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Most of the studies using the colorectal tissue explants challenge model have been conducted after one single-dose and before reaching a steady-state. We consider that longer exposure as in 28-day post-exposure prophylaxis (PEP) course and in an at-risk setting, such as after a sexual risk exposure to HIV could give us valuable information about these drugs. In a substudy we assessed pharmacokinetics, changes on immune system and ex-vivo rectal mucosal susceptibility to HIV-1 infection after taking maraviroc (MVC), raltegravir (RAL) and ritonavir-boosted lopinavir (LPV/r) PEP-based regimens in 30 men who have sex with men. Participants received 28 days of twice-daily MVC (n=11), RAL (n=10) or LPV/r (n=9) all with tenofovir/emtricitabine backbone. Blood, rectal fluid (RF) and rectal tissue (RT) samples were collected at day 7, 28 and 90 after starting PEP. The samples obtained at day 90 were considered baseline. All studied antiretrovirals were quantifiable at 7 and 28 days in all tissues. Activation markers were increased in CD4 mucosal mononuclear cells (MMC) after 28 days of MVC: CD38+ 68.5 vs 85.1, p=0.008 and CD38+DR+ 16.1 vs 26.7, p=0.008. Exposure to MVC at both end-points (7 and 28 days) was associated with significant suppression of HIV-1BAL (p=0.005 and p=0.028) but we did not observe this effect with RAL or LPV/r. Merging together changes in MMC in all arms, we found a positive correlation in the CD8 T-cell lineage between the infectivity at day 7 and activation (CD38+ r=0.43, p=0.025, DR+ r=0.547, p=0.003 and 38+DR+ r=0.526, p=0.05), senescence (CD57+CD28- r=0.479, p=0.012), naïve cells (RA+CCR7+ r=0.484, p=0.01) and CCR5 expression (r=0.593, p=0.001). We conclude that maraviroc in combination with tenofovir/emtricitabine was associated with viral suppression in rectal explants and that overall ex-vivo HIV infectivity correlated with activation and senescence in CD8 mucosal mononuclear cells.

Background and study aims Serrated polyposis syndrome (SPS) is a condition with high risk for colorectal cancer. The Endocuff device has been shown to increase adenoma detection in the general and screening population. We aimed to ascertain whether Endocuff-assisted colonoscopy increases detection of serrated lesions in comparison with standard colonoscopy during the surveillance of patients with SPS. Methods In a multicenter randomized controlled study, patients who met SPS criteria I and/or III under surveillance (previous resection of all serrated lesions ≥ 4 mm) were consecutively randomly allocated 1:1 to Endocuff-assisted colonoscopy or standard colonoscopy, performed by expert endoscopists. The main outcome was the mean number of serrated lesions detected per patient. Results 122 patients (standard colonoscopy n = 60; Endocuff-assisted colonoscopy n = 62; 59 % men; mean age 60.6 (standard deviation [SD] 7.5) were included at 4 centers. Baseline variables (demographic data, SPS phenotype, colorectal cancer [CRC] history, cumulative polyps, and follow-up), cecal intubation rate, and withdrawal time were similar between groups. There was no statistically significant difference between Endocuff-assisted colonoscopy and standard colonoscopy for the mean number of serrated lesions detected per patient: 5.8 (95 % confidence interval [95 %CI] 4.4 – 7.2) and 5.0 (3.9 – 6.1), respectively (P = 0.36). There were also no differences between Endocuff-assisted and standard colonoscopy for detection of sessile serrated lesions (mean number per patient 2.5 [1.3 – 3.6] vs. 2.0 [1.1 – 3.0], P = 0.54) and adenomas (0.9 [0.5 – 1.3] vs. 0.5 [0.3 – 0.7], P = 0.12). Conclusion Use of Endocuff-assisted colonoscopy did not significantly increase the number of serrated lesion detected per patient during surveillance of SPS.

Background This study aimed to evaluate a new computational histology prediction system based on colorectal polyp textural surface patterns using high definition white light images. Methods Textural elements (textons) were characterized according to their contrast with respect to the surface, shape, and number of bifurcations, assuming that dysplastic polyps are associated with highly contrasted, large tubular patterns with some degree of bifurcation. Computer-aided diagnosis (CAD) was compared with pathological diagnosis and the diagnosis made by endoscopists using Kudo and Narrow-Band Imaging International Colorectal Endoscopic classifications. Results Images of 225 polyps were evaluated (142 dysplastic and 83 nondysplastic). The CAD system correctly classified 205 polyps (91.1 %): 131/142 dysplastic (92.3 %) and 74/83 (89.2 %) nondysplastic. For the subgroup of 100 diminutive polyps (≤ 5 mm), CAD correctly classified 87 polyps (87.0 %): 43/50 (86.0 %) dysplastic and 44/50 (88.0 %) nondysplastic. There were no statistically significant differences in polyp histology prediction between the CAD system and endoscopist assessment. Conclusion A computer vision system based on the characterization of the polyp surface in white light accurately predicted colorectal polyp histology.

