND METHODS: Data on 618 consecutive patients with malignant biliary stricture, in whom 1271endoscopic retrograde cholangiopancreatography procedures with biliary stenting have been performed in the years 2012-2017 with at least 3­year follow­up,  were retrospectively derived from a hospital database. RESULTS: The main indications for stenting were pancreatic cancer (37%) and cholangiocarcinoma (34%). The use of SEMSs resulted in a greater decline of serum bilirubin as compared with PSs (37% vs 32% of baseline concentration; P = 0.01). Consequently, hospital stay was shorter by more than 2 days (mean [SD], 9.5 [5.6] vs 11.8 [7.9] days; P <0.001). The median (interquartile range) patency time of SEMSs was more than 2 times longer than for PSs (118 [56-232] days vs 46 [18-97] days; P <0.001), and procedure­related complications were less frequent (19.3% vs 12.9%, respectively in the SEMS and PS group; P = 0.001). SEMSs proved also to be more cost­effective; the hospital profit was 1375 USD for a single hospitalization with SEMS insertion. CONCLUSIONS: In patients with malignant strictures of the biliary tree SEMSs outperform PSs. SEMSs should be used as a treatment of choice for biliary drainage in that group of patients.

The prospective validation of a scoring system to assess mucosal cleanliness during esophagogastroduodenoscopy.

BACKGROUND AND AIMS: Cleanliness of the mucosa of the upper gastrointestinal (UGI) tract is critical for performing a high-quality esophagogastroduodenoscopy (EGD). The aim of this study was to validate a recently developed UGI cleanliness scale (the Polprep: Effective Assessment of Cleanliness in Esophagogastroduodenoscopy [PEACE] system) in the detection of clinically significant lesions (CSLs) in the UGI tract. METHODS: Patients who underwent a complete diagnostic EGD were prospectively enrolled from August 2021 to October 2022. The UGI tract (esophagus, stomach, and duodenum) cleanliness was scored from 0 to 3 for each segment. The primary outcomes were the detection of CSLs and PEACE scores. RESULTS: Of 995 patients enrolled from 5 centers, adequate cleanliness (AQ; all scores ≥2) was found in 929 patients. In multivariate regression analysis, AQ was associated with the number of diagnosed CSLs (odds ratio [OR], 1.78; 95% confidence interval [CI], 1.06-3.01; P = .03). Other factors related to CSL detection were duration of EGD (OR, 1.29, 95% CI, 1.23-1.35, P < .001), male sex (OR, 1.33, 95% CI, 1.04-1.71; P = .025), and EGD indication (dyspepsia, alarm symptoms, gastritis surveillance, other indications vs gastroesophageal reflux disease) (OR, 0.43 [95% CI, 0.31-0.6, P < .001], OR, 0.44 [95% CI, 0.28-0.67, P < .001], OR, 0.44 [95% CI, 0.25-0.76; P = .004], and OR, 0.44 [95% CI, 0.31-0.62; P < .001], respectively). Twenty-seven patients were diagnosed with UGI neoplasia, all in patients with adequate cleanliness of the UGI tract. CONCLUSIONS: Adequate cleanliness of the UGI tract as assessed with the PEACE system was associated with a significantly higher detection rate of CSLs during EGD. The relationship of this scale with UGI neoplasia detection warrants further investigation.

Potential benefits of one­time gastroscopy in search for precancerous conditions.

INTRODUCTION: Precancerous conditions for esophageal (EA) and gastric adenocarcinoma (GA) are Barrett's esophagus (BE) and atrophic gastritis (AG), respectively. Their surveillance is crucial for the detection of early lesions. OBJECTIVES: The study aimed to assess whether one­timeesophagogastroduodenoscopy (EGD) in search for precancerous conditions would be effective in the population with low­to­moderate esophageal and gastric cancer risk. PATIENTS AND METHODS: A total of 5984 individuals who underwent diagnostic EGD in 3 endoscopic centers, from March 2018 to October 2019, were analyzed to assess the age of occurrence of precancerous conditions and cancers. Age distribution of the patients with malignant gastric and esophageal tumors registered in the national cancer registry from 2014 to 2017 was analyzed. RESULTS: In comparison with individuals below 40 years old, the risk of EA and GA diagnosis increased at the age of 60 to 64 years (odds ratio [OR], 12.1; 95% CI, 1.5-98.6), gastric and esophageal dysplasia at the age of 55 to 59 years (OR, 3.6; 95% CI, 1.3-9.7), and BE and AG at the age of 40 to 44 years (OR, 1.6; 95% CI, 1.04-2.4). The number of procedures per 1 cancer that could be potentially avoided was 236, 235, 290, 360, 394, and 344 for the age groups of 40-44 years, 45-49 years, 50-54 years, 55-59 years, 60-64 years, and 65-69 years, respectively. The assessed potential benefit­to­harm ratio was 47, 38, 31, 28, and 32 for the age groups of 40-49 years, 50-54 years, 55-59 years, 60-64 years, and 65-69 years, respectively. CONCLUSIONS: One­time EGD in search for precancerous conditions could be potentially applicable in individuals between 40 and 69 years of age.

