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Introduction: Calcium is an essential co-factor in the coagulation cascade, and hypocalcemia is associated with adverse outcomes in bleeding patients, including trauma patients, women with postpartum hemorrhage, and patients with intracranial hemorrhage. In this retrospective, single-center, cohort study, we aimed to determine whether admission-ionized calcium (Ca++) is associated with higher rates of therapeutic interventions among patients presenting with acute nonvariceal upper gastrointestinal bleeding (NV-UGIB). Methods: Adult patients admitted due to NV-UGIB between January 2009 and April 2020 were identified. The primary outcome was defined as a need for clinical intervention (two or more packed cell transfusions, need for endoscopic, surgical, or angiographic intervention). Univariate and multivariable logistic regression analyses were performed to determine whether Ca++ was an independent predictor of the need for therapeutic interventions. Propensity score matching was performed to adjust the imbalances of covariates between the groups. Results: A total of 434 patients were included, of whom 148 (34.1%) had hypocalcemia (Ca++ <1.15 mmol/L). Patients with hypocalcemia were more likely to require therapeutic interventions than those without hypocalcemia (48.0% vs. 18.5%, p < 0.001). Specifically, patients with hypocalcemia were more likely to require endoscopic intervention for control of bleeding (25.0% vs. 15.7%, p = 0.03) and multiple packed cell transfusions (6.8% vs. 0.3%, p < 0.001). Additionally, they had significantly longer hospital stay (5.0 days [IQR 3.0–8.0] vs. 4.0 days [IQR 3.0–6.0], p = 0.01). After adjusting for multiple covariates, Ca++ was an independent predictor of the need for therapeutic intervention (aOR 1.62, 95% confidence interval [CI] 1.22–2.14, p < 0.001). The addition of Ca++ to the Modified Glasgow Blatchford score improved its accuracy in the prediction of therapeutic intervention from AUC of 0.68 (95% CI 0.63–0.72) to 0.72 (95% CI 0.67–0.76), p = 0.02. After incorporation of the propensity score, the results did not change significantly. Conclusion: These findings suggest that hypocalcemia is common and is associated with an adverse clinical course in patients with NV-UGIB. Measurement of Ca++ on admission may facilitate risk stratification in these patients. Trials are needed to assess whether the correction of hypocalcemia will lead to improved outcomes. [ABSTRACT FROM AUTHOR]

BACKGROUND : Clinically significant post-endoscopic bleeding (CSPEB) is a common complication following colonic endoscopic mucosal resection (EMR). Current prediction tools are clinical and do not use the appearance of the post-EMR mucosal defect. We aimed to predict CSPEB by analyzing blood vessel morphology within the post-EMR mucosal defect. METHODS : 43 patients with CSPEB were matched to 43 non-bleeders for clinical variables associated with CSPEB. Computerized image analysis quantified the morphologic characteristics of the blood vessels in the defect. Variables were measured in relation to the mucosal defect area. Multivariate analysis and a neural network (NNET) were used as prediction models. RESULTS : The CSPEB group vessels had larger maximum diameter (113.07 vs. 69.03; P < 0.001), larger minimum radius (5.09 vs. 3.28; P = 0.002), larger perimeter value (337.82 vs. 193.86; P < 0.001), larger vessel length-of-outline (351.83 vs. 220.68; P = 0.002), and larger fractal dimension (1.11 vs. 1.10; P = 0.005) compared with non-bleeders. Discriminant analysis yielded 86 % sensitivity and 76.7 % specificity and an NNET classifier yielded 100 % sensitivity and 76.9 % specificity for identifying patients at risk. CONCLUSIONS : Blood vessel morphology in the post-EMR defect can be used to predict bleeding following colonic EMR. [ABSTRACT FROM AUTHOR]

