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Pancreatite Autoimune , Icterícia , Pâncreas , Neoplasias Pancreáticas/diagnóstico , Prednisona/administração & dosagem , Proteínas de Arabidopsis , Pancreatite Autoimune/diagnóstico , Pancreatite Autoimune/imunologia , Pancreatite Autoimune/fisiopatologia , Pancreatite Autoimune/terapia , Diagnóstico Diferencial , Ferredoxina-NADP Redutase , Glucocorticoides/administração & dosagem , Humanos , Biópsia Guiada por Imagem/métodos , Icterícia/diagnóstico , Icterícia/etiologia , Testes de Função Hepática/métodos , Imageamento por Ressonância Magnética/métodos , Masculino , Pessoa de Meia-Idade , Imagem Multimodal/métodos , Pâncreas/diagnóstico por imagem , Pâncreas/patologia , Tomografia por Emissão de Pósitrons/métodos , Tomografia Computadorizada por Raios X/métodosRESUMO
Background and study aims The COVID-19 pandemic has had a profound impact on gastroenterology training programs. We aimed to objectively evaluate procedural training volume and impact of COVID-19 on gastroenterology fellowship programs in the United States. Methods This was a retrospective, multicenter study. Procedure volume data on upper and lower endoscopies performed by gastroenterology fellows was abstracted directly from the electronic medical record. The study period was stratified into 2 time periods: Study Period 1, SP1 (03/15/2020 to 06/30/2020) and Study Period 2, SP2 (07/01/2020 to 12/15/2020). Procedure volumes during SP1 and SP2 were compared to Historic Period 1 (HP1) (03/15/2019 to 06/30/2019) and Historic Period 2 (HP2) (07/01/2019 to 12/15/2019) as historical reference. Results Data from 23 gastroenterology fellowship programs (total proceduresâ=â127,958) with a median of 284 fellows (range 273-289; representing 17.8â% of all trainees in the United States) were collected. Compared to HP1, fellows performed 53.6â% less procedures in SP1 (total volume: 28,808 vs 13,378; mean 105.52â±â71.94 vs 47.61â±â41.43 per fellow; P â<â0.0001). This reduction was significant across all three training years and for both lower and upper endoscopies ( P â<â0.0001). However, the reduction in volume was more pronounced for lower endoscopy compared to upper endoscopy [59.03â% (95â% CI: 58.2-59.86) vs 48.75â% (95â% CI: 47.96-49.54); P â<â0.0001]. The procedure volume in SP2 returned to near baseline of HP2 (total volume: 42,497 vs 43,275; mean 147.05â±â96.36 vs 150.78â±â99.67; P â=â0.65). Conclusions Although there was a significant reduction in fellows' endoscopy volume in the initial stages of the pandemic, adaptive mechanisms have resulted in a return of procedure volume to near baseline without ongoing impact on endoscopy training.
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Background and study aims Endoscopic ultrasound-guided gastroenterostomy (EUS-GE) using a 15-mm lumen apposing metal stent (LAMS) has emerged as a viable alternative to surgical gastrojejunostomy for management of gastric outlet obstruction (GOO). However, given the size of the anastomosis created with a 15-mm LAMS, long-term luminal patency and clinical outcomes may be suboptimal. The aim of this study was to evaluate the technical feasibility, efficacy, and safety of EUS-GE with a large-diameter (20âmm) LAMS (LLAMS). Patients and methods A retrospective analysis of a prospectively maintained database of all patients undergoing EUS-GE with LLAMS between December 1, 2018 and September 30, 2020 was performed. All EUS-GEs were performed using a cautery-enhanced LLAMS. Results Thirty-three patients were referred for endoscopic management of GOO. Two patients were excluded due to a lack of an adequate window for EUS-GE. The remaining 31 patients (93.94â%) (mean age: 61.35â±â16.52 years; 54.84â% males) underwent EUS-GE using LLAMS for malignant (nâ=â23) and benign (nâ=â8) GOO. Technical success was achieved in all patients (100â%) with attempted EUS-GE. Complete clinical success (tolerance of regular diet) was achieved in 93.55â% of patients (nâ=â29). Two patients (6.45â%) had partial clinical success and died of unrelated causes prior to advancing diet beyond full liquids. Overall mean follow-up was 140.84â±â160.41 days (median 70, range 4-590). All stents remained patent with no evidence of recurrent GOO symptoms. One patient (3.23â%) developed an asymptomatic clean-based jejunal ulcer on 3-month follow-up endoscopy. Conclusions EUS-GE with LLAMS is a technically feasible, effective and safe option for patients with GOO allowing for tolerability of regular diet. Future prospective, ideally randomized studies comparing long-term outcomes of EUS-GE with 20- and 15-mm LAMS are required.
