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Background and study aims Endoscopic ultrasound-guided through-the-needle biopsy (TTNB) of pancreatic cystic lesions (PCLs) is associated with a non-negligible risk for adverse events (AEs). We aimed to identify the hierarchic interaction among independent predictors for TTNB-related AEs and to generate a prognostic model using recursive partitioning analysis (RPA). Patients and methods Multicenter retrospective analysis of 506 patients with PCLs who underwent TTNB. RPA of predictors for AEs was performed and the model was validated by means of bootstrap resampling. Results Mean cysts size was 36.7mm. Most common diagnoses were intraductal papillary mucinous neoplasm (IPMN, 45%), serous cystadenoma (18.8%), and mucinous cystadenoma (12.8%). Fifty-eight (11.5%) AEs were observed. At multivariate analysis, age (odds ratio [OR] 1.32, 1.09-2.14; p=0.05), number of TTNB passes (OR from 2.17, 1.32-4.34 to OR 3.16, 2.03-6.34 with the increase of the number of passes), complete aspiration of the cyst (OR 0.56, 0.31-0.95; p=0.02), and diagnosis of IPMN (OR 4.16, 2.27-7.69; p

Background: It is unclear whether patients with intraductal papillary mucinous neoplasia harbor a higher risk of developing extrapancreatic malignancies. Aims: We performed a pooled estimate of the incidence of extrapancreatic malignancies in patients with intraductal papillary mucinous neoplasia, with a particular focus on the comparison to the general population. Methods: Computerized bibliographic search of main databases was performed through February 2021. The primary endpoint was the pooled incidence of extrapancreatic malignancies in patients with intraductal papillary mucinous neoplasms. Additional outcome was the comparison between intraductal papillary mucinous neoplasia patients and the general population, expressed in terms of standardized incidence ratio along with 95% confidence intervals. Results: Eighteen studies with 8709 patients were included. The pooled rate of metachronous extrapancreatic malignancies was 10 (6–13)/1000 persons-year. No difference was observed according to intraductal papillary mucinous neoplasia histology and sex, whereas a significantly superior incidence of extrapancreatic malignancies was observed in patients with main-duct (36.7%, 25.4%–48%) as compared to branch-duct intraductal papillary mucinous neoplasia (26.2%, 17.6%–34.8%; p = 0.03). Pooled standardized incidence ratio comparing expected rates in the general population was 1.01 (0.79–1.29); no difference was observed concerning rates of metachronous gastric cancer (standardized incidence ratio 1.60, 0.72–3.54) and colorectal cancer (1.29, 0.92–1.18), whereas biliary cancer was observed more frequently in intraductal papillary mucinous neoplasia patients (2.29, 1.07–4.93). Conclusion: Patients with intraductal papillary mucinous neoplasia harbor an overall rate of extrapancreatic malignancies as high as 27.3%. The rate of metachronous extrapancreatic malignancies is not superior to the general population. © 2021 Elsevier Ltd, BASO ~ The Association for Cancer Surgery, and the European Society of Surgical Oncology

OBJECTIVE: To compare recurrence rates among three endoscopic treatment modalities for 5-9 mm left-sided colorectal polyps. METHODS: Consecutive adults referred for elective colonoscopy (1/2015-1/2018) with at least one polyp of eligible size (5-9 mm) located distally to the splenic flexure were randomly assigned (1:1:1) to one of three treatment modalities: (1) cold snare polypectomy (CSP), (2) hot snare polypectomy (HSP) and (3) argon plasma coagulation (APC) ablation (50-60 W, flow: 2 l/min). The polyp site was marked with an endoscopic tattoo, and a follow-up colonoscopy with scar biopsies was performed >6 months after the index procedure. Outcomes were polyp recurrence rate and occurrence of complications. RESULTS: One hundred nineteen patients were enrolled, of whom 112 (62.5% males, mean age 61.1 ± 9.9 years) with 121 polyps (CSP, 39; HSP, 45; APC, 37) returned for follow-up colonoscopy. Mean polyp size was 6.7 ± 0.91 mm, 58% were located in the sigmoid, 33% in the rectum and 8% in the descending colon. The majority of polyps resected by CSP or HSP were neoplastic (tubular adenomas: 25.9%, tubulovillous adenomas: 11.1% and sessile serrate adenomas/polyps: 17.5%). No cases of delayed bleeding or perforation occurred. Scar biopsies at follow-up colonoscopy (performed after a mean interval of 13.4 ± 3.8 months) revealed 7 (5.8%) cases of polyp recurrence, showing no significant difference among the three treatment groups [CSP, 3/39 (7.7%); HSP, 1/45 (2.2%); APC, 2/37 (5.4%); P = 0.51). CONCLUSIONS: CSP, HSP and APC-ablation are effective and well-tolerated treatment modalities for 5-9 mm left-sided colorectal polyps. The present randomized study did not detect any difference in polyp recurrence rate among the three endoscopic techniques. Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.

Current guidelines advocate 3–4 passes with a fine-needle aspiration (FNA) to achieve high rates of diagnostic samples for malignancy when performing endoscopic ultrasound (EUS)-guided sampling of solid pancreatic lesions, in the absence of on-site cytologic evaluation. The aim of this study is to compare 2 vs. 3 needle passes in EUS-FNA for solid pancreatic lesions in terms of incremental diagnostic yield and to identify factors associated with the procedure’s outcome. In this retrospective study, 2 passes of EUS-FNA were found to have similar diagnostic yield compared to 3 passes for the diagnosis of solid pancreatic masses, suggesting that there might be no significant incremental tissue yield when 3 passes are performed.