Background Capsule endoscopy (CE) is the first-line investigation in cases of suspected Crohn's disease (CD) of the small bowel, but the factors associated with a higher diagnostic yield remain unclear. Objective Our aim is to develop and validate a scoring index to assess the risk of the patients in this setting on the basis of biomarkers. Patients and methods Data on fecal calprotectin, C-reactive protein, and other biomarkers from a population of 124 patients with suspected CD of the small bowel studied by CE and included in a PhD study were used to build a scoring index. This was first used on this population (internal validation process) and after that on a different set of patients from a multicenter study (external validation process). Results An index was designed in which every biomarker is assigned a score. Three risk groups have been established (low, intermediate, and high). In the internal validation analysis (124 individuals), patients had a 10, 46.5, and 81% probability of showing inflammatory lesions in CE in the low-risk, intermediate-risk, and high-risk groups, respectively. In the external validation analysis, including 410 patients from 12 Spanish hospitals, this probability was 15.8, 49.7, and 80.6% for the low-risk, intermediate-risk, and high-risk groups, respectively. Conclusion Results from the internal validation process show that the scoring index is coherent, and results from the external validation process confirm its reliability. This index can be a useful tool for selecting patients before CE studies in cases of suspected CD of the small bowel.

Background Bile leak after liver transplantation (LT) is commonly treated with endoscopic retrograde cholangiopancreatography (ERCP); however, there are limited data regarding the optimal treatment strategy. Objective We aimed to examine the role of ERCP in LT recipients with bile leaks at two large institutions. Methods We reviewed all ERCPs performed in LT recipients with bile leak and duct-to-duct biliary anastomosis at two high-volume transplant centers. Results Eighty patients were included. Forty-seven (59%) patients underwent ERCP with plastic stent placement (with or without sphincterotomy) and 33 patients (41%) underwent sphincterotomy alone. Complete resolution was obtained in 94% of the stent group vs. 58% of the sphincterotomy group ( p Conclusion ERCP with plastic stent placement is highly successful and more effective than sphincterotomy alone for post-LT bile leak treatment. These results indicate that ERCP and plastic stent placement should be considered the standard of care for the treatment of bile leaks in LT.

Background & Aims Guidelines recommend routine antibiotic prophylaxis for patients undergoing endoscopic ultrasonography-guided fine needle aspiration (EUS-FNA) of pancreatic cysts, but there is conflicting evidence for its necessity. We investigated whether performing the procedure without antimicrobial prophylaxis increases the incidence of infection. Methods We performed a multicenter, randomized, noninferiority trial to compare prophylaxis with ciprofloxacin vs placebo in patients with a pancreatic cyst requiring EUS-FNA at multiple centers in Spain. From September 2014 to June 2018, patients were randomly assigned to groups that received the prophylaxis with ciprofloxacin (n = 112) or saline solution (n = 114, placebo). We recorded patients' demographic data, lesion characteristics, and procedure data and followed patients for 21 days. A total of 205 patients completed the trial (90.7%), receiving ciprofloxacin or the control, with no statistically significant differences in demographics, baseline data, or procedure characteristics between groups. The primary outcome was FNA-related infection. Secondary outcomes were incidence of fever, procedure complications, and medication-related adverse events. Results The only case of FNA-related infection (0.44%) occurred in a patient in the placebo group (0.87%); this patient developed acute pancreatitis and bacteremia after the procedure. Prevention of infection was not inferior in the control group; the difference between proportions was 0.87% (95% confidence interval, –0.84% to 2.59%). There were no differences between groups in fever (2 patients in each group: 1.78% vs 1.76%; P = 1.00) or other adverse events. Conclusions In a randomized trial of patients undergoing EUS-FNA for pancreatic cyst evaluation, we found the risk of infection to be low. The incidence of infections did not differ significantly with vs without ciprofloxacin prophylaxis. (ClinicalTrials.gov, Number: NCT02261896).

Background & Aims Dye-based pancolonic chromoendoscopy is recommended for colorectal cancer surveillance in patients with Lynch syndrome. However, there is scarce evidence to support its superiority to high-definition white-light endoscopy. We performed a prospective study assess whether in the hands of high detecting colonoscopists, high-definition, white-light endoscopy is noninferior to pancolonic chromoendoscopy for detection of adenomas in patients with Lynch syndrome. Methods We conducted a parallel controlled study, from July 2016 through January 2018 at 14 centers in Spain of adults with pathogenic germline variants in mismatch repair genes (60% women; mean age, 47 ± 14 years) under surveillance. Patients were randomly assigned to groups that underwent high-definition white-light endoscopy (n = 128) or pancolonic chromoendoscopy (n = 128) evaluations by 24 colonoscopists who specialized in detection of colorectal lesions in high-risk patients for colorectal cancer. Adenoma detection rates (defined as the proportion of patients with at least 1 adenoma) were compared between groups, with a noninferiority margin (relative difference) of 15%. Results We found an important overlap of confidence intervals (CIs) and no significant difference in adenoma detection rates by pancolonic chromoendoscopy (34.4%; 95% CI 26.4%–43.3%) vs white-light endoscopy (28.1%; 95% CI 21.1%–36.4%; P = .28). However, pancolonic chromoendoscopy detected serrated lesions in a significantly higher proportion of patients (37.5%; 95% CI 29.5–46.1) than white-light endoscopy (23.4%; 95% CI 16.9–31.4; P = .01). However, there were no significant differences between groups in proportions of patients found to have serrated lesions of 5 mm or larger (9.4% vs 7.0%; P = .49), of proximal location (11.7% vs 10.2%; P = .68), or sessile serrated lesions (3.9% vs 5.5%; P = .55), respectively. Total procedure and withdrawal times with pancolonic chromoendoscopy (30.7 ± 12.8 minutes and 18.3 ± 7.6 minutes, respectively) were significantly longer than with white-light endoscopy (22.4 ± 8.7 minutes and 13.5 ± 5.6 minutes; P Conclusions In a randomized parallel trial, we found that for Lynch syndrome surveillance, high-definition white-light endoscopy is not inferior to pancolonic chromoendoscopy if performed by experienced and dedicated endoscopists. ClinicalTrials.gov no: NCT02951390.