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BACKGROUND: Adenoma detection rate (ADR) is one of the most important quality indicators of colonoscopy. Monitoring endoscopists and providing feedback has shown to improve ADR. We performed a systematic review of the literature and meta-analysis to determine the effect of any form of feedback on ADR. METHODS: A literature search for comparative studies that employed any form of feedback to assess the impact on ADR before and after the feedback was done on MEDLINE, EMBASE, and Cochrane Database. The primary outcome of interest was ADR. Secondary outcomes included polyp detection rate, advanced adenoma detection rate, sessile serrated adenoma detection rate, withdrawal time, and cecal intubation rate. Cochrane Revman 5.3 software was used for statistical analysis. RESULTS: A total of 12 studies met the inclusion criteria for the analysis of primary outcomes. There were 78,355 subjects (45.42% male) with a mean age of 59.52 years. There was a significant improvement in ADR after any form of feedback compared to no feedback: 36.18% vs. 26.75%; pooled odds ratio 1.51, 95% confidence interval 1.37-1.66; P<0.001. There was a substantial heterogeneity (I2=82%). ADR improved in both active or passive feedback, irrespective of whether endoscopists knew about being monitored for their performance or not. CONCLUSIONS: Monitoring and providing feedback to endoscopists in any form leads to improvement in ADR. Feedback is an easy and effective way of improving the ADR of endoscopists, especially in those not achieving the recommended benchmarks.
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BACKGROUND AND AIMS: Although molecular analysis of pancreatic cyst fluid may aid pancreatic cyst classification, clinical practice remains highly variable. Therefore, we performed a systematic review and meta-analysis to evaluate the diagnostic performance of KRAS and GNAS mutations in EUS-acquired pancreatic cyst fluid for diagnosis of intraductal papillary mucinous neoplasms (IPMNs) and mucinous cystic lesions (MCLs). METHODS: Individualized searches were developed in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) and Meta-Analysis of Observational Studies in Epidemiology (MOOSE) guidelines and meta-analysis analyzed according to the Cochrane Diagnostic Test Accuracy working group methodology. A bivariate model was used to compute the pooled sensitivity and specificity and to plot the summary receiver operating characteristics curve with summary point and corresponding 95% confidence interval (95% CI). RESULTS: Six studies (785 lesions) were included. For IPMNs and MCLs, KRAS + GNAS (combination) had significantly higher diagnostic accuracy than KRAS alone and GNAS alone (all P < .001). The pooled sensitivity, specificity, and diagnostic accuracy of KRAS + GNAS mutations for diagnosis of IPMNs were 94% (95% CI, 72-99; I2 = 86.74%), 91% (95% CI, 72-98; I2 = 89.83), and 97% (95% CI, 95-98), respectively, with each significantly higher compared with carcinoembryonic antigen (CEA) alone (all P < .001). For diagnosis of MCLs, KRAS + GNAS had a similar sensitivity and specificity compared with CEA alone; however, diagnostic accuracy was significantly improved (97% [95% CI, 95-98] vs 89% [95% CI, 86-91]; P < .001). CONCLUSIONS: Molecular analysis for KRAS + GNAS mutations in EUS-acquired pancreatic cyst fluid has high sensitivity and specificity with significantly improved diagnostic accuracy for diagnosis of IPMNs and MCLs when compared with CEA alone.
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Cisto Pancreático , Neoplasias Pancreáticas , Biomarcadores Tumorais/análise , Biomarcadores Tumorais/genética , Cromograninas/genética , Líquido Cístico/química , Subunidades alfa Gs de Proteínas de Ligação ao GTP/genética , Humanos , Mutação , Cisto Pancreático/genética , Neoplasias Pancreáticas/diagnóstico , Neoplasias Pancreáticas/genética , Proteínas Proto-Oncogênicas p21(ras)/genéticaAssuntos
Adenocarcinoma/diagnóstico , Neoplasias Duodenais/diagnóstico , Abscesso Hepático/diagnóstico , Dor Abdominal/diagnóstico por imagem , Dor Abdominal/etiologia , Adenocarcinoma/complicações , Neoplasias Duodenais/complicações , Evolução Fatal , Feminino , Humanos , Abscesso Hepático/complicações , Pessoa de Meia-IdadeAssuntos
Síndrome do Ligamento Arqueado Mediano/diagnóstico , Dor Abdominal/etiologia , Adulto , Anestésicos Locais/uso terapêutico , Aortografia , Bupivacaína/uso terapêutico , Plexo Celíaco/cirurgia , Procedimentos Cirúrgicos do Sistema Digestório , Endossonografia , Feminino , Gânglios Simpáticos , Glucocorticoides/uso terapêutico , Humanos , Síndrome do Ligamento Arqueado Mediano/complicações , Síndrome do Ligamento Arqueado Mediano/fisiopatologia , Síndrome do Ligamento Arqueado Mediano/terapia , Náusea/etiologia , Bloqueio Nervoso , Período Pós-Prandial , Triancinolona/uso terapêutico , Ultrassonografia Doppler , Vômito/etiologiaRESUMO
BACKGROUND: Although gastric variceal (GV) bleeding is less common than esophageal variceal bleeding, the severity of GV bleeding is often greater with higher morbidity and mortality rates. Minimally invasive endovascular treatments such as balloon-occluded retrograde transvenous obliteration (BRTO) and transjugular intrahepatic portosystemic shunt (TIPS) have been used for the management of GVs with varying results, and individual and institutional differences exist in the use of BRTO and TIPS. We performed a systematic review and meta-analysis to compare the feasibility, efficacy, and safety of BRTO and TIPS for the treatment of GVs because of portal hypertension. METHODS: Searches of PubMed, EMBASE, Google Scholar, and Cochrane Library databases were performed from inception through March 2019. Summary odds ratio (OR) with 95% confidence intervals (CI) was estimated for technical success, hemostasis rate, postprocedural complications, rebleeding rate, incidence of hepatic encephalopathy, and mortality rate at 1 year utilizing a random-effects model. RESULTS: Seven studies with a total of 676 patients (BRTO: 462 and TIPS: 214) were included. There was no difference in pooled technical success rate (OR, 0.87; 95% CI, 0.28-2.73; P=0.81), hemostasis rate (OR, 2.74; 95% CI, 0.61-12.26; P=0.19), and postoperative procedure-related complications (OR, 1.95; 95% CI, 0.44-8.72; P=0.38). However, treatment with BRTO was associated with lower rates of postoperative rebleeding (OR, 0.30; 95% CI, 0.18-0.48; P<0.00001), postoperative encephalopathy (OR, 0.06; 95% CI, 0.02-0.15; P < 0.00001), and mortality at 1 year (OR, 0.43; 95% CI, 0.21-0.87; P=0.02). CONCLUSIONS: BRTO was associated with lower rates of rebleeding, postprocedure hepatic encephalopathy, and mortality at 1 year. BRTO should be considered first-line modality for the treatment of GVs because of portal hypertension.
