Complications of endoscopic retrograde cholangiography in the post-MRCP era: A tertiary center experience

AIM: To evaluate our experience in endoscopic retrograde cholangio-pancreatography (ERCP) in terms of fulfilling the ASGE guidelines in indications, positive findings,and complications in the post-magnetic resonance cholangiopancreatography (MRCP) era.METHODS: Between November 2001 and February 2003, consecutive ERCP cases were prospectively evaluated with regard to the indications, findings, cannulation techniques,devices used during the procedure, sedation given,duration of procedure, and complications. These data were entered in a database for subsequent processing and analysis.RESULTS: Of 336 cases, 21.4% were diagnostic and 78.6% therapeutic ERCP. The indications for ERCP fulfilled the ASGE guidelines in 323 cases (96.1%). Suspected bile duct stone was the most frequent indication (26.8%), and this was followed by cholangitis (24.4%), dilated common bile duct (14.9%), and cholestatic jaundice (13.4%).Cannulation success rate was 94%. Biliary sphincterotomy was performed in 175 (52.1%) patients. Repeated ERCP was performed on 31.5% of the patients. Overall, the complication rate was 9.8% with 0.3% being procedurerelated mortality. The complications were pancreatitis (5.4%), bleeding (0.8%), cholangitis (2.4%) and others (1.5%). No significant difference was observed between the complication rate and the type of ERCP performed.CONCLUSION: Our study showed that post-ERCP complication rate was comparable with the other large prospective studies and there was no difference in the complication between the diagnostic and therapeutic ERCP.

Gamma-glutamyl transferase and cardiovascular risk in nonalcoholic fatty liver disease:The Gut and Obesity Asia initiative

BACKGROUND Gamma-glutamyl transferase(GGT)is associated with the risk of cardiovascular disease(CVD)in the general population.AIM To identify the association of baseline GGT level and QRISK2 score among patients with biopsy-proven nonalcoholic fatty liver disease(NAFLD).METHODS This was a retrospective study involving 1535 biopsy-proven NAFLD patients from 10 Asian centers in 8 countries using data collected by the Gut and Obesity in Asia(referred to as“GO ASIA”)workgroup.All patients with available baseline GGT levels and all 16 variables for the QRISK2 calculation(QRISK2-2017;developed by researchers at the United Kingdom National Health Service;https://qrisk.org/2017/;10-year cardiovascular risk estimation)were included and compared to healthy controls with the same age,sex,and ethnicity.Relative risk was reported.QRISK2 score>10%was defined as the high-CVD-risk group.Fibrosis stages 3 and 4(F3 and F4)were considered advanced fibrosis.RESULTS A total of 1122 patients(73%)had complete data and were included in the final analysis;314(28%)had advanced fibrosis.The median age(interquartile range[IQR])of the study population was 53(44-60)years,532(47.4%)were females,and 492(43.9%)were of Chinese ethnicity.The median 10-year CVD risk(IQR)was 5.9%(2.6-10.9),and the median relative risk of CVD over 10 years(IQR)was 1.65(1.13-2.2)compared to healthy individuals with the same age,sex,and ethnicity.The high-CVD-risk group was significantly older than the low-risk group(median[IQR]:63[59-67]vs 49[41-55]years;P<0.001).Higher fibrosis stages in biopsy-proven NAFLD patients brought a significantly higher CVD risk(P<0.001).Median GGT level was not different between the two groups(GGT[U/L]:Median[IQR],high risk 60[37-113]vs low risk 66[38-103],P=0.56).There was no correlation between baseline GGT level and 10-year CVD risk based on the QRISK2 score(r=0.02).CONCLUSION The CVD risk of NAFLD patients is higher than that of healthy individuals.Baseline GGT level cannot predict CVD risk in NAFLD patients.However,advanced fibrosis is a predictor of a high CVD risk.

Gastroesophageal reflux disease at the turn of millennium

Gastroesophageal reflux disease (GERD) has been an area of active research in the Asia-Pacific region in the recent years. This article outlines some of the interesting research findings. It comprises three parts. The first part dealt with recent data on the changing epidemiology of GERD in Asia.The second part summarized published studies on the relationship between GERD and Helicobacter pylori, relevant to the Asia-Pacific region. The last part discussed some of the recent advances in the treatment of GERD.