Content-based image retrieval (CBIR) is an application of machine learning used to retrieve images by similarity on the basis of features. Our objective was to develop a CBIR system that could identify images containing the same polyp ('polyp fingerprint').A machine learning technique called Bag of Words was used to describe each endoscopic image containing a polyp in a unique way. The system was tested with 243 white light images belonging to 99 different polyps (for each polyp there were at least two images representing it in two different temporal moments). Images were acquired in routine colonoscopies at Hospital Clínic using high-definition Olympus endoscopes. The method provided for each image the closest match within the dataset.The system matched another image of the same polyp in 221/243 cases (91%). No differences were observed in the number of correct matches according to Paris classification (protruded: 90.7% vs. non-protruded: 91.3%) and size ( 10 mm: 91.6% vs. 10 mm: 90%).A CBIR system can match accurately two images containing the same polyp, which could be a helpful aid for polyp image recognition.

Introduction Over the past 20 years, aberrant crypt foci (ACF) have emerged as potential precursors and biomarkers for colorectal cancer (CRC). However, data regarding their molecular pathogenesis, as well as their endoscopic and histological identification, remain inconsistent. Methods A wide cohort of ACF from 100 control subjects and 100 case patients, including patients with adenoma and CRC, were characterized for endoscopic, morphologic, and molecular features. Results We observed that among all the endoscopic features evaluated, only the number of large ACF correlated with CRC risk (P = 0.003), whereas the histological classification, as assessed by 2 different pathologists, was inconsistent and did not differ between control and case patients. Moreover, only a few APC and BRAF mutations and no microsatellite instability were detected in our samples. KRAS mutations were detected in 16.3% of ACF samples, which also exhibited increased MGMT hypermethylation. However, none of those events were found to be predictive of CRC risk. Discussion Although ACF might be preneoplastic lesions of the colon, they are not suitable biomarkers for assessing CRC progression.

Polyp miss-rate is a drawback of colonoscopy that increases significantly for small polyps. We explored the efficacy of an automatic computer-vision method for polyp detection.Our method relies on a model that defines polyp boundaries as valleys of image intensity. Valley information is integrated into energy maps that represent the likelihood of the presence of a polyp.In 24 videos containing polyps from routine colonoscopies, all polyps were detected in at least one frame. The mean of the maximum values on the energy map was higher for frames with polyps than without (P 0.001). Performance improved in high quality frames (AUC = 0.79 [95 %CI 0.70 - 0.87] vs. 0.75 [95 %CI 0.66 - 0.83]). With 3.75 set as the maximum threshold value, sensitivity and specificity for the detection of polyps were 70.4 % (95 %CI 60.3 % - 80.8 %) and 72.4 % (95 %CI 61.6 % - 84.6 %), respectively.Energy maps performed well for colonic polyp detection, indicating their potential applicability in clinical practice.

