Main Recommendations
ESGE recommends against routine preoperative biliary drainage in patients with malignant extrahepatic biliary obstruction; preoperative biliary drainage should be reserved for ...patients with cholangitis, severe symptomatic jaundice (e. g., intense pruritus), or delayed surgery, or for before neoadjuvant chemotherapy in jaundiced patients. Strong recommendation, moderate quality evidence.
ESGE recommends the endoscopic placement of a 10-mm diameter self-expandable metal stent (SEMS) for preoperative biliary drainage of malignant extrahepatic biliary obstruction. Strong recommendation, moderate quality evidence.
ESGE recommends SEMS insertion for palliative drainage of of extrahepatic malignant biliary obstruction. Strong recommendation, high quality evidence.
ESGE recommends against the insertion of uncovered SEMS for the drainage of extrahepatic biliary obstruction of unconfirmed etiology. Strong recommendation, low quality evidence.
ESGE suggests against routine preoperative biliary drainage in patients with malignant hilar obstruction. Weak recommendation, low quality evidence.
ESGE recommends uncovered SEMSs for palliative drainage of malignant hilar obstruction. Strong recommendation, moderate quality evidence.
ESGE recommends temporary insertion of multiple plastic stents or of a fully covered SEMS for treatment of benign biliary strictures. Strong recommendation, moderate quality evidence.
ESGE recommends endoscopic placement of plastic stent(s) to treat bile duct leaks that are not due to transection of the common bile duct or common hepatic duct. Strong recommendation, moderate quality evidence.
Abstract
We are currently living in the throes of the COVID-19 pandemic that imposes a significant stress on health care providers and facilities. Europe is severely affected with an exponential ...increase in incident infections and deaths. The clinical manifestations of COVID-19 can be subtle, encompassing a broad spectrum from asymptomatic mild disease to severe respiratory illness. Health care professionals in endoscopy units are at increased risk of infection from COVID-19. Infection prevention and control has been shown to be dramatically effective in assuring the safety of both health care professionals and patients. The European Society of Gastrointestinal Endoscopy (www.esge.com) and the European Society of Gastroenterology and Endoscopy Nurses and Associates (www.esgena.org) are joining forces to provide guidance during this pandemic to help assure the highest level of endoscopy care and protection against COVID-19 for both patients and endoscopy unit personnel. This guidance is based upon the best available evidence regarding assessment of risk during the current status of the pandemic and a consensus on which procedures to perform and the priorities on resumption. We appreciate the gaps in knowledge and evidence, especially on the proper strategy(ies) for the resumption of normal endoscopy practice during the upcoming phases and end of the pandemic and therefore a list of potential research questions is presented. New evidence may result in an updated statement.
Background & Aims We previously established long-term culture conditions under which single crypts or stem cells derived from mouse small intestine expand over long periods. The expanding crypts ...undergo multiple crypt fission events, simultaneously generating villus-like epithelial domains that contain all differentiated types of cells. We have adapted the culture conditions to grow similar epithelial organoids from mouse colon and human small intestine and colon. Methods Based on the mouse small intestinal culture system, we optimized the mouse and human colon culture systems. Results Addition of Wnt3A to the combination of growth factors applied to mouse colon crypts allowed them to expand indefinitely. Addition of nicotinamide, along with a small molecule inhibitor of Alk and an inhibitor of p38, were required for long-term culture of human small intestine and colon tissues. The culture system also allowed growth of mouse Apc-deficient adenomas, human colorectal cancer cells, and human metaplastic epithelia from regions of Barrett's esophagus. Conclusions We developed a technology that can be used to study infected, inflammatory, or neoplastic tissues from the human gastrointestinal tract. These tools might have applications in regenerative biology through ex vivo expansion of the intestinal epithelia. Studies of these cultures indicate that there is no inherent restriction in the replicative potential of adult stem cells (or a Hayflick limit) ex vivo.
