Árpád Patai

Background/Objectives: Difficult biliary cannulation during endoscopic retrograde cholangiopancreatography (ERCP) poses significant challenges and increases the risk of adverse events. Pancreatic guidewire (PGW)-assisted techniques offer potential solutions, but real-world comparative data are limited. Methods: This cohort study of prospectively collected data analyzed 234 ERCP cases from the Hungarian ERCP Registry, focusing on three PGW-assisted methods: transpancreatic sphincterotomy (TPS), double-guidewire technique (DGW), and prophylactic pancreatic stent-assisted cannulation (PPS-C). Results: TPS demonstrated the highest primary cannulation success rate (83.1%), significantly outperforming DGW (67.7%) and PPS-C (67.6%) (p < 0.001). With salvage methods, cannulation success was high across all groups. Post-ERCP pancreatitis rates were low (5.0% TPS, 5.6% DGW, 3.9% PPS-C), but prophylactic measures (pancreatic stents, indomethacin) were underutilized. Conclusions: Our findings suggest that TPS is a safe and effective alternative for difficult biliary cannulation in ERCP. Routine considerations of post-ERCP pancreatitis prophylaxis (prophylactic pancreatic stents and non-steroidal suppositories) are recommended in all PGW-assisted cannulations to minimize complications.

Background: The European Colonoscopy Quality Investigation (ECQI) Group aims to raise awareness for improvement in colonoscopy standards across Europe. We analysed data collected on a sample of procedures conducted across Europe to evaluate the achievement of the polyp detection rate (PDR) target. We also investigated factors associated with PDR, in the hope of establishing areas that could lead to a quality improvement. Methods: 6445 form completions from 12 countries between 2 June 2016 and 30 April 2018 were considered for this analysis. We performed an exploratory analysis looking at PDR according to European Society of Gastrointestinal Endoscopy (ESGE) definition. Stepwise multivariable logistic regression analysis was conducted to determine the most influential associated factors after adjusting for the other pre-specified variables. Results: In our sample there were 3365 screening and diagnostic procedures performed in those over 50 years. The PDR was 40.5%, which is comparable with the ESGE minimum standard of 40%. The variables found to be associated with PDR were in descending order: use of high-definition equipment, body mass index (BMI), patient gender, age group, and the reason for the procedure. Use of HD equipment was associated with a significant increase in the reporting of flat lesions (14.3% vs. 5.7%, p < 0.0001) and protruded lesions (34.7% vs. 25.4%, p < 0.0001). Conclusions: On average, the sample of European practice captured by the ECQI survey meets the minimum PDR standard set by the ESGE. Our findings support the ESGE recommendation for routine use of HD colonoscopy.

The European Colonoscopy Quality Investigation (ECQI) Group aims to raise awareness for improvement in colonoscopy standards across Europe. We analyzed data collected on a sample of procedures conducted across Europe to evaluate the achievement of the European Society of Gastrointestinal Endoscopy (ESGE) mean withdrawal time (WT) target. We also investigated factors associated with WT, in the hope of establishing areas that could lead to a quality improvement. Methods: 6445 form completions from 12 countries between 2 June 2016 and 30 April 2018 were considered for this analysis. We performed an exploratory analysis looking at WT according to the ESGE definition. Stepwise multivariable logistic regression analysis was conducted to determine the most influential associated factors after adjusting for the other pre-specified variables. Results: In 1150 qualifying colonoscopies, the mean WT was 7.8 min. Stepwise analysis, including 587 procedures where all inputs were known, found that the variables most associated with mean WT were a previous total colonoscopy in the last five years (p = 0.0011) and the time of day the colonoscopy was performed (p = 0.0192). The main factor associated with a WT < 6 min was the time of day that a colonoscopy was performed. Use of sedation was the main factor associated with a higher proportion of WT > 10 min, along with a previous colonoscopy. Conclusions: On average, the sample of European practice captured by the ECQI survey met the minimum standard set by the ESGE. However, there was variation and potential for improvement.

Background and Aims: Acute non-variceal upper gastrointestinal bleeding (UGIB) is associated with significant morbidity and mortality. Our aim was to evaluate the incidence, management, risk factors and outcomes of acute non-variceal UGIB in a population-based study from Hungary. Methods: The present prospective one–year study involved six major community hospitals in Western Hungary covering a population of 1,263,365 persons between January 1 and December 31, 2016. Data collection included demographics, comorbidities endoscopic management, Glasgow-Blatchford score (GBS), Rockall score (RS) transfusion requirements, length of hospital stay and mortality. Results: 688 cases of acute non-variceal UGIB were included with an incidence rate of 54.4 (95%CI: 50.5-58.6) per 100,000 per year. Endoscopy was performed within 12 hours in 71.8%. 5.3% of the patients required surgical treatment and the overall mortality was 13.5%. Weekend presentation was associated with increased transfusion requirements (p=0.047), surgery (p=0.016) and mortality (p=0.021). Presentation with hemodynamic instability or presence of comorbidities was associated with transfusion (p5points). Conclusions: Incidence rates of acute non-variceal UGIB in Western Hungary are in line with international trends. Longer pre-hospital time, comorbidities, hemodynamic instability, weekend presentation, treatment with anticoagulants or non-steroidal anti-inflammatory drugs was associated with worse outcomes.