Endoscopic submucosal dissection vs endoscopic mucosal resection for colorectal polyps:A meta-analysis and metaregression with single arm analysis

BACKGROUND Endoscopic submucosal dissection(ESD)has shown to be effective in management of colorectal neoplasm in the Asian countries,while its implementation in Western countries where endoscopic mucosal resection(EMR)is preferred is still debatable.AIM To compare the surgical,histological,and oncological outcomes between ESD and EMR in the treatment of colorectal polyps,with subgroup analysis comparing the efficacy of ESD and EMR between Japan and the rest of the world.METHODS Embase and Medline databases were searched from inception to October 2020 in accordance with PRISMA guidelines for studies comparing en bloc,complete resection,margin involvement,resection time,need for additional surgery,complications,and recurrence rate of ESD with EMR.RESULTS Of 281344 colorectal polyps from 21 studies were included.When compared to EMR,the pooled analysis revealed ESD was associated with higher en bloc and complete resection rate,and lower lateral margin involvement and recurrence.ESD led to increased procedural time,need for additional surgery,and perforation risk.No significant difference in bleeding risk was found between the two groups.Meta-regression analysis suggested only right colonic polyps correlated with an increased perforation risk in ESD.Confounders including polyp size and invasion depth did not significantly influence the en bloc and complete resection rate,bleeding risk and recurrence.In subgroup analysis,Japan performed better than the rest of the world in both ESD and EMR with perforation risk of 4%and 0.0002%,respectively,as compared to perforation risk of 8%and 1%,respectively,in reports coming from rest of the world.CONCLUSION ESD resulted in better resection outcomes and lower recurrence compared to EMR.With appropriate training,ESD is preferred over EMR as the first-line therapy for resection of colorectal polyps,without restricting to lesions greater than 20 mm and those with high suspicion of submucosal invasion.

Post-metallic stent placement bleeding caused by stent-induced ulcers

Placement of self-expandable metal stents (SEMS) is an effective mode of palliative treatment for patients with malignant gastrointestinal obstruction. Gastrointestinal mucosal bleeding complicates about 5% of placement of SEMS but is not well described. We report three cases of gastrointestinal bleeding post-SEMS placement and suggest that bleeding is caused by direct mucosal infringement by the sharp edges of the ends of the stents.

Multinational survey on the preferred approach to management of Barrett’s esophagus in the Asia-Pacific region

BACKGROUND Major societies provide differing guidance on management of Barrett’s esophagus(BE),making standardization challenging.AIM To evaluate the preferred diagnosis and management practices of BE among Asian endoscopists.METHODS Endoscopists from across Asia were invited to participate in an online questionnaire comprising eleven questions regarding diagnosis,surveillance and management of BE.RESULTS Five hundred sixty-nine of 1016(56.0%)respondents completed the survey,with most respondents from Japan(n=310,54.5%)and China(n=129,22.7%).Overall,the preferred endoscopic landmark of the esophagogastric junction was squamocolumnar junction(42.0%).Distal palisade vessels was preferred in Japan(59.0%vs 10.0%,P<0.001)while outside Japan,squamo-columnar junction was preferred(59.5%vs 27.4%,P<0.001).Only 16.3%of respondents used Prague C and M criteria all the time.It was never used by 46.1%of Japanese,whereas 84.2%outside Japan,endoscopists used it to varying extents(P<0.001).Most Asian endoscopists(70.8%)would survey long-segment BE without dysplasia every two years.Adherence to Seattle protocol was poor with only 6.3%always performing it.73.2%of Japanese never did it,compared to 19.3%outside Japan(P<0.001).The most preferred(74.0%)treatment of non-dysplastic BE was proton pump inhibitor only when the patient was symptomatic or had esophagitis.For BE with low-grade dysplasia,6-monthly surveillance was preferred in 61.9%within Japan vs 47.9%outside Japan(P<0.001).CONCLUSION Diagnosis and management of BE varied within Asia,with stark contrast between Japan and outside Japan.Most Asian endoscopists chose squamo-columnar junction to be the landmark for esophagogastric junction,which is incorrect.Most also did not consistently use Prague criteria,and Seattle protocol.Lack of standardization,education and research are possible reasons.

First endoscopic procedure for diagnosis and staging of mediastinal lymphadenopathy

AIM:To compare a first diagnostic procedure of transbronchial needle aspiration(TBNA)with selection of endoscopic ultrasound-guided fine-needle aspiration(EUS-FNA)or TBNA for mediastinal lymphadenopathy.METHODS:Sixty-eight consecutive patients with mediastinal lymphadenopathy on computed tomography(CT),who required cytopathological diagnosis,were recruited.The first 34 underwent a sequential approach in which TBNA was performed first,followed by EUS-FNA if TBNA was unrevealing.The next 34 underwent a selective approach where either TBNA or EUS-FNA was selected as the first procedure based on the CT findings.RESULTS:The diagnostic yield of TBNA as the first diagnostic procedure in the sequential approach was 62%.In the selective approach,the diagnostic yield of the first procedure was 71%.There was no significant difference in the overall diagnostic yield,but there were significantly fewer combined procedures with the selective approach.CONCLUSION:Selecting either EUS-FNA or TBNA as the first diagnostic procedure achieved a comparable diagnostic yield with significantly fewer procedures than performing TBNA first in all patients.