Background: Small intestinal bacterial overgrowth (SIBO), characterized by either increased numbers or presence of colonic type bacteria in the small bowel has been previously described in functional dyspepsia (FD), based on breath testing. In this study, we aim to examine the prevalence of SIBO among FD patients using small bowel aspirate culture. Methods: We prospectively enrolled outpatients fulfilling Rome IV criteria for FD. Severity of symptoms was graded using the patient assessment of upper gastrointestinal symptom severity index (PAGI-SYM) questionnaire. Patients underwent upper gastrointestinal endoscopy and duodenal fluid was aspirated in sterile traps. SIBO was defined as ≥10 3 colony forming units/mL of duodenal aspirate and/or presence of colonic type bacteria. Patients undergoing gastroscopy due to gastroesophageal reflux symptoms-control group (CG)-And patients with irritable bowel syndrome (IBS) fulfilling Rome IV criteria were also recruited. Results: We enrolled 227 FD subjects, 30 CG, and 90 IBS patients. Among FD patients, 144 (63.4%), 64 (28.2%), and 19 (8.4%) had postprandial distress syndrome (PDS), epigastric pain syndrome (EPS), and overlapping PDS-EPS syndrome, respectively. SIBO prevalence was 20.8%, 12.5%, and 31.6% among PDS, EPS, and overlapping PDS-EPS FD subtypes, respectively. Overall, SIBO prevalence was significantly higher in FD (44/227 [19.4%]) compared to CG (1/30 [3.3%]) (p = 0.037) and similar to IBS (44/227 [19.4%] vs. 15/90 [16.7%], p = 0.63) subjects. SIBO presence was associated neither with total nor with any subscale score of the PAGI-SYM questionnaire. Conclusion: In a cohort of Greek FD patients, SIBO prevalence was similar to that of IBS subjects and higher compared to that of controls. © 2020

Background & Aims: Several endoscopic methods have been proposed for the treatment of large biliary stones. We assessed the comparative efficacy of these treatments through a network meta-analysis. Methods: Nineteen randomized controlled trials (2752 patients) comparing different treatments for management of large bile stones (>10 mm) (endoscopic sphincterotomy, balloon sphincteroplasty, sphincterotomy followed by endoscopic papillary large balloon dilation [S+EPLBD], mechanical lithotripsy, single-operator cholangioscopy [SOC]) with each other were identified. Study outcomes were the success rate of stone removal and the incidence of adverse events. We performed pairwise and network meta-analysis for all treatments, and used Grading of Recommendations, Assessment, Development, and Evaluation criteria to appraise the quality of evidence. Results: All treatments except mechanical lithotripsy significantly outperformed sphincterotomy in terms of stone removal rate (risk ratio [RR], 1.03–1.29). SOC was superior to other adjunctive interventions (vs balloon sphincteroplasty [RR, 1.24; 95% CIs, 1.07–1.45], vs S+EPLBD [RR, 1.23; range, 1.06–1.42] and vs mechanical lithotripsy [RR, 1.34; range, 1.14–1.58]). Cholangioscopy ranked the highest in increasing the success rate of stone removal (surface under the cumulative ranking [SUCRA] score, 0.99) followed by S+EPLBD (SUCRA score, 0.68). SOC and S+EPLBD outperformed the other modalities when only studies reporting on stones greater than 15 mm were taken into consideration (SUCRA scores, 0.97 and 0.71, respectively). None of the assessed interventions was significantly different in terms of adverse event rate compared with endoscopic sphincterotomy or with other treatments. Post-ERCP pancreatitis and bleeding were the most frequent adverse events. Conclusions: Among patients with large bile stones, cholangioscopy represents the most effective method, in particular in patients with larger (>15 mm) stones, whereas S+EPLBD could represent a less expensive and more widely available alternative. © 2021 AGA Institute

In the above-mentioned article, the name of Enrique Rodriguez de Santiago has been corrected. This was corrected in the online version on June 17, 2021. In the above-mentioned article, the institutions of Daniele Regge have been corrected. This was corrected in the online version on July 8, 2021. © 2021 Georg Thieme Verlag. All rights reserved.

The coronavirus disease 2019 (COVID-19) pandemic has led to unprecedented disruptions in fellowship training programs worldwide. In gastroenterology, the strain in healthcare service provision and the emphasis on preventing viral transmission has adversely impacted hands-on training opportunities, with trainees facing the constant pressure to meet training requirements under the continuous threat of viral transmission. Emerging evidence highlight the scale of the problem, specifically with regard to endoscopy competence due to cancellation of elective endoscopic procedures, provision of inpatient and outpatient consultative care as well as academic education and the mental well-being of trainees. As such, it has been necessary for trainees, trainers and training programs collectively to adapt to these challenges and incorporate novel and adaptive solutions to circumvent these training barriers. This review aims to summarise data on the global impact of COVID-19 on gastroenterology training and the practical interventions that could be implemented. (Acta gastroenterol. belg., 2021, 84, 627-635).

This review attempts to present the available evidence regarding the use of biodegradable stents in refractory benign esophageal strictures, especially highlighting their impact on clinical success and complications. A comprehensive literature search was conducted in PubMed, using the terms “biodegradable” and “benign”; evidence from cohort and comparative studies, as well as data from one pooled analysis and one meta-analysis are presented. In summary, the results from these studies indicate that the effectiveness of biodegradable stents ranges from more than one third to a quarter of cases, fairly similar to other types of stents used for the same indication. However, their implementation may reduce the need for re-intervention during follow up. Biodegradable stents also seem to reduce the need for additional types of endoscopic therapeutic modalities, mostly balloon or bougie dilations. Results from pooled data are consistent, showing moderate efficacy along with a higher complication rate. Nonetheless, the validity of these results is questionable, given the heterogeneity of the studies included. Finally, adverse events may occur at a higher rate but are most often minor. The lack of high-quality studies with sufficient patient numbers mandates further studies, preferably randomized, to elucidate the exact role of biodegradable stents in the treatment of refractory benign esophageal strictures. © 2020 Hellenic Society of Gastroenterology.