BACKGROUND: Data on the outcome of adverse events (AEs) and the risk of developing acute-on-chronic liver failure (ACLF) after ERCP in patients with cirrhosis are unknown. We examined the incidence and risk factors of post-ERCP AEs in patients with cirrhosis and the appearance of ACLF after ERCP. METHODS: In this multicenter, retrospective, matched-cohort study, we evaluated ERCPs performed from January 2002 to 2015. A group of patients with cirrhosis with non-ERCP interventions and one without interventions was also analyzed for the development of ACLF. RESULTS: A total of 441 ERCPs were analyzed; 158 in patients with cirrhosis (cases) and 283 in patients without cirrhosis (controls). The overall rate of AEs after all ERCPs was significantly higher in cases compared to controls (17% vs 9.5, p = 0.02). Cholangitis developed more in cases compared to controls (6.3% vs 1.8%; p = 0.01). In a subanalysis of those with sphincterotomy, the rate of bleeding was higher in those with cirrhosis (9.4% vs 3.4%; p = 0.03). Logistic regression identified cirrhosis (OR, 2.48; 95% CI, 1.36-4.53; p = 0.003) and sphincterotomy (OR, 2.66; 95% CI, 1.23-5.72; p = 0.01) as risk factors of AEs. A total of 18/158 (11.4%) cases developed ACLF after ERCP. ACLF occurred in 7/27 cases with post-ERCP AEs and in 11/131 without post-ERCP AEs (25.9% vs 8.3%; p = 0.01). A total of 3.2% (13/406) patients without interventions developed ACLF compared to 17.5% (102/580) who developed ACLF after non-ERCP interventions. Patients with decompensated cirrhosis at ERCP had a higher risk of developing ACLF (17% vs 6.8%; p = 0.04). Patients with a MELD score >= 15 were 3.1 times more likely (95% CI: 1.14-8.6; p = 0.027) to develop ACLF after ERCP. CONCLUSIONS: The rate of AEs after ERCP is higher in patients with cirrhosis compared to the non-cirrhotic population. The incidence of ACLF is higher in those with AEs after ERCP compared to those without AEs, especially cholangitis. The development of ACLF is common after ERCP and other invasive procedures. ACLF can be precipitated by numerous factors which include preceding events before the procedure, including manipulation of the bile duct, and AEs after an ERCP.

Methodology evaluation for decision support systems for health is a time-consuming task. To assess performance of polyp detection methods in colonoscopy videos, clinicians have to deal with the annotation of thousands of images. Current existing tools could be improved in terms of flexibility and ease of use. We introduce GTCreator, a flexible annotation tool for providing image and text annotations to image-based datasets. It keeps the main basic functionalities of other similar tools while extending other capabilities such as allowing multiple annotators to work simultaneously on the same task or enhanced dataset browsing and easy annotation transfer aiming to speed up annotation processes in large datasets. The comparison with other similar tools shows that GTCreator allows to obtain fast and precise annotation of image datasets, being the only one which offers full annotation editing and browsing capabilites. Our proposed annotation tool has been proven to be efficient for large image dataset annotation, as well as showing potential of use in other stages of method evaluation such as experimental setup or results analysis.

BACKGROUND AND AIMS: Diagnostic yield of Small Bowel Capsule Endoscopy (SBCE) for the assessment of small bowel (SB) lesions is higher than radiologic imaging techniques. However, magnetic resonance enterography (MRE) data are scarce and inconclusive. Colon Capsule Endoscopy (CCE) is a new capsule modality. The primary aim of our study was to compare MRE and capsule endoscopy (CE) for the assessment of Crohn’s disease (CD). The secondary objectives were to compare the diagnostic accuracy of both CE modalities and changes in Montreal classification after each examination. METHODS: We included 47 patients with established (n = 32) or suspected CD (n = 15). MRE was performed first to rule out strictures. In patients with a suspected stricture by MRE, an Agile Patency Capsule was performed. SB disease activity was measured by MaRIA score (MRE) and Lewis Index (CE). RESULTS: SB lesions were found in 36 of47 patients with CE and in 21 of47 patients with MRE (76.6% vs 44.7%, P = 0.001). Jejunal inflammation was detected by CE in 31.9% of patients and by MRE in 6.4% of patients (15/47 vs 3/47; P = 0.03); lesions in ileum were detected in 57.4% of patients by CE, and in 21.3% of patients by MRE (27/ 47 vs 10/ 47; P = 0.04). Finally, in terminal ileum, CE showed lesions in 68.1% (32/47) of patients, whereas MRE detected lesions in 38.3% (18/ 47 patients), (P = 0.001). The original Montreal classification was changed in 53.1% of patients (25/ 47) based on CE findings and in 12.7% of patients (6/47) based on MRE findings (P < 0.05). CONCLUSIONS: In our cohort CE was significantly superior to MRE for detecting SB lesions, mainly superficial and proximal lesions. CE is useful for a appropriate patients’ classification according to Montreal classification.

Background. Individuals with a family history of colorectal cancer (CRC) have an increased risk of CRC. We evaluated the diagnostic yield of CCE in the detection of lesions and also two different colon preparations. Methods. A prospective multicenter study was designed to assess CCE diagnostic yield in a cohort of asymptomatic individuals with a family history of CRC. CCE and colonoscopy were performed on the same day by 2 endoscopists who were blinded to the results of the other procedure. Results. Fifty-three participants were enrolled. The sensitivity, specificity, PPV, and NPV of CCE for detecting advanced adenomas were 100%, 98%, 67%, and 100%. Sensitivity, specificity, PPV, and NPV of CCE for the diagnosis of individuals with polyps were 87%, 97%, 93%, and 88%, respectively. CCE identify 100% of individuals with significant or advanced lesions. Overall cleanliness was adequate by 60.7% of them. The PEG-ascorbic boost seems to improve colon cleanliness, with similar colonic transit time. Conclusion. CCE is a promising tool, but it has to be considered as an alternative technique in this population in order to reduce the number of colonoscopies performed. More studies are needed to understand appropriate screening follow-up intervals and optimize the bowel preparation regimen.

