Clinical practice guideline on the use of single-operator cholangioscopy in the diagnosis of indeterminate biliary stricture and the treatment of difficult biliary stones

BACKGROUND AND AIMS

Single-operator cholangioscopy (SOC) offer a diagnostic and therapeutic alternative with an improved optical resolution over conventional techniques; however, there are no standardized clinical practice guidelines for this technology. This evidence-based guideline from the Colombian Association of Digestive Endoscopy (ACED) intends to support patients, clinicians, and others in decisions about using in adults the SOC compared to endoscopic retrograde cholangiopancreatography (ERCP), to diagnose indeterminate biliary stricture and to manage difficult biliary stones.

METHODS

ACED created a multidisciplinary guideline panel balanced to minimize potential bias from conflicts of interest. Universidad de los Andes and the Colombia Grading of Recommendations Assessment, Development and Evaluation (GRADE) Network supported the guideline-development process, updating and performing systematic evidence reviews. The panel prioritized clinical questions and outcomes according to their importance for clinicians and patients. The GRADE approach was used, including GRADE Evidence-to-Decision frameworks.

RESULTS

The panel agreed on one recommendation for adult patients with indeterminate biliary strictures and one for adult patients with difficult biliary stones when comparing SOC versus ERCP.

CONCLUSION

For adult patients with indeterminate biliary strictures, the panel made a conditional recommendation for SOC with stricture pattern characterization over ERCP with brushing and/or biopsy for sensitivity, specificity, and procedure success rate outcomes. For the adult patients with difficult biliary stones the panel made conditional recommendation for SOC over ERCP with large-balloon dilation of papilla. Additional research is required on economic estimations of SOC and knowledge translation evaluations to implement SOC intervention in local contexts.

[Post-colonoscopy colorectal cancer: Evaluation of a cohort in its clinical and colonoscopic characteristics, survival and its causes according to the World Endoscopy Organization]

Post-colonoscopy colorectal cancer (PCCRC) is a tumor that appears after a normal colonoscopy before the established time for the endoscopic follow up. Its origin reflects the quality of the colonoscopy and the different tumoral biologics between the CRC and the CRCPC. Our aim is to describe the characteristics of the PCCRC in our region, to identify risk factors, to discriminate the potential causes according to the World Endoscopý Organization (WEO) and to determine its impact in the patient's survival. We studied patients with colorectal cancer (CRC) attended at the gastro-oncology clinic of two institutions of Medellin-Colombia, between January 2012 and December 2021 that had been submitted to a colonoscopy between 6-36 months before the colonoscopy in which the CRC was diagnosed. 919 patients during 10 years for CRC, 68 cases of PCCRC (6.9%); It was more frequent in older patients (74 vs. 66 years; p=0.03), with background of adenomatous polyps (36.8% vs. 20.1%; p=0.01) and in right colon (57.4% vs. 40.6%; p=0.006), with a tendency in patients with diverticulosis (41.2% vs. 31.3%; p=0.05) and diabetes (25% vs. 14%; p=0.06); less survival at 5 and 10 years (58% and 55.2% vs. 67% and 63%; p < 0.001). According to the WEO, the PCCRC presents in 61.3% because of abnormal findings omitted in inadequate colonoscopies, 29% in a suitable colonoscopy and 9.7% incomplete resections of adenomas. In conclusion, the rate of PCCRC was 6.9% with more propension in older patients, a background of polyp resection, and proximal colon. According to the WEO, the abnormal findings omitted more frequently were related with inadequate colonoscopies. The patients with PCCRC had less survival.

