Hannah Pitanga Lukashok

Background and Objectives: Chronic liver inflammation leads to fibrosis and cirrhosis. To avoid portal hypertension-related complications, fibrosis' early detection is imperative. Biopsy remains the gold standard, but magnetic resonance elastography (MRE) and EUS-guided elastography are noninvasive procedures currently used for liver stiffness measurement (LSM). Two-dimensional EUS-guided shear-wave elastography (EUS-SWE) represents a more-every-day used technique. The aim of this study is to correlate LSM determined by vibration-controlled transient elastography (VCTE) and EUS-SWE and determine the measurements' accuracy in diagnosing cirrhosis. Methods: A single-center, nested case-control study was performed between March 2020 and November 2021. Patients were classified into 2 study groups: the cirrhosis group and the control group. Patients from both groups underwent VCTE and EUS-SWE for LSM. A P value < 0.05 was considered statistically significant. Results: Of the 59 participants included (mean age 63.5 years; 71.1% female), 29 had cirrhosis (49.15%) and 30 were controls (50.84%). In cirrhosis patients, liver fibrosis (F) was staged as F3–4 by VCTE in 82.8%, with a median LSM of 17.8 kPa; through EUS-SWE, 27 kPa in the right hepatic lobe (RHL) and 25 kPa in the left hepatic lobe (LHL). Controls fibrosis was staged as F0–2 by VCTE in 30/30 (100%), with a median LSM of 4.6 kPa (P < 0.001); through EUS-SWE, 5.6 kPa in the RHL (P < 0.001) and 6.5 kPa in the LHL (P < 0.001). The observed agreement was 91.5% for VCTE, 93.2% for RHL-EUS-SWE, and 96.6% for LHL-EUS-SWE. The AUROCs for EUS-SWE and VCTE were over 0.95. Conclusions: VCTE and EUS-SWE are comparable techniques for diagnosing cirrhosis; however, EUS-SWE had a higher agreement than VCTE, especially in LHL assessment.

Aims To assess the anterograde's drainage clinical and technical success in non-neoplastic obstructed biliary and pancreatic ducts. Methods Data from patients with an obstructed biliary or pancreatic duct between 01/2021-10/2022 were retrospectively analyzed. Clinical and technical success were the primary endpoints. Adverse events, re-stenosis, and re-intervention were also evaluated ([Table 1]). Results Twenty patients included: 15/20 EUS-guided biliary drainage (EUS-BD) and 5/20 EUS-guided pancreatic duct drainage (EUS-PDD). A) EUS-BD: Anterograde drainage was performed in 7/15 using a single pigtail stent, 5/15 double pigtail stents and 3/15 lumen-apposing metal stent (LAMS). Stomach puncture was the preferred approach site in 12/15. A 15/15 (100%) technical success was achieved, but a 8/15 (60%) clinical success based on bilirubin decrease. During follow-up, adverse events were documented in 5/15 cases: upper GI bleeding, cholangitis, and subhepatic fluid collection. Stent migrated in 3/15 cases. There was no re-stenosis, but reintervention was necessary on 8/15. Survival rate 13/15. B) EUS-PDD: In 3/5 cautery-assisted dilation was required. In 1/5, balloon dilation was also necessary. Used stents: single and double pigtail stents, LAMS, and self-expandable metal stents (SEMS). Technical and clinical success was achieved in 5/5 (100%), with no adverse events [1] [2] [3]. Conclusions Anterograde EUS-BD and EUS-PDD for managing non-neoplastic obstructed biliary and pancreatic ducts are valuable alternatives when ERCP is not feasible. Reintervention after EUS-BD and EUS-PDD appears to be related to stent migration and re-stenosis, respectively. Article published online: 14 April 2023 © 2023. European Society of Gastrointestinal Endoscopy. All rights reserved. Georg Thieme Verlag KG Rüdigerstraße 14, 70469 Stuttgart, Germany