The beneficial effect of sinus bradycardia during targeted temperature management (TTM) in cardiac arrest patients remains doubtful. We aimed to investigate the impact of sinus bradycardia on survival and neurological outcome. MEDLINE (PubMed), Cochrane, Google Scholar, and ClinicalTrials.gov databases were searched for studies reporting on comatose postcardiac arrest patients presenting sinus bradycardia during TTM. Outcomes were the 180-day survival and final neurologic function assessed by the Cerebral Performance Category scale. The effect size on study outcomes is presented as odds ratio (OR) with 95% confidence interval (CI). Two studies with 681 patients were included. Compared to no-sinus bradycardia group, in patients with sinus bradycardia below 50 bpm, a significant effect of sinus bradycardia on reduction of 180-day mortality was reported (OR = 0.42; 95% CI: 0.29-0.59). No heterogeneity was detected. Sinus bradycardia below 50 bpm during TTM may be protective and should be considered in comatose postcardiac arrest patients. © Copyright 2020, Mary Ann Liebert, Inc., publishers 2020.

Artificial intelligence (AI) systems, especially after the successful application of Convolutional Neural Networks, are revolutionizing modern medicine. Gastrointestinal Endoscopy has shown to be a fertile terrain for the development of AI systems aiming to aid endoscopists in various aspects of their daily activity. Lesion detection can be one of the two main aspects in which AI can increase diagnostic yield and abilities of endoscopists. In colonoscopy, it is well known that a substantial rate of missed neoplasia is still present, representing the major cause of interval cancer. In addition, an extremely high variability in adenoma detection rate, the main key quality indicator in colonoscopy, has been extensively reported. The other domain in which AI is believed to have a considerable impact on everyday clinical practice is lesion characterization and aid in "optical diagnosis". By predicting in vivo histology, such pathology costs may be averted by the implementation of two separate but synergistic strategies, namely the "leave-in-situ"strategy for < 5 mm hyperplastic lesions in the rectosigmoid tract, and "resect and discard"for the other diminutive lesions. In this opinion review we present current available evidence regarding the role of AI in improving lesions' detection and characterization during colonoscopy. © The Author(s) 2020. Published by Baishideng Publishing Group Inc. All rights reserved.

Functional dyspepsia (FD) is one of the most prevalent chronic functional gastrointestinal disorders. Several distinct pathophysiological mechanisms, including gastro duodenal motor disorders, visceral hypersensitivity, brain-gut interactions, duodenal subtle inflammation, and genetic susceptibility, have been implicated in the pathogenesis of the disease, so far. However, emerging evidence suggests that both quantitative and qualitative disturbances of the gastrointestinal microbiota may also be implicated. In this context, several studies have demonstrated differences of the commensal bacterial community between patients with FD and healthy controls, while others have shown that intestinal dysbiosis might associate with disease’s symptoms severity. Elucidating these complex interactions constituting the microbiota and host crosstalk, may eventually lead to the discovery of novel, targeted therapeutic approaches that may be efficacious in treating the multiple aspects of the disorder. In this review, we summarize the data of the latest research with focus on the association between gut microbiota alterations and host regarding the pathogenesis of FD. © 2020 by the authors. Licensee MDPI, Basel, Switzerland.

Background and Aims: Previous meta-analysis showed marginal benefit of high-definition white-light endoscopy (HD-WLE) over standard-definition colonoscopy (SDC) for adenoma detection, but with residual uncertainty due to inclusion of nonrandomized studies. We aimed to further assess the effect of HD-WLE on adenoma detection by including only randomized controlled trials (RCTs). Methods: A literature search was performed for RCTs evaluating HD-WLE versus SDC in terms of adenoma, advanced adenoma, and serrated sessile adenoma detection rates as well as the mean number of adenomas per colonoscopy (MAC), the mean number of advanced adenomas per colonoscopy (MAAC), and the mean number of sessile serrated adenomas per colonoscopy (MSSAC). The effect size on study outcomes is presented as the risk ratio (RR; 95% confidence interval [CI]) or mean difference (MD; 95% CI). We assessed the strength of evidence using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. Results: Six RCTs involving 4594 individuals (HD-WLE, 2323; SDC, 2271) were included. Clinical indications were screening (1 study), positive result for fecal occult blood test, personal/family history of colorectal cancer (1 study), and mixed indications (4 studies). Withdrawal time was similar between the 2 arms (MD, −0.06; 95% CI, −0.25 to 0.12; P = .50). The adenoma detection rate was significantly higher in the HD-WLE arm compared with the SDC arm (40% vs 35%; RR, 1.13; 95% CI, 1.05-1.22; P = .001; I2 = 0%; GRADE, low). This effect was consistent for advanced and sessile serrated adenoma detection rates (RR, 1.33; 95% CI, 1.03-1.72; P = .03; I2 = 0%; GRADE, low; and RR, 1.55; 95% CI, 1.05-2.28; P = .03; I2 = 0%; GRADE, low, respectively). In contrast, the difference was not significant for MAC, MAAC, and MSSAC. Conclusions: Meta-analyses of RCT data support the use of HD-WLE in clinical practice, although the additional benefit is limited. © 2020 American Society for Gastrointestinal Endoscopy