Introduction and aim: As the efficacy of the first-line traditional treatment used to eradicate Helicobacter pylori (H. p.) decreased below 75% in Hungary, a new protocol had to be created. Method: Supposing the success rate of the traditional therapy (14-day double dose of proton pump inhibitor [PPI], 1000 mg amoxicillin b.i.d., 500 mg clarithromycin b.i.d. [PAC]) to be 75% and the efficacy of the new protocol (10-day 120 mg bismuth dicitrate q.i.d., double dose PPI b.i.d., 500 mg tetracycline q.i.d. and 500 mg tinidazole b.i.d. [BQT]) to be 90%, we calculated 109 patients on each arm. Patients were recruited after upper gastrointestinal endoscopy from 5 endoscopic units in Vas county. The heterogeneity of groups, success rate and side effects of both therapies were evaluated by Fisher exact test; p<0.05 was considered significant. Results: 110 patients were included in the BQT and 109 patients in the PAC group. There was no heterogeneity between the two groups in age, gender and indication of eradication. H. p. eradication was successful in 103/110 (93.6%) in the BQT and 81/109 (74.3%) in the PAC group (p<0.001). The odds ratio in the BQT group for successful eradication was 5.05 (95% confidence interval: 2.02–14.42) as compared to the PAC group (p<0.001). The side effects of the two groups were similar, in the BQT group the frequency was 34.5%. Conclusion: 10 day-long BQT containing double dose PPI with 120 mg bismuth dicitrate q.i.d., 500 mg tetracycline q.i.d. and 500 mg tinidazole b.i.d. is recommended as the first-line treatment for the eradication of H. p. because of its high efficacy and tolerable side effects. Orv Hetil. 2019; 160(34): 1340–1345.

We read with great interest the article by Hamada et al. on bleeding after sphincterotomy (BAS) [1]. The authors presented a Japanese, retrospective, observational study showing that continuation of antiplatelet agents does not influence BAS. Their conclusions can be confirmed by our “post hoc” analysis [2] using prospective clinical trial data [3] on the effect of indomethacin in the prevention of post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis. In our prospective, randomized, placebo-controlled study [3], we included 576 patients who received 100 mg rectal indomethacin before endoscopic sphincterotomy. Acetylsalicylic acid (ASA) was continued in 87 patients before ERCP, as per UK guidelines [4], and clopidogrel was continued in 29 patients in whom urgent biliary sphincterotomy was required. The frequency of BAS did not increase in patients who were treated by either ASA or clopidogrel during sphincterotomy, and BAS was not altered even in patients receiving rectal indomethacin. Our conclusions were that ASA, clopidogrel, and indomethacin did not influence BAS, and therefore their benefits can be enjoyed without any compromises. However, as only a small number of patients were treated with clopidogrel, we recommend further investigation of this issue by multicenter, prospective, randomized studies.

The greatest challenges for endoscopists performing biliary therapy in endoscopic retrograde cholangiopancreatography (ERCP) are to achieve selective biliary cannulation and prevent post-ERCP pancreatitis (PEP). Nonsteroidal anti-inflammatory drugs have proven prophylactic effect in PEP. However, the patient population that would benefit from this approach has not been defined. A total of 539 patients undergoing our cannulation protocol with early precut were randomized into a placebo-controlled, prospective, double-blind study to rectally receive either 100 mg indomethacin or placebo. The effect of indomethacin on PEP was stratified based on difficulties of cannulation and analyzed in patients with different risks. In 70.3% of patients, biliary intubation was successful in the first 5 atraumatic attempts, PEP rate was low, and indomethacin was ineffective (7.4% in the placebo group and 5.2% in the indomethacin group, P=0.406). In the next phase of intubation using guidewire, the success rate increased up to 83.5%, and PEP rate rose up to 8.7%, the effect of indomethacin was significant (11.9% vs. 5.4%, P=0.018). Applying early precut success rate of biliary cannulation increased up to 98.1% and overall indomethacin diminished the frequency of PEP from 13.8% to 6.7% (P=0.007). Preventive effect of indomethacin was demonstrated in cases with defined procedure-related risk (28.3% vs. 13.8%, P=0.028) and with defined patient-related risk (16.3% vs. 7.0%, P=0.004), but not in patients without risk factors. Rectally administered 100 mg indomethacin results in significantly lower PEP rate, particularly in cases with difficult cannulation and with identifiable patient-related or procedure-related risk factors.

Rectal indomethacin has been proven to be effective for prevention of post-ERCP pancreatitis (PEP) but its impact on bleeding after biliary sphincterotomy (BABES) and cardiovascular mortality has not been extensively studied. We aimed to assess the effect of indomethacin on the rate of BABES and short-term cardiovascular mortality, particularly in patients receiving antiplatelet therapy (APT).In this double-blind, randomized, placebo-controlled, single-center study, 100 mg indomethacin or placebo was given within 1 hour before biliary endoscopic sphincterotomy to in-patients including those who are receiving APT (acetylsalicylic acid [ASA] and/or clopidogrel). Cardiovascular mortality and BABES were observed for 30 days.Of 576 randomized patients (289 indomethacin, 287 placebo), 87 patients used 100 mg/day ASA and 29 patients took 75 mg/day clopidogrel, among them 5 patients were on dual APT. The ASA and clopidogrel taking patients were older than patients without APT (P < 0.001), but these groups were similar in other parameters. BABES occurred similarly in different subgroups: indomethacin (8.0%) vs placebo (9.4%) (P = 0.56), ASA (10.3%) vs non-ASA (8.4%) (P = 0.54), clopidogrel (6.9%) vs nonclopidogrel (8.8%) (P > 0.99). No BABES was observed among patients on dual APT. There was no difference in cardiovascular mortality between subgroups (P > 0.99).Results indicate that single dose of 100 mg indomethacin does not increase BABES rate and cardiovascular mortality. This result is independent from administering antiplatelet agents.