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Oclusão com Balão , Varizes Esofágicas e Gástricas , Hipertensão Portal , Derivação Portossistêmica Transjugular Intra-Hepática , Oclusão com Balão/efeitos adversos , Varizes Esofágicas e Gástricas/cirurgia , Hemorragia Gastrointestinal/etiologia , Hemorragia Gastrointestinal/terapia , Humanos , Hipertensão Portal/complicações , Derivação Portossistêmica Transjugular Intra-Hepática/efeitos adversos , Resultado do TratamentoAssuntos
Diarreia/parasitologia , Strongyloides/isolamento & purificação , Estrongiloidíase/parasitologia , Animais , Anticorpos Anti-Helmínticos/sangue , Antinematódeos/uso terapêutico , Doença Crônica , Diarreia/diagnóstico , Diarreia/tratamento farmacológico , Humanos , Ivermectina/uso terapêutico , Masculino , Pessoa de Meia-Idade , Strongyloides/efeitos dos fármacos , Strongyloides/imunologia , Estrongiloidíase/complicações , Estrongiloidíase/diagnóstico , Estrongiloidíase/tratamento farmacológico , Resultado do TratamentoAssuntos
Migração de Corpo Estranho/complicações , Obstrução Intestinal , Intestino Delgado , Pseudocisto Pancreático , Implantação de Prótese/efeitos adversos , Stents Metálicos Autoexpansíveis/efeitos adversos , Idoso de 80 Anos ou mais , Anastomose Cirúrgica/instrumentação , Feminino , Migração de Corpo Estranho/diagnóstico por imagem , Migração de Corpo Estranho/cirurgia , Cálculos Biliares/complicações , Gastrostomia/instrumentação , Humanos , Obstrução Intestinal/diagnóstico por imagem , Obstrução Intestinal/etiologia , Obstrução Intestinal/cirurgia , Intestino Delgado/diagnóstico por imagem , Intestino Delgado/cirurgia , Pâncreas/cirurgia , Pseudocisto Pancreático/etiologia , Pseudocisto Pancreático/terapia , Pancreatite/etiologia , Estômago/cirurgiaRESUMO
BACKGROUND: Currently, little is known about the onset, natural progression, and management of esophageal injuries after atrial fibrillation (AF) ablation. OBJECTIVES: We sought to provide a systematic review on esophageal injury after AF ablation and identify temporal relationships between various types of esophageal lesions, their progression, and clinical outcomes. METHODS: A comprehensive search of PubMed and Web of Science was conducted until September 21, 2017. All AF ablation patients who underwent upper gastrointestinal endoscopy within 1 week of the procedure were included. Patients with esophageal lesions were classified into 3 types by using our novel Kansas City classification: type 1: erythema; type 2a: superficial ulcers; type 2b: deep ulcers; type 3a: perforation without communication with the atria; and type 3b: perforation with atrioesophageal fistula. RESULTS: Thirty studies met our inclusion criteria. Of the 4473 patients, 3921 underwent upper gastrointestinal evaluation. The overall incidence of esophageal injuries was 15% (570). There were 206 type 1 lesions (36%), 222 type 2a lesions (39%), and 142 type 2b lesions (25%). Six of 142 type 2b lesions (4.2%) progressed further to type 3, of which, 5 were type 3a and 1 was type 3b. All type 1 and type 2a and most type 2b lesions resolved with conservative management. One type 3a and 1 type 3b lesions were fatal. CONCLUSION: Based on our classification, all type 1 and most type 2 lesions resolved with conservative management. A small percentage (4.2% [6 of 142]) of type 2b lesions progressed to perforation and/or fistula formation, and these patients need to be followed closely.