The aim of the present study was to assess, for the first time to our knowledge, Listeria monocytogenes CFU changes, as well as to determine the transcription of key virulence genes, namely, sigB, prfA, hly, plcA, plcB, inlA, inlB, inlC, inlJ, inlP, and lmo2672 after in vitro exposure to human gastric and duodenal aspirates. Furthermore, investigations of the potential correlation between CFU changes and gene regulation with factors influencing gastric (proton pump inhibitor intake and presence of gastric atrophy) and duodenal pH were the secondary study aims. Gastric and duodenal fluids that were collected from 25 individuals undergoing upper gastrointestinal endoscopy were inoculated with L. monocytogenes serotype 4b strain LQC 15257 at 9 log CFU•mL-1 and incubated at 378C for 100 min and 2 h, respectively, with the time corresponding to the actual exposure time to gastric and duodenal fluids in the human gastrointestinal tract. Sampling was performed upon gastric fluid inoculation, after incubation of the inoculated gastric fluids, upon pathogen resuspension in duodenal fluids and after incubation of the inoculated duodenal fluids. L. monocytogenes CFU changes were assessed by colony counting, as well as reverse transcription quantitative PCR by using inlB as a target. Gene transcription was assessed by reverse transcription quantitative PCR. In 56% of the cases, reduction of the pathogen CFU occurred immediately after exposure to gastric aspirate. Upregulation of hly and inlC was observed in 52 and 58% of the cases, respectively. On the contrary, no upregulation or downregulation was noticed regarding sigB, prfA, plcA, plcB, inlA, inlB, inlJ, inlP, and lmo2672. In addition, sigB and plcA transcription was positively and negatively associated, respectively, with an increase of the pH value, and inlA transcription was negatively associated with the presence of gastric atrophy. Finally, a positive correlation between the transcriptomic responses of plcB, inlA, inlB, inlC, inlJ, inlP, and lmo2672 was detected. This study revealed that the CFU of the pathogen was negatively affected after exposure to human gastroduodenal aspirates, as well as significant correlations between the characteristics of the aspirates with the virulence potential of the pathogen. © 2020 International Association for Food Protection. All rights reserved.

Background: Recent prospective randomized controlled trials have evaluated deep convolutional neural network (CNN) based computer aided detection (CADe) of lesions in real-time colonoscopy. We conducted this meta-analysis to compare the adenoma detection rate (ADR) of deep CNN based CADe assisted colonoscopy to standard colonoscopy (SC) from randomized controlled trials (RCTs). Methods: Multiple databases were searched (from inception to May 2020) and parallel RCTs that compared deep CNN based CADe assisted colonoscopy to SC were included for this analysis. Using Mantel-Haenzel (M-H) random effects model, pooled risk ratios (RR) and mean difference (MD) were calculated. In between study heterogeneity was assessed by I2% values. Outcomes assessed included other per patient adenoma parameters. Findings: Six RCTs were included in our final analysis that utilized deep CNN based CADe system in real-time colonoscopy. Total numbers of patients assessed were 4962 (2480 in CADe and 2482 in SC group). CADe based colonoscopy demonstrated statistically higher pooled ADR, RR=1.5 (95% CI 1.3–1.72), p

BACKGROUND Endocuff - a plastic device with flexible projections - mounted on the distal tip of the colonoscope, promises improved colonic mucosa inspection. AIM To elucidate the effect of Endocuff on adenoma detection rate (ADR), advanced ADR (AADR) and mean number of adenomas per colonoscopy (MAC). METHODS Literature searches identified randomized-controlled trials evaluating Endocuff-assisted colonoscopy (EAC) vs conventional colonoscopy (CC) in terms of ADR, AADR and MAC. The effect size on study outcomes was calculated using fixed or random effect model, as appropriate, and it is shown as relative risk (RR) [95% confidence interval (CI)] and mean difference (MD) (95%CI). The rate of device removal in EAC arms was also calculated. RESULTS We identified nine studies enrolling 6038 patients. All studies included mixed population (screening, surveillance and diagnostic examinations). Seven and two studies evaluated the first and the second-generation device, respectively. EAC was associated with increased ADR compared to CC [RR (95%CI): 1.18 (1.05-1.32); Ι2 = 71%]; EAC benefits more endoscopists with ADR ≤ 35% compared to those with ADR > 35% [RR (95%CI): 1.37 (1.08-1.74); Ι2 = 49% vs 1.10 (0.99-1.24); Ι2 = 71%]. In terms of AADR and MAC, no difference was detected between EAC and CC [RR (95%CI): 1.03 (0.85-1.25); Ι2 = 15% and MD (95%CI): 0.30 (-0.17-0.78); Ι2 = 99%]. Subgroup analysis did not show any difference between the two device generations regarding all three endpoints. In EAC arms, the device had to be removed in 3% (95%CI: 2%-5%) of the cases mainly due to tortuous sigmoid or presence of diverticula along it. CONCLUSION EAC increases ADR compared to CC, especially for endoscopists with lower ADR. On the other hand, no significant effect on AADR and MAC was detected. © The Author(s) 2019. Published by Baishideng Publishing Group Inc. All rights reserved.

Background and aims: The effect of fellow involvement on colonoscopy outcomes is controversial. Thus, we evaluated this effect on adenoma detection rate (ADR) and on other colonoscopy quality indicators. Methods: MEDLINE and Cochrane central register of controlled trials were searched up to September 2018 for studies evaluating fellow-involved colonoscopies vs. attending physicians-only examinations in terms of colonoscopy outcomes. Primary outcome was ADR, while advanced ADR (AADR), mean number of adenomas per colonoscopy (MAC), cecum intubation rate (CIR) and adverse events rate comprised the secondary outcomes. The effect size on study outcomes was calculated using random-effects model and it is presented as Odds Ratio (OR) or Mean Difference (MD) with 95% confidence interval (CI). Results: Nineteen observational studies involving 34,059 patients (fellow-involved 16,875, attending physician-only 17,184) were included. Compared to the attending physician-only group, fellow involvement marginally increased ADR [OR (95%CI) = 1.12 (1.00–1.26); p = 0.06, I2 = 76%]. Attending physicians with low-to-moderate ADR (