Background Colorectal cancer is a significant cause of mortality and morbidity in western countries. Polypectomy reduces the incidence and mortality of colorectal cancer. Following polypectomy, recommendations regarding the frequency and duration of surveillance rely mostly on features of the resected polyps and are summarized in various gastroenterological societal guidelines. In this study, we aimed to delineate the accuracy of current post-polypectomy surveillance recommendations and to check whether active intervention would lead to an improvement in accuracy and consistency with societal guidelines. Methods We prospectively collected polypectomy reports over a 3-month period in 2 tertiary medical centers. We then performed an intervention that included: 1) presentation of results from 1st phase; 2) re-affirming the guidelines in a departmental meeting; 3) addition of a dedicated reporting form for post-polypectomy surveillance recommendations in the patients' electronic medical file. Finally, we conducted a second prospective collection of post-polypectomy recommendations, over a second 3-month period. Results Prior to the intervention, 76% of the colonoscopies with polypectomy had a recommendation for surveillance, compared to 85% after the intervention (P=0.003). Prior to the intervention, 65% of patients received a recommendation consistent with societal guidelines, compared with 78% after the intervention (P=0.001). Conclusion Intervention, including re-affirmation of the current guidelines and creation of a dedicated reporting platform, significantly increases the number of follow-up recommendations after polypectomy and their consistency with societal guidelines. [ABSTRACT FROM AUTHOR]

Background: Endoscopic resection of ampullary adenomas is a safe and effective alternative to surgical resection. A subgroup of patients have large laterally spreading lesions of the papilla Vateri (LSL-P), which are frequently managed surgically. Data on endoscopic resection of LSL-P are limited and long-term outcomes are unknown. The aim of this study was to compare the outcomes of endoscopic resection of LSL-P with those of standard ampullary adenomas.Methods: A retrospective analysis of a prospectively collected and maintained database was conducted. LSL-P was defined as extension of the lesion ≥ 10 mm from the edge of the ampullary mound. Piecemeal endoscopic mucosal resection of the laterally spreading component was followed by resection of the ampulla. Patient, lesion, and procedural data, as well as results of endoscopic follow-up, were collected.Results: 125 lesions were resected. Complete endoscopic resection was achieved in 97.6 % at the index procedure (median lesion size 20 mm, interquartile range [IQR] 13 - 30 mm). Compared with ampullary adenomas, LSL-Ps were significantly larger (median 35 mm vs. 15 mm), contained a higher rate of advanced pathology (38.6 % vs. 18.5 %), and had higher rates of intraprocedural bleeding (50 % vs. 24.7 %) and delayed bleeding (25.0 % vs. 12.3 %). Both groups had similar rates of histologically proven recurrence at first surveillance (16.4 % vs. 17.9 %). Median follow-up for the entire cohort was 18.5 months. For patients with at least two surveillance endoscopies (n = 68; median follow-up 29 months, IQR 18 - 48 months), 95.6 % were clear of disease and considered cured.Conclusions: LSL-P can be resected endoscopically with comparable outcomes to standard ampullectomy, albeit with a higher risk of bleeding. Endoscopic treatment should be considered as an alternative to surgical resection, even for large LSL-P. [ABSTRACT FROM AUTHOR]

Objective of the work: Pancreatic cancer (PC) is a deadly disease that is most commonly diagnosed at an incurable stage. Early diagnosis is the most important factor for improving prognosis. Evidence is beginning to accumulate that screening and surveillance may lead to the early detection of precursor lesions and/or pancreatic cancer in asymptomatic individuals. Proper screening methods and identification of such precursor lesions may enable effective pre-emptive interventions to prevent further fatalities. The primary objective of this project was to examine the feasibility of identifying precursor or early cancerous lesions in high-risk individuals by endoscopic ultrasound (EUS) screening to prevent the deaths from pancreatic cancer. Research aim: Pancreatic cancer screening guidelines, based on consensus opinions, have been applied in various tertiary centers around the world; however, evidence for effectiveness is lacking. At Rambam Health Care Campus, we have established a cohort of high-risk individuals, and we report our local 10-year experience results of screening for pancreatic cancer. Methods: Between 2008 and 2018, a cohort of 123 asymptomatic high-risk individuals came for annual/biannual EUS screening for pancreatic cancer. Retrospective and prospectively collected data were obtained, analyzed, and compared on the basis of several variables. These variables include age at beginning of screening, gender, smoking, obesity, diabetes, and presence of tumor markers, as well as the patients' personal and family history of cancers. Findings on each EUS are described. Results: Three patients out of 123 underwent potentially life-saving surgery as a result of this screening program. All of these three had only one first-degree relative (FDR) with pancreatic cancer at the time of their first screenings, but two eventually had a second FDR with PC. Findings from 296 EUS exams regarding smoking, obesity, and other risk factors are presented. Minor, possibly trivial, EUS findings are found to be common. Detection of precursor pancreatic lesions is feasible with EUS screenings. Conclusions: Adherence was an important limiting factor in screening. Better stratification of patients according to specific risk factors, including thorough genetics and family history, may direct when and how to initiate screening. International collaborations, such as the International Cancer of Pancreas Screening (CAPS) Consortium, of which Rambam is a collaborating partner, are needed to collate evidence for impact of screening to prevent pancreatic cancer morbidity and mortality, and are essential to achieve proof of concept. Different countries with varying health-care systems and budgets can find variance of appropriateness of screening procedures. [ABSTRACT FROM AUTHOR]