Aims To evaluate the real-world effectiveness of an AI-assisted colonoscopy (AI-VCC) and compare the results among experts and non-experts endoscopists (Fig. 1). Methods Consecutive patients ≥45 years old who underwent VCC (11/2020-03/2021). First, a standard HD-VCC was performed. Then, an AI-VCC was performed by a second operator blinded to previous findings. Adenoma detection rate (ADR) was a quality indicator of the procedure. The polyp detection rate (PDR), and the adenoma and polyp miss rates (AMR and PMR, respectively) were also calculated. The results were compared between experts and non-experts endoscopists. NCT04915833 [1] [2] [3] [4] [5] [6] (Fig. 2). Results 115 patients were included. 58/115 (50.4%) had a total of 205 polyps/adenoma, with a PDR and ADR of 132/205 (64.3%) and 73/205 (35.6%) with VCC, respectively: 19/205 (9.3%) NICE II, 7/205 (3.4%) >10 mm. With AI-assistance, the ADR and PDR increased from 16.5% to 18.2% and from 50.4% to 60%, respectively. The ADR increased from 10.8% to 16.2% in the junior group with the AI-VCC. No difference in ADR was observed in the senior cohort ([Table 1]). PMR was 43.13%, AMR was 5.19%. Sensitivity among different colon segments ranged from 56.25% (rectum) to 78.26% (ascending colon). Capability of AI for appropriate polyp and adenoma presence discharging (negative predictive value, NPV) ranged from 61.54% (sigmoid) to 89.09% (cecum). Lower rates for specificity (8.42-49.49%) and PPV (9.89-19.78%) were observed due to high false positives. ([Table 2]). Conclusions Junior endoscopists benefit from the AI-assisted polyp detector during screening colonoscopy as it helps them achieve an ADR comparable to that of senior endoscopists. Article published online: 14 April 2023 © 2023. European Society of Gastrointestinal Endoscopy. All rights reserved. Georg Thieme Verlag KG Rüdigerstraße 14, 70469 Stuttgart, Germany

Aims To estimate EUS-guided shear wave elastography (EUS-SW) diagnostic accuracy for chonic pancreatitis (CP) and solid pancreas neoplasms (PN). Methods Included cases with recent diagnosis of CP or PN undergoing EUS-SW (12/20-11/22); a control group (CG) with cases requiring EUS evaluation for subepithelial lesion. Fatty pancreas score, strain ratio (SR), histogram (SH), and ten EUS-SW elasticity (SWE) measurements and dispersion (SWD) were assessed. SWE/SWD variation was based on quotient among IQR and median. SWE and SWD association was estimated with a MANOVA in <30% variation. SWE and SWD cut-off values were calculated with Youden’s index [1] [2]. Results 88 enrolled cases (37 CG, 14 CP, 37 PN). Fatty pancreas score II and III was similar in CG (37.8%/56.8%) and CP (57.1%/42.9%); there was a significant difference in PN, with a score II, III, and IV of 24.3%, 40.5%, and 29.7%, respectively (p<.001). Median SR was similar among CG (3.6; IQR 2.9 – 4.3) and CP (3.9; IQR 3.6 – 4.7), but significantly different to PN (7.6; IQR 5.3 – 11.1; p<.001). Median SWE and SWD were 10.5 kPa (7.3 – 16.6) and 1.9 [m/s]/kHz (1.6 – 2.4), with a <30% variation in 30.7% and 64.8%, respectively (table 1). Diabetes was associated to higher SWE and SWD (p<.05). Predicted SWE were significantly different among PN vs CG (-13.1; -24.4 to -1.7; p=.0242) ([Fig. 1]). SWE ≥17.4 diagnosed PN with a 75% sensitivity, 91% specificity, 60% PPV and 95% NPV; while SWD ≥2.31 predicted PN with a diagnostic accuracy of 54%, 70%, 35%, 84%, respectively. Conclusions EUS-SW is a valuable measuring tool for CP and PN diagnostic workups. NCT05095831 ([Fig. 2]). Article published online: 14 April 2023 © 2023. European Society of Gastrointestinal Endoscopy. All rights reserved. Georg Thieme Verlag KG Rüdigerstraße 14, 70469 Stuttgart, Germany

La enfermedad por reflujo gastroesofágico (ERGE) es sumamente prevalente en nuestro medio. Sus síntomas son variados y los mecanismos fisiopatológicos son múltiples. Por lo tanto, el diagnóstico de esta entidad suele ser complejo. Han sido descriptos una serie de métodos diagnósticos. No obstante, el patrón de oro continúa siendo el tiempo de exposición ácida, medido durante el monitoreo ambulatorio de reflujo a través de pH-metría. El objetivo de este primer consenso latinoamericano fue evaluar críticamente, sobre la base de las mejores evidencias disponibles a la fecha, los diferentes métodos diagnósticos propuestos para la ERGE y emitir recomendaciones consensuadas luego de la discusión entre un grupo de expertos y una votación. Este consenso fue desarrollado por un grupo de expertos a partir de una búsqueda sistemática de la literatura y utilizando la metodología GRADE (Grading of Recommendations Assessment, Development and Evaluation) para la evaluación de la calidad de la evidencia y la decisión de la fuerza de recomendación. Se emitieron recomendaciones en cuanto a la utilidad de diferentes métodos diagnósticos en relación con la ERGE.