Background and Aims. Inpatients’ bowel preparation before colonoscopy is frequently inadequate, and various interventions have been investigated to improve it, so far. We aimed to evaluate the efficacy of various interventions to improve inpatients’ colon preparation quality. Methods. We systematically reviewed the literature for publications on interventions aiming to improve the quality of inpatients’ colon preparation until June, 2018. Significant heterogeneity—measured with I2—was detected at the level of P < 0 1. Adequacy rates were measured using inverse variance, and the size effect of different interventions was calculated using random effects model and expressed as odds ratio (OR). Results. Seventeen studies enrolling 2733 inpatients were included. Overall, 67% (60-75%) of the participants achieved adequate colon cleansing (I2 = 97%; P < 0 001). In six studies assessing the impact of educational interventions to patient/physician/nurse vs. no intervention, adequate bowel preparation was achieved in 77% (62-91%) vs. 50% (32-68%) of the patients (OR 95%CI = 3 49 (1.67-7.28), P = 0 0009; I2 = 74%; P = 0 002). Ten studies examined variations (qualitative and/or quantitative) in bowel preparation regimens with adequate preparation detected in 71% (60-81%) of the participants, and a single study examined the administration of preparation through an esophagogastroduodenoscope, resulting in adequate prep in 71% of the patients. Conclusions. Despite several interventions, only two-thirds of inpatients achieve adequate colon preparation before colonoscopy. Educational interventions significantly improve inpatients’ bowel preparation quality. Copyright © 2019 Paraskevas Gkolfakis et al. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

The original version of this article contained mistakes, and the authors would like to correct them. The correct details are given below: & On page 6, right column line 4, SIBO should read IBS-C. & Figure 4, the legend of panel (d) should read IBS-M(+) (n = 10). & Figure 5, the legend of panel (b) should read IBS-M(+) (n = 10). The authors apologize for potential issues raised by these mistakes. © 2018, Springer Science+Business Media, LLC, part of Springer Nature.

Introduction: The impact of antithrombotic treatment on the findings of small-bowel capsule endoscopy for patients with obscure gastrointestinal bleeding remains contentious. We aimed to determine the effect of these agents on small-bowel video capsule endoscopy positive findings. Methods: MEDLINE, Cochrane Library, and Google Scholar were searched for studies reporting on patients receiving concurrent antithrombotic treatment, while undergoing capsule endoscopy for obscure gastrointestinal bleeding (OGIB). Outcomes were the effect of antithrombotic therapy—overall and per type of antithrombotic agent—on the examination’s positive findings and re-bleeding risk. The effect size of study outcomes is presented as odds ratio (OR) with 95% confidence interval (CI). Results: Fourteen studies with 1023 patients were included. We detected significant heterogeneity with no evidence of publication bias. Compared to antithrombotic drug nonusers, antithrombotic treatment was associated with an increased prevalence of positive findings [OR 1.98 (95% CI 1.34–2.93); P = 0.0006]. This effect did not differ between antiplatelet and anticoagulant treatments [OR 2.22 (95% CI 1.28–3.84); P = 0.005 and 2.53 (95% CI 1.66–3.87); P < 0.0001, respectively]. Antithrombotic use over no use was not associated either with overt [OR 1.17 (95% CI 0.51–2.66); P = 0.71] or with occult [OR 0.86 (95% CI 0.38–1.95); P = 0.71] bleeding pattern. However, concurrent antithrombotic treatment was associated with higher odds for re-bleeding compared to no treatment [OR 2.53 (95% CI 1.46–4.37); P = 0.0009]. Conclusions: Antithrombotic treatment is associated with more positive findings in small-bowel video capsule endoscopy in OGIB as well as higher odds of re-bleeding. © 2018, Springer Science+Business Media, LLC, part of Springer Nature.

Background & aims: Video capsule endoscopy (VCE) is the first-line diagnostic procedure for investigating obscure gastrointestinal bleeding (OGIB). Different re-bleeding rates following index VCE have been reported among Western and Eastern studies. Methods: We conducted a comprehensive literature search to identify studies examining re-bleeding rates after VCE for OGIB. Meta-analysis assessed the pooled proportion of re-bleeding events after VCE for OGIB according to study's origin (Western vs. Eastern) and according to the length of follow-up (≥24 months vs.

Background/Aim: Adenocarcinoma is one of the most common malignant tumors of the small intestine complicating Crohn’s disease. However, the coexistence of both conditions with diverticulosis of small bowel in young age makes this coincidence rare and clinical diagnosis very difficult. Case Report: We report a case of a woman admitted to our Department with acute abdominal pain and fever. The surgical and histological investigation, revealed a rare coexistence that has never been mentioned in the published medical literature. Conclusion: Ileal diverticulosis is not frequent and often asymptomatic as well as adenocarcinoma of the small bowel. In this case, those diseases along with Crohn’s disease led the patient to acute symptoms.

Background The usefulness of purgative preparation before small-bowel video capsule endoscopy is controversial. We aimed to examine the effect of purgative preparation on small-bowel video capsule endoscopy outcomes. Methods We performed literature searches in MEDLINE and the Cochrane library for randomized controlled trials evaluating the effect of purgative preparation (polyethylene glycol, sodium phosphate, others) vs. clear-liquid diet/fasting in patients undergoing small-bowel capsule endoscopy. Meta-analysis outcomes included the examination's diagnostic yield, small-bowel mucosal visualization quality, the examination's completion rate, and gastric and small-bowel transit times. The effect size on study outcomes was calculated using a fixed- or random-effect model, as appropriate, and is shown as the risk ratio (RR) with 95% confidence interval (CI). Results We identified 12 eligible trials with 17 sets of data including 1221 subjects. Significant heterogeneity was detected with no evidence of publication bias. As compared with clear-liquid diet, purgative bowel preparation did not increase capsule endoscopy diagnostic yield (RR 1.17 [95%CI 0.97 to 1.40]; P =0.11). Neither the small-bowel mucosal visualization quality (RR 1.14 [95%CI 0.96 to 1.35]; P =0.15) nor completion rate for the examination (RR 0.99 [95%CI 0.95 to 1.04]; P =0.76) significantly improved after purgative preparation. Purgatives also had no effect on video capsule endoscopy gastric and small-bowel transit times. Conclusions Our analysis challenges the usefulness of purgative preparation for improving the diagnostic yield of small-bowel video capsule endoscopy and the quality of small-bowel mucosal visualization. © Georg Thieme Verlag KG Stuttgart.New York.