In this descriptive study, we examined the role of single-operator cholangioscopy (SOC) in the evaluation of biliary complications after liver transplantation (LT). We prospectively included adult recipients of deceased donor LT who were referred for endoscopic retrograde cholangiopancreatography between June 2009 and July 2011. All patients underwent SOC with biopsy of the biliary anastomosis. Sixteen patients were included: 12 with biliary anastomotic strictures (ASs), 2 with common bile duct stones, 1 with a bile leak, and 1 with sphincter of Oddi dysfunction. Patients with ASs displayed 1 of 2 patterns: (A) mild erythema (n = 9) or (B) edema, ulceration, and sloughing (n = 3). Those without ASs displayed a pale mucosa with mild edema at the anastomosis. Patients with ASs and pattern B required a longer period of stenting than patients with pattern A (457 versus 167 days, P = 0.02). In addition, patients with pattern A had a better response and better resolution of their strictures with endoscopic therapy than those with pattern B (66% versus 33%, P = 0.13). Histological examinations of ASs showed nonspecific intraepithelial inflammation in patients with patterns A and B. Biopsy samples from patients without ASs showed normal columnar epithelial bile duct cells. The total cholangioscopy time for all procedures was 26.8 ± 10.1 minutes. In conclusion, SOC in LT recipients is feasible and allows adequate visualization and tissue sampling of ASs and bile ducts. Two distinct visual patterns that are easily identified with SOC may help to predict the outcomes of endoscopic therapy in patients with biliary complications after LT.

The adenoma detection rate (ADR) is the main quality indicator of colonoscopy. The ADR recommended in fecal immunochemical testing (FIT)-based colorectal cancer screening programs is unknown.Using the COLONPREV (NCT00906997) study dataset, we performed a post-hoc analysis to determine if there was a correlation between the ADR in primary and work-up colonoscopy, and the equivalent figure to the minimal 20% ADR recommended. Colonoscopy was performed in 5722 individuals: 5059 as primary strategy and 663 after a positive FIT result (OC-Sensor™; cut-off level 15 µg/g of feces). We developed a predictive model based on a multivariable lineal regression analysis including confounding variables.The median ADR was 31% (range, 14%-51%) in the colonoscopy group and 55% (range, 21%-83%) in the FIT group. There was a positive correlation in the ADR between primary and work-up colonoscopy (Pearson's coefficient 0.716;ADR in primary and work-up colonoscopy of a FIT-positive result are positively and significantly correlated.

The aim of this study was to evaluate the restoration of gastrointestinal motility after NOTES using capsule endoscopy (CE).Twenty adult Yorkshire pigs were randomly assigned to four groups: transgastric NOTES (gNOTES), transrectal NOTES (rNOTES), transvaginal NOTES (vNOTES), and laparoscopy (LAP). At the end of a 30-min peritoneoscopy with identification of seven predetermined organs, an array of eight receivers and the recorder were attached to the abdominal wall. The CE was delivered into the antrum with the help of an endoscope and a polypectomy snare. Animals were kept alive for 14 d.Median time for surgery was longer in gNOTES (56 min, range 47-63) and vNOTES (54 min, range 44-79) than in LAP (32 min, range 32-33; P0.05 and P0.01) and in rNOTES (45.5 min, range 33-56) (P = ns). This increase was related to a larger incision and longer closure times. Images from the CE were successfully retrieved in 19 cases. The CE was retained in the stomach in all animals in gNOTES (459 min; range 360-600), but only in one animal in rNOTES and vNOTES and in none in the LAP group. Failure of passage of the CE beyond the stomach was associated with gNOTES and longer closure of the incision. Animals in the gNOTES group gained less weight than the others and this change was statistical significant when compared with vNOTES animals (1.7 kg, range -1.98 to 4.5 versus 8.4 kg, range 5.8 to 11.45; P0.01).Gastric emptying is delayed after gNOTES peritoneoscopy compared with rNOTES, vNOTES, and LAP and this effect is associated with less weight gain.

Resumen Introduccion La calidad y tolerancia de la limpieza anterograda del colon son elementos clave para el exito del programa de cribado poblacional de cancer colorrectal (PPCCR). Objetivos Evaluar la calidad de la limpieza y la tolerancia segun la hora de administracion del polietilenglicol en individuos del PPCCR. Metodo Los participantes del PPCCR fueron aleatorizados en 2 grupos: a) grupo control (colonoscopia programada 09:00-12:00 h), preparacion con polietilenglicol la tarde antes; b) grupo a estudio (colonoscopia programada 12:00-15:00 h), preparacion con polietilenglicol la manana de la exploracion, con opcion de dosis partida. Se valoro la calidad de la limpieza con la escala de Boston y la tolerancia mediante un cuestionario. Resultados Se incluyeron 282 individuos: 134 se prepararon el dia anterior y 148 el mismo dia, 26 de los cuales realizaron dosis partida. El 95% de los individuos (n = 268) presentaron una limpieza adecuada. La calidad de la preparacion fue superior en el grupo a estudio (p = 0,045). El tiempo entre la finalizacion de la ingesta y el comienzo de la prueba se correlaciono inversamente con la puntuacion de la escala de Boston, (p = 0,036; r = −0,125). La tolerancia no se relaciono con el horario de la ingesta (p > 0,2). Los individuos del grupo a estudio presentaron peor aceptacion del horario que los del grupo control (26 vs. 10%, respectivamente; p = 0,001). Conclusiones Los pacientes que se preparan lo mas cerca posible de la hora de la exploracion presentan mejor calidad de la limpieza sin detrimento en la tolerancia, aunque esta pauta resulta mas incomoda.