The role of endoscopic and demographic features in the diagnosis of gastric precancerous conditions.

INTRODUCTION: The diagnosis of atrophic gastritis (AG) and intestinal metaplasia (IM) is a crucial screening and surveillance strategy for gastric adenocarcinoma. OBJECTIVES: The main objective was to assess the performance of endoscopic diagnosis of gastric precancerous conditions in a real­life scenario. PATIENTS AND METHODS: A total of 2099 gastroscopies with biopsy to evaluate gastritis performed in 3 endoscopic centers from March 2018 to October 2019 were retrospectively analyzed. Endoscopic data regarding gastritis, atrophy, and intestinal metaplasia were compared with histopathological reports. RESULTS: The endoscopic diagnosis sensitivity was 69.5% for AG and 19.4% for IM. The specificity of endoscopic detection of AG was 69.5% and of IM, 97.9%. The endoscopic detection of gastritis was a risk factor for AG and IM diagnosis (odds ratio [OR], 5.1; 95% CI, 1.9-14.1 and OR, 14.5; 95% CI, 5.9-35.8, respectively) and the patient's age was a risk factor for AG, IM, dysplasia, and advanced stage of AG (ASAG) diagnosis (OR, 1.05; 95% CI, 1.04-1.06; OR, 1.035; 95% CI, 1.03-1.04; OR, 1.04; 95% CI, 1.02-1.06; and OR, 1.05; 95% CI, 1.02-1.09, respectively). The age threshold of 45 or 40 years with endoscopically diagnosed gastritis for obtaining biopsy would result in 96.3% and 95% ASAG or dysplasia diagnosis sensitivity, and in the reduction of the number of biopsies by 20.2% and 20.5%, respectively. CONCLUSIONS: The application of the age threshold with or without an endoscopic diagnosis of gastritis could reduce the number of mapping biopsies to detect advanced stages of atrophic gastritis or dysplasia with high sensitivity.

Performance of plastic stents used for benign and malignant biliary strictures: experience of a single high­volume endoscopy unit.

INTRODUCTION: Endoscopic plastic biliary stenting has been used for more than 30 years as a temporary or definitive treatment of benign and malignant neoplasms. These stents are commonly available, inexpensive, and easy to implant. OBJECTIVES: We aimed to evaluate the duration of plastic stent patency, to assess complications associated with stent use, and to determine the optimal timing of stent replacement depending on the indication for biliary stenting. PATIENTS AND METHODS: This was a retrospective cohort study with a 5­year follow­up including patients who underwent plastic biliary stent implantation between 2012 and 2013 in a tertiary referral gastroenterological center. The performance of stents was assessed on the basis of medical records, direct contact with patients or their family members, and information derived from the national death registry. RESULTS: We assessed 830 biliary stenting procedures performed in 346 patients. The indications for biliary stenting included choledocholithiasis in 120 patients (34.7%), benign stricture in 70 patients (20.2%), and malignant stricture in 156 patients (45.1%). The mean duration of stent patency for these conditions was 110, 106, and 55 days, respectively (P <0.001). Stents implanted for malignant perihilar strictures had a shorter duration of patency than those used for distal strictures (40 days vs 76 days, P = 0.002). CONCLUSIONS: The patency of plastic stents depends on the underlying disease. In patients with benign biliary disease, stent replacement is recommended after about 3.5 months. In patients with cancer, the timing of stent replacement should be guided by survival prognosis and location of stricture.

Scoring system assessing mucosal visibility of upper gastrointestinal tract: The POLPREP scale.

BACKGROUND AND AIM: The proper visibility of mucosa during esophagogastroduodenoscopy (EGD) is crucial for the detection of early upper gastrointestinal tract lesions. In contrast to colonoscopy, no validated scoring system for the assessment of upper gastrointestinal mucosal cleanliness has been developed so far. The aim of the study was to create and validate standardized grading system (POLPREP) to assess the mucosal cleanliness during EGD. METHODS: To assess the visibility of mucosa during EGD, 4-point scale was developed (0-3). Twelve operators assessed 18 images of esophagus, stomach, and duodenum twice (in 2 weeks interval). In validation round, the images and endoscopy reports of 443 EGDs performed in six centers were assessed. RESULTS: The inter-observer accordance of POLPREP was 0.8 (intra-class correlation coefficient; 0.79 consultants, 0.85 trainees). The intra-observer repeatability was 0.64 (Fleiss kappa value; 0.64 consultants, 0.64 trainees). The lesions detection rate was significantly higher in clean (scores 2 and 3; 19.7%) than in "unclean" segments (score 1; 7.7%, P = 0.049). Score 3 was associated with over three-fold higher lesion detection than score 1 (odds ratio 3.2, 95% confidence interval 1.1-9; P = 0.03). CONCLUSIONS: The proposed POLPREP scale allows for unified assessment of upper gastrointestinal tract mucosal cleanliness. The higher cleanliness scores are related with greater upper gastrointestinal pathologies detection.