Background/Aims: Peroral endoscopic myotomy (POEM) has been increasingly used for achalasia in Latin America, where Chagas disease is prevalent, and this makes POEM more challenging. The aim of this study was to determine the learning curve for POEM in Latin America.Methods: Patients undergoing POEM in Latin America with a single operator were included from a prospective registry over 4 years. Non-linear regression and cumulative sum control chart (CUSUM) analyses were conducted for the learning curve.Results: A total of 125 patients were included (52% male; mean age, 59 years), of which 80 had type II achalasia (64%), and 38 had Chagas disease (30%). The average pre-procedure and post-procedure Eckardt scores were 6.79 and 1.87, respectively. Technical success was achieved in 93.5% of patients, and clinical success was achieved in 88.8%. Adverse events occurred in 27 patients (22%) and included bleeding (4 patients), pneumothorax (4 patients), mucosal perforation (13 patients), mediastinitis (2 patients), and leakage (4 patients). The CUSUM chart showed a median procedure time of 97 min (range, 45-196 min), which was achieved at the 61st procedure. Procedure duration progressively decreased, with the last 10 procedures under 50 min approaching a plateau (p-value <0.01).Conclusions: Mastering POEM in Latin America requires approximately 61 procedures for both POEM efficiency and to accomplish the procedure within 97 minutes.

BACKGROUND: Bougies dilation is considered an effective technique for the treatment of simple benign esophageal strictures. The “rule of three” has been advocated to prevent reported adverse events such as bleeding and perforation. However, adherence to this rule has increased the cost and duration of treatment. OBJECTIVE: To demonstrate the safety and long-term benefits of progressive bougie dilations until reaching 15 mm (45Fr) in one single session endoscopy with non-adherence to the rule of three. METHODS: A retrospective analysis of a prospectively collected data of patients with simple benign esophageal strictures treated with multiple progressive bougie dilators until reaching 15 mm (45Fr) in one single session. RESULTS: The median age was 58 years (range 28-89), and 83.3% of patients were female. The main presenting symptom was dysphagia for solids in 11/12 cases (91.6%). The cause of their simple benign esophageal stricture was distributed as follows: 7/12 esophageal webs, 2/12 peptic stenosis, 2/12 Schatzki rings and one caustic injury. 75% required only one session for clinical success. No serious adverse events were described. No recurrence of symptoms was noted in a median follow-up of 20 months. CONCLUSION: The rule of three in patients with simple benign esophageal strictures secondary to esophageal webs, Schatzki rings and peptic strictures treated with Savary-Gilliard dilators is not necessary, showing good clinical results. Prospective studies with more patients are necessary.

We describe the feasibility and outcomes of endoclipping in the treatment of complicated variceal bleeding (four gastric and two esophageal) in six cirrhotic patients (mean age 62.33, range 36 – 82), by performing a mechanical closure of the variceal wall rupture. In all patients, previous endoscopic treatments had been performed in other centers and failure to control bleeding was observed in accordance with BAVENO V definitions and criteria [1]. Hemodynamic stabilization was performed, and intravenous treatments with fresh frozen plasma, vitamin K at 30 mg/d, octreotide (bolus of 50 µg followed by 25 µg/h), albumin, antibiotic, and proton pump inhibitor (40 mg/d) were administered. After approval by the ethics committee of our institution and completion of written informed consents, the procedures were carried out using a standard endoscope (EG-2990i HD, Pentax, Japan) and endoclips (EZ-clip Olympus, Japan) ([Fig. 1]; [Video 1] and [Video 2]). The technique was successful in all cases and no acute complication or rebleeding was observed in the follow-up period (mean 15 months). The patients were discharged from the critical care unit after 24 hours, and discharged from hospital 72 hours later. Endoscopic treatments for variceal bleeding are band ligation (esophageal) and cyanoacrylate injection (gastric fundal varices). However, in cases of variceal wall rupture, it could be difficult to apply these treatments. Endoclips are used in the treatment of nonvariceal gastrointestinal bleeding [2]. They offer a mechanical closure of the disrupted wall and achieve hemostasis by compression. There is one study comparing this treatment with band ligation in esophageal varices, and demonstrating its effectiveness [3]. In addition, there is one case report of successful endoclip placement in a gastric fundal varix in a patient with portal hypertension as a result of schistosomiasis [4]. Application of endoclips was feasible and safe in our series, and it could be a viable alternative for these cases. Endoscopy_UCTN_Code_TTT_1AO_2AD