Uso de stent en estenosis colorrectal benigna

Introducción. La estenosis colorrectal benigna hace referencia a una condición anatómica caracterizada por una disminución del diámetro de la luz intestinal distal a la válvula ileocecal, ocasionando una serie de signos y síntomas de tipo obstructivo. Es una entidad poco frecuente, secundaria en la gran mayoría de veces a la realización de anastomosis intestinales al nivel descrito. El objetivo de esta investigación fue determinar la utilidad del stent colónico en estenosis secundaria a patología colorrectal no neoplásica. Métodos. Estudio descriptivo de una cohorte de pacientes que desarrolló estenosis colorrectal de origen benigna confirmada por colonoscopía, en 3 hospitales de alta complejidad de la ciudad de Medellín, Colombia, entre los años 2007 y 2021. Resultados. Se incluyeron 34 pacientes con diagnóstico de estenosis colorrectal de origen benigno, manejados con stents metálicos autoexpandibles. La mediana de seguimiento fue de 19 meses y se obtuvo éxito clínico en el 73,5 % de los casos. La tasa de complicación fue del 41,2 %, dada principalmente por reobstrucción y migración del stent, y en menor medida por perforación secundaria a la colocación del dispositivo. Conclusión. Los stents metálicos autoexpandibles representan una opción terapéutica en pacientes con obstrucción colorrectal, con altas tasas de mejoría clínica en pacientes con patología estenosante no maligna. Cuando la derivación por medio de estoma no es una opción, este tipo de dispositivos están asociados a altas tasas de éxito clínico y mejoría de la calidad de vida de los pacientes.

Interval gastric cancer: A call to attentiveness and action

INTRODUCTION AND AIMS

Endoscopy is the most effective method for identifying gastric adenocarcinoma (GAC). Interval gastric cancer (IGC) is GAC that is diagnosed 2-3 years after a normal endoscopy. Its characteristics are unknown in the Colombian environment. The clinical, histopathologic, and endoscopic characteristics were evaluated, along with the presentation rate, proton pump inhibitor (PPI) use, and IGC survival rate, and compared with other types of GAC.

METHODS

A retrospective, analytic study was conducted on a prospective cohort. It evaluated 513 patients with GAC treated at our institution, within the time frame of January 2012 and June 2018. The patients had endoscopic diagnosis of GAC and endoscopy within the past three years that was negative for tumor.

RESULTS

A total of 513 patients diagnosed with GAC were evaluated. Forty-two of the patients had IGC (8.2%): 9 early lesions and 33 advanced lesions (79%). The IGCs were smaller (31 vs. 41 mm; P < .01), as well as flatter and more depressed (P < .01). There was no association with PPI use, but there was an association with a history of gastrectomy and anastomosis (P = .02), as well as the absence of red flags (P < .003). The most frequent locations were the gastric body (52%) and the antrum (26%). Overall two-year survival was similar between IGC and GAC (37.1 vs. 39.3%, P = .72).

CONCLUSION

A total of 8.2% of recently diagnosed GAC were cases of IGC. The presence of anastomosis and the absence of red flags were related to IGC. Overall survival was poor and there were no differences from the other types of GAC detected.

The OLGA-OLGIM staging and the interobserver agreement for gastritis and preneoplastic lesion screening: a cross-sectional study

Stomach cancer (SC) incidence and mortality are relevant public health issues worldwide. In Colombia, screening for preneoplastic lesions (PNL) and the presence of H. pylori is not routinely performed. Therefore, the aim of this study was to evaluate OLGA-OLGIM staging and the interobserver agreement in gastritis and preneoplastic lesions in patients with gastroduodenal symptoms from Colombia. A cross-sectional study was conducted in 272 patients with gastroduodenal symptoms. Gastric biopsies were taken following the Updated Sydney System with the OLGA-OLGIM classification, and the results were evaluated by two pathologists. Chronic gastritis and PNL were reported in 76% and 24% of the patients, respectively. Furthermore, 25% of the patients with PNL displayed gastric atrophy (GA) and 75% intestinal metaplasia (IM). Agreement in the histopathological reading for IM was good, whereas for OLGA was variable, and for the H. pylori quantity was poor. OLGA-OLGIM stages 0-II were the most frequent (96%), while stage III (4%) and SC (4%) were the least frequent. Age and coffee consumption were associated with a higher prevalence of PNL. This work determined that 4% of the population is at high risk of developing SC and would benefit from follow-up studies. Reinforcement of training programs to improve the agreement in histopathology readings is required.