Inflammatory changes of different NOTES approaches remain unknown. The aim of this study was to compare the inflammatory effects of NOTES and laparoscopy.Forty female pigs were assigned to transgastric, transrectal, and transvaginal NOTES and laparoscopic peritoneoscopy groups. Antiseptic technique was utilized for NOTES whereas laparoscopy was performed sterile. Intraperitoneal pressures were monitored and maintained below 15 mmH(2)O. Pneumoperitoneum was maintained with CO(2) in all groups. Pre- and postoperative blood samples of IL-6, Il-1β, and TNFα, and peritoneal fluid collected at surgery were analyzed. Animals were followed daily for 14 days. At necropsy, peritoneal fluid was collected for cytokine analysis.Thirty-nine peritoneoscopies were successfully completed. The median procedure time was longer in the NOTES groups (57 min, range = 33-109) than in the laparoscopy group (33 min, range 32-36; P0.001); this was related to longer incision time and closure time. All 39 completed follow-up. Severe bleeding in the post-transrectal approach required early sacrifice of the remaining animal. Besides this, complications were similar among groups. At necropsy, adhesions were seen in four animals in the gastric group, five in the rectal group, two in the vaginal group, and two in the laparoscopic group (P = ns). There were no statistical differences in serum levels of TNFα among the groups. When serum TNFα values were expressed as the difference from the baseline, in the transvaginal group they were significantly lower than in the transrectal at 2 h [0.5 pg/ml (range = -14 to 59) vs. 60 pg/ml (range = -8 to 303); P = 0.041] and at 8 h [-5.5 pg/ml (range = -86 to 55] vs. 37 pg/ml (range = -30 to 62); P = 0.031]. The limitations of this study were that the analyses of IL-6 and Il-1β were not possible because most of the samples were below detectable levels, it was an animal model, and the sample size was small.Inflammatory parameters are similar between NOTES and laparoscopic peritoneoscopy despite longer surgery time in the NOTES group. The vaginal route seems to reduce the inflammatory stress.

Background & Aims: It is essential to optimize standard colonoscopy technique to be able to increase polyp detection. We sought to compare the performance of colonoscopy using a high-definition, wide-angle endoscope (HDE) versus a standard colonoscope (SC) for the detection of colorectal neoplasia. Patients and Methods: All consecutive consenting adult patients referred from primary care centers were included and randomly assigned at a 1:1 ratio to undergo HDE or SC. Times to reach and withdraw from the cecum were measured. Morphology, size, location, and pathologic diagnosis of each polyp were recorded. Sample size calculation resulted in a total of 682 patients needed. Results: A total of 693 consecutive patients fulfilled all inclusion criteria (73 excluded owing to insufficient bowel preparation). Each arm included 310 patients with no baseline characteristic differences. Time to reach the cecum was slightly superior for SC (8.9 ± 4.8 minutes vs 8.2 ± 4.5 minutes; P = .055). Pathology examination was feasible in 418 lesions (272 adenomas, 109 hyperplastic polyps, and 37 inflammatory lesions). Both techniques detected a similar number and type of lesions, and there were no differences in the distribution along the colon, in the degree of dysplasia, or morphology of adenomas. The per-patient basis analyses demonstrated that there were no differences between the 2 arms of the study in the detection rates of polyps (SC, 0.84 ± 1.59; HDE, 0.83 ± 1.30), adenomas (0.45 ± 1.07 vs 0.43 ± 0.87), small adenomas (0.22 ± 0.71 vs 0.28 ± 0.78), flat adenomas (0.30 ± 0.91 vs 0.21 ± 0.63), or hyperplastic polyps (0.16 ± 0.50 vs 0.18 ± 0.54). Conclusion: HDE did not detect significantly more colorectal neoplasia than SC.