Background and study aims Adenomas of the duodenum and ampulla are uncommon. For lesions ≤ 20 mm in size and confined to the papillary mound, endoscopic resection is well supported by systematic study. However, for large laterally spreading lesions of the duodenum or papilla (LSL-D/P), surgery is often performed despite substantial associated morbidity and mortality. We aimed to compare actual endoscopic outcomes of such lesions and costs with those predicted for surgery using validated prediction tools. Patients and methods Patients who underwent endoscopic resection of LSL-D/P were analyzed. Two surgeons assigned the hypothetical surgical management. The National Surgical Quality Improvement Program (NSQIP), and the Portsmouth Physiological and Operative Severity Score for the enUmeration of Mortality and morbidity (P-POSSUM) were used to predict morbidity, mortality, and length of hospital stay. Actual endoscopic and hypothetical surgical outcomes and costs were compared. Results A total of 102 lesions were evaluated (mean age of patients 69 years, 52 % male, mean lesion size 40 mm). Complete endoscopic resection was achieved in 93.1 % at the index procedure. Endoscopic adverse events occurred in 18.6 %. Recurrence at first surveillance endoscopy was seen in 17.7 %. For patients with ≥ 2 surveillance endoscopies (n = 55), 90 % were clear of disease and considered cured (median follow-up 27 months). Compared with hypothetical surgical resection, endoscopic resection had less morbidity (18 % vs. 31 %; P = 0.001) and shorter hospital stay (median 1 vs. 4.75 days; P < 0.001), and was less costly than surgery (mean $ 11 093 vs. $ 19 358; P < 0.001). Conclusion In experienced centers, even extensive LSL-D/P can be managed endoscopically with favorable morbidity and mortality profiles, and reduced costs, compared with surgery. [ABSTRACT FROM AUTHOR]

Background Endoscopic ultrasound (EUS) with fi ne-needle aspiration (FNA) is universally used for the investigation and diagnosis of pancreatic cystic lesions (PCL). Infectious complications following EUS-FNA of PCL are rare. Antibiotic prophylaxis to reduce the risk of infection is recommended; however, there is no consensus on the optimal regimen or route of administration. Potential advantages of a single-dose intravenous (IV) antibiotic over a prolonged oral regimen include simplicity, guaranteed delivery and fewer antibiotic related adverse events, but there are only limited data to support this. We aimed to investigate the safety and efficacy of a single 1 g dose of IV ceft riaxone in preventing infectious complications following EUS-FNA of PCL. Methods A retrospective analysis was conducted of EUS-FNA of PCL procedures performed at our center. We reviewed patient medical records for any presentation to a hospital in our district within 30 days of the procedure. An infectious complication was defined as fever/rigors, or bacteremia, or abdominal pain accompanied by imaging or laboratory results suggestive of infection, within 30 days of the procedure. Data collection included patient demographics, procedural data and outcome. Results EUS-FNA of 204 PCL (mean size 18.0 mm) was performed. Successful fl uid aspiration was achieved in 94% of cases. Single-dose IV ceft riaxone was given in 146/204 (72%) cases. Four patients had a complication (pancreatitis n=1, post-procedural pain n=3). No infectious complications and no IV antibiotic-related adverse events were identified. Conclusion A single dose of IV ceft riaxone appears to be a safe, effective and convenient intervention for preventing infectious complications aft er FNA. [ABSTRACT FROM AUTHOR]