Although colonoscopy has been proven effective in reducing the incidence of colorectal cancer through the detection and removal of precancerous lesions, it remains an imperfect examination, as it can fail in detecting up to almost one fourth of existing adenomas. Among reasons accounting for such failures, is the inability to meticulously visualize the colonic mucosa located either proximal to haustral folds or anatomic curves, including the hepatic and splenic flexures. In order to overcome these limitations, various colonoscope attachments aiming to improve mucosal visualization have been developed. All of them-transparent cap, Endocuff, Endocuff Vision and Endorings- A re simply mounted onto the distal tip of the scope. In this review article, we introduce the rationale of their development, present their mode of action and discuss in detail the effect of their implementation in the detection of lesions during colonoscopy. © 2018 The Author(s).

Endoscopic biliary stent placement is an efficient method for the decompression of the biliary system in various benign and malignant causes. Dislocation and stent migration is a well-known complication, with most displaced stents passing through the bowel, uneventfully. Rarely, migrated stents can be accounted for potentially life-threatening complications. © 2018 The Authors. Clinical Case Reports published by John Wiley & Sons Ltd.

Background This study assessed Greek gastroenterology fellows’ satisfaction regarding training, working conditions, quality of life and future employment perspectives. Methods Greek gastroenterology fellows completed an anonymous multiple-choice electronic questionnaire designed to rate their satisfaction using a five-step Likert scale in two major domains: 1) fellowship program (training, working conditions, research activity, acquisition of endoscopic competencies, quality of life); and 2) professional expectations. Pareto analysis was used to determine the factors that had the most negative effect on fellows’ satisfaction. Results In 2016, over a two-month period, 121 invitations were distributed and 70 (58%) fellows responded. Overall, responders reported a low level of satisfaction with their training programs: the mean total satisfaction score was 42.94±11.55 (range 15-75). Pareto analysis revealed that the main factors negatively affecting satisfaction were financial remuneration, routine or menial work, and uncertainty about professional future (98.6%, 94.3% and 92.9% unfavorable answers, respectively). Of the total participants, 53% felt tired or very tired and 44.3% of them reported high levels of stress following a normal working day. Although the majority of the fellows did not regret choosing gastroenterology fellowship training, 34.4% of them would choose a different training environment, if possible. Conclusion Our study revealed that Greek gastroenterology fellows are dissatisfied with their training programs and with their professional perspectives. It also detected the issues that contribute most to this unfavorable outcome. © 2017 Hellenic Society of Gastroenterology.

Colonoscopy is the gold standard for colorectal cancer prevention; however, it is still an imperfect modality. Precancerous lesions can be lost during screening examinations, thus increasing the risk of interval cancer. A variety of factors either patient-, or endoscopist dependent or even the procedure itself may contribute to loss of lesions. Sophisticated modalities including advanced technology endoscopes and add-on devices have been developed in an effort to eliminate colonoscopy's drawbacks and maximize its ability to detect potentially culprit polyps. Novel colonoscopes aim to widen the field of view. They incorporate more than one cameras enabling simultaneous image transmission. In that way the field of view can expand up to 330°. On the other hand a plethora of add-on devices attachable on the standard colonoscope promise to detect lesions in the proximal aspect of colonic folds either by offering a retrograde view of the lumen or by straightening the haustral folds during withdrawal. In this minireview we discuss how these recent advances affect colonoscopy performance by improving its quality indicators (cecal intubation rate, adenoma detection rate) and other metrics (polyp detection rate, adenomas per colonoscopy, polyp/ adenoma miss rate) associated with examination's outcomes. © The Author(s) 2017. Published by Baishideng Publishing Group Inc. All rights reserved.

Background and study aims The Endocuff (ARC Medical Design, Leeds, UK) is a device that, when mounted on the tip of an endoscope, may assist with inspection of a greater surface of the colonic mucosa by pulling backwards, flattening, and stretching the colonic folds as the endoscope is gradually withdrawn. We aimed to compare the adenoma miss rates of Endocuff-assisted colonoscopy with those of conventional colonoscopy. Patients and methods The included patients underwent same-day, back-to-back, (Endocuff-assisted colonoscopy as the index procedure followed by conventional colonoscopy or vice versa, randomly assigned 1:1) colonoscopies, performed by six endoscopists with documented adenoma detection rates>35%, in four tertiary endoscopy facilities. Results We randomized 200 patients (mean age 61.2 years [standard deviation 9.8]; 86.5% colorectal cancer screening surveillance cases). Overall, there were seven incomplete examinations using Endocuff and one with conventional colonoscopy (P =0.03). Times for endoscope insertion (5.0 minutes [0.8-21.0] vs. 5.0 minutes [1.0-16.0]; P =0.49) and withdrawal (6.0 minutes [3.2-29.0] vs. 6.0 minutes [3.1-17.0]; P =0.06) were similar for Endocuff-assisted and conventional colonoscopy. We detected one cancer and 195 adenomas; 84 in the proximal colon. Endocuff-assisted colonoscopy showed significantly lower overall and proximal colon adenoma miss rates compared with conventional colonoscopy (14.7% [8.0%-21.0%] vs. 38.4% [28.1%-48.6%] and 10.4% [1.8%-19.1%] vs. 38.9% [23.0%-54.8%], respectively). No difference between the two arms was shown regarding advanced adenoma miss rates, either overall or in the proximal colon. There were no serious adverse events related to the procedures. Conclusions In comparison with conventional colonoscopy, Endocuff-assisted colonoscopy has a significantly lower adenoma miss rate when performed by high-detector endoscopists. However, the incomplete colonoscopy rate with Endocuff is higher. ClinicalTrials.gov Identifier: NCT02340065. © Georg Thieme Verlag KG Stuttgart.New York.