Background and Aims Pancreatic cysts and solid lesions are routinely examined by EUS-guided FNA (EUS-FNA). The aim of this study was to compare the incidence of adverse events (AEs) of this procedure by using the lexicon recommended by the American Society for Gastrointestinal Endoscopy (ASGE). Methods This was a prospective and comparative study of patients who underwent EUS-FNA in which a 22-gauge needle was used. In the pancreatic cystic lesions group (group I), complete fluid evacuation in a single needle pass was attempted, and ciprofloxacin was given during the procedure and for 3 days after. In the pancreatic solid lesions group (group II), the number of passes was determined by the on-site evaluation of the sample. AEs were defined and graded according to the lexicon recommended by the ASGE. Patients were followed for 48 hours, 1 week, and 1 month after the procedure. Results A total of 146 patients were included, 73 in group I and 73 in group II. Potential factors influencing the incidence of AEs (ie, access route for FNA) were similar in both groups. AEs occurred in 5 of 146 patients (3.4%; 95% confidence interval [CI], 1.3%-8%): 4 in group I (5.5%; 95% CI, 1.7%-13.7%) and 1 in group II (1.4%; 95% CI, −0.5% to 8.1%) ( P = .03). Severity was mild in 1 of 5 patients (20%) and moderate in 3 of 5 patients (60%). One patient with a solid mass in the head of the pancreas had a duodenal perforation after EUS and died after surgery. All other AEs occurred in the first 48 hours and resolved with medical therapy. There were 3 incidents of transient hypoxia and self-limited abdominal pain in 1 and 2 patients, respectively. No patients were lost to follow-up. Conclusion EUS-FNA of pancreatic cysts has an AEs rate similar to that of solid pancreatic masses, which is small enough to consider this procedure a safe and effective method for managing patients with both types of lesions. AEs occurred early after EUS-FNA, and patients should be closely followed during the first 2 days after the procedure.

Background: The aim of this study was to determine the accuracy of advanced endoscopy for prediction of relapse in ulcerative colitis, in comparison with serum and fecal biomarkers. Methods: Patients with ulcerative colitis with sustained clinical remission defined as absence of blood in stool for a minimum of 3 months and Mayo endoscopic subscore of 0 were included. High-resolution rectosigmoidoscopy was performed at baseline and at the end of study (week 52 or relapse), assessing mucosal pit pattern by chromoendoscopy and narrow band imaging as well as vascular pattern by narrow band imaging. Histology was evaluated at baseline and at the end of the study. Follow-up for 1 year or until relapse with clinical evaluations and serum and fecal biomarkers every 3 months was established. Relapse was defined as presence of blood in stool and a Mayo endoscopic subscore $1 with histologic confirmation. Results: Seventeen out of 64 patients (27%) relapsed during the follow-up period. Baseline clinical characteristics in patients who relapsed and those who did not were similar. Neither pit or vascular pattern nor histology was significantly different between relapsers and nonrelapsers. Among serum biomarkers, high platelet count was significantly associated with higher relapse rates. Fecal calprotectin was predictor of relapse within 3- and 12-month period with high specificity but low sensitivity. Conclusions: Advanced endoscopy and histology do not predict relapse over 1-year period in patients with ulcerative colitis. Fecal calprotectin can predict relapse in 3- and 12-month period with low accuracy. (Inflamm Bowel Dis 2014;20:1187–1193)

Background. Transesophageal natural-orifice transluminal endoscopic surgery (NOTES) mediastinoscopy has been described as a feasible, less-invasive alternative to video-assisted mediastinoscopy (VAM). We aimed to investigate hemodynamic and respiratory effects during transesophageal NOTES mediastinoscopy compared with VAM. Patients and methods. This was a short-survival experiment in 20 female pigs randomized to NOTES (n = 10) or VAM (n = 10) mediastinoscopy. In the NOTES group, an endoscopist accessed the mediastinum through a 5-cm submucosal tunnel in the esophageal wall, and CO2 was used to create the pneumomediastinum. Conventional VAM was carried out by thoracic surgeons. A 30-minute systematic exploration of the mediastinum was then performed, including invasive monitoring for hemodynamic and respiratory data. Blood samples were drawn for gas analyses. Results. All experiments except 2 in the NOTES group (one because of technical difficulties, the other because of thoracic lymphatic duct lesion) were completed as planned, and animals survived 24 hours. Also, 3 animals in the NOTES group presented a tension pneumothorax that was immediately recognized and percutaneously drained. VAM and NOTES animals showed similar pulmonary and systemic hemodynamic behavior during mediastinoscopy. Pulmonary gas exchange pattern was mildly impaired during the NOTES procedure, showing lower partial arterial oxygen pressure associated with higher airway pressures (more important in animals that presented with pneumothorax). Conclusions. NOTES mediastinoscopy induces minimal deleterious respiratory effects and hemodynamic changes similar to conventional cervical VAM and could be feasible when performed under strict hemodynamic and respiratory surveillance. Notably, serious complications caused by the injury of pleura are more frequent in NOTES, which mandates an improvement in technique and suitable equipment.