Large (≥20 mm) nonpedunculated colorectal polyps (LNPCPs) may have synchronous LNPCPs in up to 18% of cases. The nature of this relationship has not been investigated. We aimed to examine the relationship between individual LNPCP characteristics and synchronous colonic LNPCPs. Consecutive patients referred for resection of LNPCPs over 130 months until March 2022 were enrolled. Serrated lesions and mixed granularity LNPCPs were excluded from analysis. Patients with multiple LNPCPs resected were identified, and the largest was labelled as dominant. The primary outcome was the identification of individual lesion characteristics associated with the presence of synchronous LNPCPs. There were 3149 of 3381 patients (93.1%) who had a single LNPCP. In 232 (6.9%) a synchronous lesion was detected. Solitary lesions had a median size of 35 mm with a predominant Paris 0-IIa morphology (42.9%) and right colon location (59.5%). In patients with ≥2 LNPCPs, the dominant lesion had a median size of 40 mm, Paris 0-IIa (47.6%) morphology, and right colon location (65.9%). In this group, 35.8% of dominant LNPCPs were non-granular compared with 18.7% in the solitary LNPCP cohort. Non-granular (NG)-LNPCPs were more likely to demonstrate synchronous disease, with left colon NG-LNPCPs demonstrating greater risk (odds ratio, 4.78; 95% confidence interval, 2.95–7.73) than right colon NG-LNPCPs (odds ratio, 1.99; 95% confidence interval, 1.39–2.86). We found that 6.9% of LNPCPs have synchronous disease, with NG-LNPCPs demonstrating a greater than 4-fold increased risk. With post-colonoscopy interval cancers exceeding 5%, endoscopists must be cognizant of an individual's LNPCP phenotype when examining the colon at both index procedure and surveillance. ClinicalTrials.gov , NCT01368289; NCT02000141; NCT02198729. [ABSTRACT FROM AUTHOR]

Background and Aim Diagnostic yield of video capsule endoscopy may be hampered by intestinal content or air bubbles. A major limitation in video capsule-related study is the lack of a validated objective score for bowel preparation quality. We aimed to design and validate a computed small bowel preparation score for research and clinical use. Methods Two experienced physicians reached a consensus regarding bowel preparation quality based on known criteria used in previous studies and their confidence of an accurate medical interpretation of the procedure. A computed algorithm based on the pixels in the color bar was created and validated. Concordance between the gastroenterologists' agreement (gold standard) and the computed analysis was assessed. Results Of 85 videos studied, 44 (52%), 13 (15%) and 28 (33%) had adequate, borderline and inadequate bowel preparation, respectively, according to the gastroenterologists' agreement. Computer analysis restricted to adequate and inadequate cases yielded accurate classification of bowel preparation in 65/72 cases (90% agreement, sensitivity 95%, specificity 82%, total accuracy 90%, Kappa 0.79). When adding the borderline definition, the computer analysis correctly classified 71/85 of the cases, yielding an overall agreement of 84% (Kappa 0.72). Minute-by-minute analysis of 10 cases also yielded an agreement of 91.4%. Conclusion The present study introduces a user-friendly computer analysis-based small bowel preparation score, which demonstrated excellent concordance with the physician 's assessment. This score holds promise as a standardization tool in research and clinical practice of video capsule endoscopy. Further validation is warranted. [ABSTRACT FROM AUTHOR]

Background and Study Aims: Endoscopic mucosal resection (EMR) is an established treatment for large (≥ 20 mm) laterally spreading lesions (LSLs). LSLs with complete or subtotal (> 90 %) circumferential extent (C-LSLs) are generally referred for surgery. Data on technique, efficacy, and safety of EMR for these lesions are absent. The aim of this study was to describe the technique and long-term outcomes of EMR for C-LSLs.Patients and Methods: Prospective observational study of consecutive patients referred for EMR of LSL at a tertiary care center over 63 months to April 2015. Amongst 979 patients with LSL, 12 patients with C-LSL were seen.Results: All lesions were tubulovillous adenomas with granular 0 - IIa + Is morphology. Median longitudinal extent was 95 mm (range 60 - 160), 58 % were located in the rectum, and 3 lesions (25 %) had complete circumferential involvement. EMR technical success was 100 %. There were no major adverse events. Symptomatic stricturing occurred in 2 cases (17 %) and was treated with endoscopic balloon dilation (median 4 sessions). Median follow up is 13 months. Minor residual adenoma was found in 7 (58 %) at first surveillance colonoscopy and was treated with snare excision. A total of 10 patients have completed a second surveillance colonoscopy with minor residual adenoma found in only 1 case. No patient required surgery or developed cancer in long-term follow-up.Conclusions: Endoscopic resection of C-LSL is feasible and safe. Minor residual adenoma is common but endoscopically treatable with long-term cure. Symptomatic stricturing amenable to balloon dilation may occur. Empiric surgical referral for C-LSL based on extensive circumferential involvement may be avoided.ClinicalTrials.gov NCT01368289. [ABSTRACT FROM AUTHOR]