Introduction: Since its introduction, small bowel video capsule endoscopy (VCE) use has evolved considerably. Aim: Evaluation of the temporal changes of small bowel VCE utilization in three tertiary centers in Greece in Era 1 (2002-2009) and Era 2 (2010-2014) and the development a forecast model for future VCE use during 2015-2017. Materials and methods: Data from all small bowel VCE examinations were retrieved and analyzed in terms of the annual number of the performed examinations, their indications and the significance of their findings. Results: Overall, we evaluated 3724 VCE examinations. The number of studies peaked in 2009 (n=595) and then decreased to reach 225 in 2014. Overall, more (53.8 vs. 51.4%) patients with iron-deficiency anemia and obscure gastrointestinal bleeding (IDA/OGIB) and fewer (10.7 vs. 14%) patients with chronic diarrhea were evaluated in Era 2 compared with Era 1 (P= 0.046). In Era 2, there were more nondiagnostic examinations (39.5 vs. 29.3%, P

Objective: Platelet activation is a consistent feature in inflammatory bowel disease. However, the role of circulating platelet derived microparticles (PDMPs) and the effects of disease activity and treatment on their levels has not been clarified yet in this disorder. Material and methods: Using flow cytometry, we measured platelet derived microparticles and platelet derived microparticles expressing Annexin V in platelet rich plasma from 47 Crohn’s disease and 43 ulcerative colitis patients and 24 healthy controls. Results: Crohn’s disease patients have greater PDMPs (0.31% ± 0.07% versus 0.14% ± 0.04%, p = 0.02) and PDMPs expressing Annexin V (27% ± 2.6% versus 14.6% ± 2.7%, p = 0.002) levels in comparison with healthy controls; however, both microparticles levels are not related with disease activity. Crohn’s disease patients on 5-ASA therapy show lower levels of PDMPs in comparison with those on no 5-ASA (0.30% ± 0.07% versus 0.32% ± 0.09%, p = 0.048). Ulcerative colitis patients have similar PDMPs and PDMPs expressing Annexin V levels, compared to healthy controls (p = 0.06 and p = 0.2, respectively) and there is no correlation of both microparticles expression with disease activity. 5-ASA has no effect on both microparticles levels in ulcerative colitis patients. Anti-TNF-α treatment has no effect on study’s microparticles expression in Crohn’s and ulcerative colitis patients. Conclusions: Circulating levels of platelet derived microparticles are increased only in Crohn’s patients, but they do not correlate with disease activity. 5-ASA treatment is associated with lower levels of PDMPs only in Crohn’s, while anti-TNF-α treatment does not influence expression of microparticles in inflammatory bowel disease patients. © 2016 Informa UK Limited, trading as Taylor & Francis Group.

Despite the effectiveness of endoscopic retrograde cholangiopancreatography (ERCP) for the treatment of choledocholithiasis, various complications have been described. We herein report the first case of prolonged post-ERCP jaundice due to toxicity of the contrast agent Iobitridol (®XENETIX, Guerbet, Roissy CdG Cedex, France) in a patient who underwent ERCP with sphincterectomy and common bile duct stone removal. While clinical improvement and normalization of aminotransferases and cholestatic enzymes after the procedure, an unexplained increase of direct bilirubin was noticed. A second ERCP was performed one week later, excluding possible remaining choledocholithiasis. Nevertheless, serum direct bilirubin increased further up to 15 mg/dL. Other potential causes of direct hyperbilirubinemia were ruled out and patient's liver biopsy was compatible with drug-induced liver toxicity. Additionally, the cause-result time connection between the use of Iobitridol and bilirubin increase indicated the possibility of a toxic effect related to the repeated use of the particular contrast agent. Iobitridol, a contrast agent, can induce prolonged direct hyperbilirubinemia. © 2016, Hepatobiliary Pancreat Dis Int. All rights reserved.

INTRODUCTION: We evaluated the effect of Helicobacter pylori (HP) eradication on p53, cyclin D1 expression, and cell proliferation in gastric mucosa. MATERIALS AND METHODS: We assessed p53, cyclin D1, and ki67 immunoexpression in gastric mucosa from 31 HP chronic gastritis patients and 12 controls. Reassessment was performed 6 months after successful HP eradication. RESULTS: Successful eradication resulted in significant decrease of p53 (1.53 ± 0.16 vs 0.83 ± 0.19, P = 0.01) and ki67 (9.84 ± 0.96 vs 4.77 ± 0.27, P ˃ 0.001) staining in the antrum. Similarly, p53 immunoreactivity significantly decreased in the corpus (1.27 ± 0.20 vs 0.46 ± 0.15, P = 0.02), while there was a trend for decreased corpus cyclin D1 and ki67 expression (0.17 ± 0.07 vs 0.0, P = 0.08 and 8.71 ± 1.24 vs 5.85 ± 0.54, P = 0.09, respectively). Impor-tantly, after successful HP eradication, the immunoreactivity of the studied parameters was similar to that of controls. CONCLUSION: Successful HP infection eradication restores p53, cyclin D1, and ki67 immunoreactivity in the gastric mucosa to the level of controls. © the authors, publisher and licensee Libertas Academica Limited.

AIM: To measure the compliance of an Academic Hospital staff with a colorectal cancer (CRC) screening program using fecal immunochemical test (FIT). METHODS: All employees of “Attikon” University General Hospital aged over 50 years were thoroughly informed by a team of physicians and medical students about the study aims and they were invited to undergo CRC screening using two rounds of FIT (DyoniFOB® Combo H, DyonMed SA, Athens, Greece). The tests were provided for free and subjects tested positive were subsequently referred for colonoscopy. One year after completing the two rounds, participants were asked to be re-screened by means of the same test. RESULTS: Among our target population consisted of 211 employees, 59 (27.9%) consented to participate, but only 41 (19.4%) and 24 (11.4%) completed the first and the second FIT round, respectively. Female gender was significantly associated with higher initial participation (P = 0.005) and test completion - first and second round - (P = 0.004 and P = 0.05) rates, respectively. Phy sician’s (13.5% vs 70.2%, P < 0.0001) participation and test completion rates (7.5% vs 57.6%, P < 0.0001 for the first and 2.3% vs 34%, P < 0.0001 for the second round) were significantly lower compared to those of the administrative/technical staff. Similarly, nurses participated (25.8% vs 70.2%, P = 0.0002) and completed the first test round (19.3% vs 57.6%, P = 0.004) in a significant lower rate than the administrative/technical staff. One test proved false positive. No participant repeated the test one year later. CONCLUSION: Despite the well-organized, guided and supervised provision of the service, the compliance of the Academic Hospital personnel with a FIT-based CRC screening program was suboptimal, especially among physicians. © 2016. Baishideng Publishing Group Inc. All Rights Reserved.