Background Natural orifice transluminal endoscopic surgery (NOTES) mediastinoscopy (MED) through the esophagus has proved to be feasible in the animal model. However, injury of the adjacent pleura and pneumothorax has been reported as a frequent adverse event when using a blind access. Objective To assess the utility and safety of a CT-based image registration system (IRS) for navigation in the mediastinum. Design Prospective, randomized, controlled trial in 30 Yorkshire pigs. Thirty-minute MEDs were performed: 15 MEDs were performed with IRS guidance (MED-IRS), and 15 MEDs were performed with a blind access. Setting Animal research laboratory. Interventions In both groups, the mediastinum was accessed through a 10-cm submucosal tunnel in the esophageal wall. Timed exploration was performed with identification of 8 mediastinal structures. Main Outcome Measurements Technical feasibility, adverse events, and the number of mediastinal structures identified. Results Thirty animals weighing 31.5 ± 3.5 kg were included in this study. MED was not possible in 2 animals in the "MED with blind access" group but was possible in all MEDs performed with IRS. The mean number of identified organs was slightly higher in "with IRS-MED" (6.13 ± 1.3) than with MED with blind access (4.7 ± 2.3; P = .066). Moreover, the right atrium and vena cava were identified in more cases with IRS-MED than in MED with blind access (13 vs 3 and 15 vs 11, P = .000 and P = .03, respectively). There were 3 (23%) adverse events with IRS-MED and 4 (27%) with "MED with blind access" ( P = not significant), with pneumothorax being the most frequent (2 and 3, respectively). Limitations Nonsurvival animal study. Conclusions This study demonstrates that the IRS system appears feasible in natural orifice transluminal endoscopic surgery MED and suggests that IRS guidance might be useful for selected procedures.

The quality and tolerability of antegrade gut lavage bowel preparation are key elements in the success of population-based colorectal cancer screening.To evaluate cleansing quality and tolerability according to the timing of polyethylene glycol administration in persons undergoing colorectal cancer screening.Participants in colorectal cancer screening were randomized to two groups: a) control group (colonoscopy scheduled at 9-12 h); preparation with polyethylene glycol on the previous afternoon; b) study group (colonoscopy scheduled at 12-15 h): preparation with polyethylene glycol on the morning of the colonoscopy, with the option of a split dose. The quality of cleansing was evaluated with the Boston scale and tolerability through a questionnaire.A total of 282 participants were included: preparation was carried out the day before the procedure in 134 and on the same day in 148, of which 26 received a split dose. Cleansing was adequate in 95% (n=268) of the participants. The quality of cleansing was higher in the study group (P=.045). The interval between the end of administration and the beginning of the procedure was inversely correlated with the Boston scale score (P=.036; r=-0.125). Tolerability was unrelated to the time of administration (P.2). Acceptance of the timing of administration was lower in the study group than in the control group (26% vs 10%, respectively; P=.001).Preparation as close as possible to the colonoscopy improves the quality of cleansing with no detrimental effects on tolerability, although this option is less comfortable.

BACKGROUND: Infection in natural orifice transluminal endoscopic surgery (NOTES) remains controversial. OBJECTIVE: To estimate the frequency of infection during NOTES peritoneoscopy with different routes of access and to compare with laparoscopy. DESIGN: Prospective randomized controlled study (Canadian Classification type I). METHODS: Forty female pigs were randomly assigned to 3 NOTES (transgastric, transrectal, and transvaginal) and laparoscopic groups. Antiseptic technique was used for NOTES, whereas laparoscopy was performed in a sterile environment. Preoperative and postoperative intravenous antibiotics were administered. Closure of the transluminal access site was performed in all animals. Peritoneal fluid was collected for culture at the end of surgery and at necropsy at day 14. RESULTS: Thirty-nine peritoneoscopies were successfully completed. Necropsy confirmed complete healing of NOTES incisions, but 2 animals in the laparoscopy group had small abscesses in the abdominal incisions. There were no statistical differences in the presence of peritoneal adhesions. Positive culture results were seen in all groups at the end of the procedure and in all animals at necropsy, but this did not lead to clinical signs of gross infection. The most common organisms that colonized the peritoneum were gram-positive cocci and gram-negative bacilli from the normal swine gastrointestinal flora. LIMITATIONS: Animal model and small sample size. CONCLUSIONS: In these small series of animals and with the careful lavage and preparation used, NOTES appeared to be comparable to laparoscopy in terms of peritoneal contamination and clinical infection. Despite the adherence to a strict antiseptic protocol, peritoneal contamination occurs but does not lead to septic complications in the swine.

To evaluate the feasibility, reproducibility and efficacy of a new tissue anchoring device in a porcine survival model.Gastrotomies were performed using a needle-knife and balloon dilator in 10 female Yorkshire pigs weighing 30-35 kg. Gastric closure was attempted using a new tissue anchoring device. The tightness of the closure was confirmed by means of air insufflation and the ability to maintain gastric distension with stability in peritoneal pressure measured with a Veress needle. All animals were monitored daily for signs of peritonitis and sepsis over 14 d. During necropsy, the peritoneal cavity and the gastric access site were examined.Transgastric access, closure and 14 d survival was achieved in all pigs. The mean closure time was 18.1 ± 19.2 min and a mean of 2.1 ± 1 devices were used. Supplementary clips were necessary in 2 cases. The closure time was progressively reduced (24.8 ± 13.9 min in the first 5 pigs vs 11.4 ± 5.9 min in the last 5, P = NS). At necropsy, the gastric access site was correctly closed in all cases with all brace-bars present. One device was misplaced in the mesocolon. Minimal adhesions were observed in 3 pigs and signs of mild peritonitis and adhesions in one.The use of this new tissue anchoring device in porcine stomachs is feasible, reproducible and effective and requires a short learning curve.