Background Video capsule endoscopy (VCE) is an established diagnostic tool for the investigation of small bowel (SB) pathology. Bowel preparation prior to VCE may improve visualization, transit time, and diagnostic yield. We aimed to evaluate the "real-life" experience comparing two different preparation protocols in patients undergoing SB VCE. Methods We performed a retrospective analysis of prospectively collected data from SB VCE procedures, performed in two tertiary care medical centers in Israel. VCE procedures performed at "Sheba Medical Center" used a 2-L polyethylene glycol (PEG) bowel preparation (n=360) while VCEs performed at "Rambam Health Care campus" used a clear liquid diet plus 12-h fast protocol (n=500). A dichotomous preparation scale (adequate, inadequate) was used to classify cleansing quality. Data collection included patient and procedural details. The proportion of VCE procedures with adequate bowel preparation and the overall positive SB findings in the two different bowel preparation protocols were evaluated. Results SB completion rates were higher in the PEG protocol (96% vs. 83%, P<0.001) and SB passage time was significantly faster in the PEG protocol (mean 217±73 vs. 238±77 min, P<0.001). Bowel preparation quality was similar between groups (8% vs. 7% inadequate preparation, P=0.591). Overall positive SB findings were similar between the two groups (57% clear liquid fasting only vs. 51% PEG protocol, P=0.119). Conclusion In this large cohort, a 2-L PEG protocol had similar preparation quality and diagnostic yield compared with clear liquid fasting. [ABSTRACT FROM AUTHOR]

Background and Aims: Propofol administered in combination with other moderate sedation medications (balanced propofol sedation [BPS]) is an appealing and effective sedation regimen for gastrointestinal (GI) endoscopy procedures. However, product labeling dictates propofol be administered only by anesthesiology personnel. We evaluated the safety of endoscopist-directed as well as anesthesiologist-administered BPS during outpatient colonoscopy. Methods: We performed a retrospective cohort study using prospectively collected endoscopy data where endoscopist-directed BPS is standard practice. Measured patient outcomes included: BPS drug dosages, postcolonoscopy oxygen saturation levels, pulse, and systolic/diastolic blood pressures, need for mask bag ventilation or endotracheal intubation, aborted colonoscopy due to sedation, hospital admission postcolonoscopy, and mortality. Results: From April 1 to November 30, 2013, 1036 patients undergoing outpatient colonoscopy (mean age 56.4 years, 55% males, 32% American Society of Anesthesiologists [ASA] I, 59% ASA II, 9% ASA III) received endoscopist-directed BPS. During the same time period, 40 patients (mean age 66.6 years, 55% males, 33% ASA II, 67% ASA III) received anesthesiologist-administered BPS. Indications for colonoscopy for the endoscopist-directed BPS included 352 (34%) colorectal cancer screening/surveillance, 404 (39%) evaluation of lower GI symptoms, 156 (15%) positive fecal occult blood, and 124 (12%) inflammatory bowel disease. BPS dosages (mean ± standard deviation) per patient were Fentanyl 0.05 mg (fixed dose), midazolam 1.6 mg ± 0.5 mg (range: 1-5 mg), and propofol 104 mg ± 62 mg (range: 10--460 mg). Propofol doses correlated inversely with patient age (r = -0.35; P < 0.001), and the mean Propofol dose was lower as ASA score increased: ASA I -- 115 mg, ASA II -- 103 mg, and ASA III -- 75 mg (P < 0.01). No patient required bag mask ventilation, endotracheal intubation, or hospital admission. There were no aborted colonoscopies secondary to sedation and no mortality. All patients were discharged directly to home. Conclusions: Endoscopist-directed BPS appears safe and effective for low-, intermediate- and high-risk patients undergoing outpatient colonoscopy. [ABSTRACT FROM AUTHOR]

The article offers information on the clinical guidelines imposed by the organization the European Society of Gastrointestinal Endoscopy (ESGE). The document explores on the important role of device-assisted enteroscopy and small-bowel endoscopy in the diagnosis as well as the treatment of the small-bowel disorders. Moreover, the recommendations of the ESGE are also stated.

The article discusses the management of colonic polyps which vary in size, morphology and risk. Topics discussed include the effectiveness of colonoscopy with polypectomy in reducing the incidence and mortality of colorectal cancer, diminutive polyps in the rectum and distal sigmoid colon and the risks of hot forceps polypectomy.