Esophageal strictures are a problem commonly encountered in gastroenterological practice and can be caused by malignant or benign lesions. Dysphagia is the symptom experienced by all patients, ...regardless of whether their strictures are caused by malignant or benign lesions. The methods most frequently used for palliation of malignant esophageal strictures are stent placement (particularly in patients with an expected survival of 3 months or less) and brachytherapy (in patients with a life expectancy of more than 3 months). Brachytherapy has been shown to be beneficial in patients with an expected survival of longer than 3 months with regard to (prolonged) dysphagia improvement, complications and quality of life. The mainstay of benign esophageal stricture treatment is dilation. Although dilation usually results in symptomatic relief, recurrent strictures do occur. In order to predict which types of strictures are most likely to recur, it is important to differentiate between esophageal strictures that are simple (i.e. focal, straight strictures with a diameter that allows endoscope passage) and those that are more complex (i.e. long (>2 cm), tortuous strictures with a narrow diameter). These complex strictures are considered refractory when they cannot be dilated to an adequate diameter. Novel treatment modalities for refractory strictures include temporary stent placement and incisional therapy.
Summary
Background
Colorectal cancer (CRC) is the third most common cancer diagnosis in the Western world.
Aim
To evaluate exhaled volatile organic compounds (VOCs) as a non‐invasive biomarker for ...the detection of CRC and precursor lesions using an electronic nose.
Methods
In this multicentre study adult colonoscopy patients, without inflammatory bowel disease or (previous) malignancy, were invited for breath analysis. Two‐thirds of the breath tests were randomly assigned to develop training models which were used to predict the diagnosis of the remaining patients (external validation). In the end, all data were used to develop final‐disease models to further improve the discriminatory power of the algorithms.
Results
Five hundred and eleven breath samples were collected. Sixty‐four patients were excluded due to an inadequate breath test (n = 51), incomplete colonoscopy (n = 8) or colitis (n = 5). Classification was based on the most advanced lesion found; CRC (n = 70), advanced adenomas (AAs) (n = 117), non‐advanced adenoma (n = 117), hyperplastic polyp (n = 15), normal colonoscopy (n = 125). Training models for CRC and AAs had an area under the curve (AUC) of 0.76 and 0.71 and blind validation resulted in an AUC of 0.74 and 0.61 respectively. Final models for CRC and AAs yielded an AUC of 0.84 (sensitivity 95% and specificity 64%) and 0.73 (sensitivity and specificity 79% and 59%) respectively.
Conclusions
This study suggests that exhaled VOCs could potentially serve as a non‐invasive biomarker for the detection of CRC and AAs. Future studies including more patients could further improve the discriminatory potential of VOC analysis for the detection of (pre‐)malignant colorectal lesions. (https://clinicaltrials.gov Identifier NCT03488537)
Gastric outlet obstruction (GOO) is a relatively common condition in which mechanical obstruction of the pylorus, distal stomach, or duodenum causes severe symptoms such as nausea, vomiting, ...abdominal pain, and early satiety. Its etiology includes both benign and malignant disorders. Currently, GOO has many treatment options, including initial conservative therapeutic protocols and more invasive procedures, such as surgical gastroenterostomy, stent placement and, the most recently implemented procedure, endoscopic ultrasound-guided gastroenterostomy (EUS-GE). Each procedure has its merits, with surgery often prevailing in patients with longer life expectancy and stents being used most often in patients with malignant gastric outlet stenosis. The newly developed EUS-GE combines the immediate effect of stents and the long-term efficacy of gastroenterostomy. However, this novel method is a technically demanding process that requires expert experience and special facilities. Thus, the true clinical effectiveness, as well as the duration of the effects of EUS-GE, still need to be determined.
Abstract
Background
COVID-19 has dramatically affected gastrointestinal endoscopy practice. We aimed to investigate its impact on procedure types, indications, and findings.
Methods
We ...retrospectively analyzed endoscopies performed in 15 Dutch hospitals by comparing periods 15 March to 25 June of 2019 and 2020 using the prospective Trans.IT database.
Results
During lockdown in 2020, 9776 patients underwent endoscopy compared with 19 296 in 2019. Gastroscopies decreased by 57 % (from 7846 to 4467) and colonoscopies by 45 % (from 12219 to 5609), whereas endoscopic retrograde cholangiopancreatography volumes remained comparable (from 578 to 522). Although endoscopy results indicative of cancer decreased (from 524 to 340), the likelihood of detecting cancer during endoscopy increased (2.7 % 95 % confidence interval (CI) 2.5 – 3.0 in 2019 versus 3.5 % 95 %CI 3.1 – 3.9 in 2020;
P
< 0.001). After lifting of lockdown, endoscopy volumes started to return to normal, except for colorectal cancer screening.
Conclusions
Fewer endoscopies were performed during the COVID-19 lockdown, leading to a significant reduction in the absolute detection of cancer. Endoscopies increased rapidly after lockdown, except for colorectal cancer screening.
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