Background Non-alcoholic fatty liver disease (NAFLD) is a common disorder with poorly understood pathogenesis. Beyond environmental and genetic factors, cumulative data support the causative role of gut microbiota in disease development and progression. Data source We performed a PubMed literature search with the following key words: "non-alcoholic fatty liver disease", "non-alcoholic steatohepatitis", "fatty liver", "gut microbiota" and "microbiome", to review the data implicating gut microbiota in NAFLD development and progression. Results Recent metagenomic studies revealed differences in the phylum and genus levels between patients with fatty liver and healthy controls. While bacteroidetes and firmicutes remain the dominant phyla among NAFLD patients, their proportional abundance and genera detection vary among different studies. New techniques indicate a correlation between the methanogenic archaeon (methanobrevibacter smithii) and obesity, while the bacterium akkermanshia municiphila protects against metabolic syndrome. Among NAFLD patients, small intestinal bacterial overgrowth detected by breath tests might induce gut microbiota and host interactions, facilitating disease development. Conclusions There is evidence that gut microbiota participates in NAFLD development through, among others, obesity induction, endogenous ethanol production, inflammatory response triggering and alterations in choline metabolism. Further studies with emerging techniques are needed to further elucidate the microbiome and host crosstalk in NAFLD pathogenesis. © 2015 The Editorial Board of Hepatobiliary & Pancreatic Diseases International.

Background Endoscopic ultrasound (EUS)-guided tissue acquisition represents the choice of methods for suspected lymph nodes (LNs) located next to the gastrointestinal tract. This study aimed to compare the pooled diagnostic performance of EUS-guided fine-needle biopsy (EUS-FNB) and fine-needle aspiration (EUS-FNA) for LNs sampling. Methods We searched PubMed/MedLine and Embase databases through August 2021. Primary outcome was diagnostic accuracy; secondary outcomes were sensitivity, specificity, sample adequacy, optimal histological core procurement, number of passes, and adverse events. We performed a pairwise meta-analysis using a random-effects model. The results are presented as odds ratio (OR) or mean difference along with 95% confidence interval (CI). Results We identified nine studies (1,276 patients) in this meta-analysis. Among these patients, 66.4% were male; the median age was 67 years. Diagnostic accuracy was not significantly different between the two approaches (OR, 1.31; 95% CI, 0.81–2.10; P = 0.270). The accuracy of EUS-FNB was significantly higher when being performed with newer end-cutting needles (OR, 1.87; 95% CI, 1.17–3.00; P = 0.009) and in abdominal LNs (OR, 2.48; 95% CI, 1.52–4.05; P Conclusions EUS-FNA and EUS-FNB perform similarly in LN sampling; however, FNB performed with end-cutting needles outperformed FNA in terms of diagnostic accuracy.

There is scarce evidence on the comparison between different methods for the drainage of distal malignant biliary obstruction (DMBO) after endoscopic retrograde cholangiopancreatography (ERCP) failure. Therefore, we performed a network meta-analysis to compare the outcomes of these techniques. We searched main databases through September 2021 and identified five randomized controlled trials. The primary outcome was clinical success. The secondary outcomes were technical success, overall and serious adverse event rate. Percutaneous trans-hepatic biliary drainage was found to be inferior to other interventions (PTBD: RR 1.01, 0.88–1.17 with EUS-choledochoduodenostomy (EUS-CD); RR 1.03, 0.86–1.22 with EUS-hepaticogastrostomy (EUS-HG); RR 1.42, 0.90–2.24 with surgical hepaticojejunostomy). The comparison between EUS-HG and EUS-CD was not significant (RR 1.01, 0.87–1.17). Surgery was not superior to other interventions (RR 1.40, 0.91–2.13 with EUS-CD and RR 1.38, 0.88–2.16 with EUS-HG). No difference in any of the comparisons concerning adverse event rate was detected, although PTBD showed a slightly poorer performance on ranking analysis (SUCRA score 0.13). In conclusion, all interventions seem to be effective for the drainage of DMBO, although PTBD showed a trend towards higher rates of adverse events.

INTRODUCTION : There is increasing evidence to support the efficacy of endoscopic ultrasound (EUS)-guided through-the-needle biopsy (TTNB) technique as a means of sampling pancreatic cystic lesions (PCLs). Results provide evidence demonstrating the benefits of this procedure over standard EUS fine-needle aspiration (FNA), thus supporting a push for its widespread implementation in clinical practice. Though this technique has demonstrated advantages, achieving these advantages in clinical practice is contingent upon careful considerations to ensure safety and efficacy. AREAS COVERED : The purpose of this review is to assess the level of evidence supporting the use of through-the-needle biopsy, revise its main technical and procedural characteristics, and to develop suggested guidelines outlining the safe assimilation of this device in clinical practice. EXPERT OPINION : EUS-TTNB enables more definitive and accurate diagnosis of PCLs by providing higher quality histological samples. However, EUS-TTNB is not appropriate for all PCLs. Selection of suitable patients as well as morphology and risk factors of the cystic lesion is a crucial component of achieving the described benefits of this procedure while minimizing risks of adverse effects. Subjects with weak or absent indications for this procedure are susceptible to a range of complications and may even result in fatality.