Composite detection rate as an upper gastrointestinal endoscopy quality measure correlating with detection of neoplasia.

BACKGROUND: Esophagogastroduodenoscopy (EGD) is commonly used diagnostic method with no widely accepted quality measure. We assessed quality indicator-composite detection rate (CDR)-consisting of detection of at least one of the following: cervical inlet patch, gastric polyp and post-ulcer duodenal bulb deformation. The aim of the study was to validate CDR according to detection rate of upper gastrointestinal neoplasms (UGN). METHODS: It was a multicenter, prospective, observational study conducted from January 2019 to October 2019. The endoscopic reports from 2896 symptomatic patients who underwent diagnostic EGD were analyzed. The EGDs were performed in three endoscopy units located in tertiary university hospital, private outpatient clinic and local hospital. RESULTS: 64 UGNs were detected. The mean CDR was 21.9%. The CDR correlated with UGN detection rate (R = 0.49, p = 0.045). Based on CDR quartiles, operators were divided into group 1 with CDR < 10%, group 2 with CDR 10-17%, group 3 with CDR 17.1-26%, and group 4 with CDR > 26%. Detection rate of UGN was significantly higher in the group 4 in comparison to group 1 (OR 4.4; 95% CI 2.2 - 9.0). In the multivariate regression model, patient age, male gender and operator's CDR > 26% were independent risk factors of UGN detection (OR 1.03; 95% CI 1.01 - 1.05, OR 2; 95% CI 1.2 - 3.5, and OR 5.7 95% CI 1.5 - 22.3, respectively). CONCLUSIONS: The CDR is associated with the detection of upper gastrointestinal neoplasms. This parameter may be a useful quality measure of EGD to be applied in general setting.

Cyclosporine A - treated nephrotic children show impaired vasodilatation but no autonomic neuropathy.

INTRODUCTION: The aim of the study was to determine the effect of long-term cyclosporine A (CsA) treatment in children with idiopathic nephrotic syndrome on autonomic nerve function and peripheral blood flow assessed with thermography. MATERIAL AND METHODS: The study group consisted of 19 nephrotic children treated with cyclosporine A compared to 16 healthy children. The assessment of blood flow was made based on the results of thermographic measurements during the cold stress test by an infrared radiation registering camera. Ewing's battery of non-invasive tests was used to assess autonomic function. RESULTS: The study showed diminished temperature increase after the cooling test in children with nephrotic syndrome treated with CsA. Sympathetic activity test results were comparable to healthy children. CONCLUSIONS: It may be hypothesized that cyclosporine A administered even in low doses induces small vessel dysfunction measured by the thermographic method. This effect seems to be independent of sympathetic nervous system involvement, which was absent in cyclosporine A treated nephrotic children.

[Assessment of the peripheral circulation in children with nephrotic syndrome treated with cyclosporin A]. / Ocena zaburzen krazenia obwodowego u dzieci z idiopatycznym zespolem nerczycowym leczonych cyklosporyna A.

Cyclosporin A (CsA) is an immunosuppressive agent used in children for the treatment of steroid-dependent idiopathic nephrotic syndrome (INS). Despite its benefitial effect on a course of the disease CsA may exert nephrotoxic effects because of its vasoconstrictive properties. CsA-dependent disorders of the peripheral flow (Raynaud phenomenon--RP) have been recently described. The aim of the study was to assess the effect of CsA on the peripheral circulation. The study group comprised 16 children (12 male, 4 female; mean age 9.8 +/- 4.5 years) treated with CsA for at least 6 months due to INS (mean treatment time 39 +/- 27 months). Thirteen age- and sex-matched individuals served as controls. Peripheral circulation disorders were evaluated by means of a cold stress test (both hands were held in lukewarm water (20 degrees C) for 1 minute and thereafter the changes in the hand temperature were recorded with thermographic camera (Inframetrics SC1000). RP assessment was performed according to the method described by Ammer and Ring. The temperature gradient of 4 degrees C or greater maintained between metacarpal and peripheral areas of a hand after 10 minutes was considered diagnostic for RP. According to these criteria RP was confirmed in only 3 patients from the study group and in 2 controls. However, the time of the temperature increase in the first 5 minutes after cooling was considerably shorter in the children with INS (0.26 +/- 0.26 degrees C/min vs 0.51 +/- 0.29 degrees C/min, p=0.02). No correlation between CsA serum concentration, CsA dose and impairment of the hand temperature increase was found. The study confirmed that in children suffering from INS treated with CsA peripheral blood flow disorders can be seen. It seems that impaired vessel reactivity may result from the vasoconstrictive effect of CsA.