Gastroenterology, Hepatology and Endoscopy Practice

: 2022  |  Volume : 2  |  Issue : 1  |  Page : 39--40

Gastroenterology elsewhere

Kayalvizhi Jayaraman 
 Department of Medical Gastroenterology, SIMS Institute of Gastroenterology Hepatobiliary Sciences and Liver, Transplantation, SRM Institute for Medical Science Hospital, Chennai, Tamil Nadu, India

Correspondence Address:
Kayalvizhi Jayaraman
No 1, Jawaharlal Nehru Salai, 100 Feet Road, Vadapalani, Chennai – 600 026, Tamil Nadu

How to cite this article:
Jayaraman K. Gastroenterology elsewhere.Gastroenterol Hepatol Endosc Pract 2022;2:39-40

How to cite this URL:
Jayaraman K. Gastroenterology elsewhere. Gastroenterol Hepatol Endosc Pract [serial online] 2022 [cited 2022 Sep 30 ];2:39-40
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 When the Wait Serves Good!

Boxhoorn L, Van Dijk SM, Van Grinsven J, Verdonk RC, Boermeester MA, Bollen TL, et al. Immediate versus postponed intervention for infected necrotizing pancreatitis. N Engl J Med 2021;385:1372-81.

Once infected pancreatic necrosis is diagnosed, at least half of the clinicians may promptly drain, even within 4 weeks. Studies show that partial walling is as good as complete encapsulation for the insertion of drains. The American Gastroenterology Association 2020 guidelines suggest draining infected collections in the face of failing antimicrobial therapy as early as 2 weeks. Dutch investigators randomized 104 patients with infected pancreatitis into immediate n = 55 (drainage within 24 h of diagnosis) and postponed n = 49 (wait for walling off) groups in the POINTER trial. The intervention progressed from percutaneous/endoscopic drainage to minimally invasive surgical procedures. The primary outcome was to assess overall complications using the Comprehensive Complication index, which was almost equal in both groups (57 vs. 58). Mortality, serious complications, length of intensive care unit stay, hospital stay, and costs were also similar across both groups. The mean number of interventions was higher in the immediate versus postponed group. Strikingly, 1/3rd of the patients in the postponed group improved with antibiotics alone. When putting together, the added perks of fewer interventions and sometimes even no intervention makes the wait to drain worth it.

 Re-thinking the Common Finding

Baumgartner M, Lang M, Holley H, Crepaz D, Hausmann B, Pjevac P, et al. Mucosal biofilms are an endoscopic feature of irritable bowel syndrome and ulcerative colitis. Gastroenterology 2021;161:1245-56.e20.

During colonoscopies, we have often encountered a green slimy layer covering the mucosa of the right colon, which is resistant to washing. It was assumed to be inadequate bowel preparation to date. Researchers from Austria have found that this “biofilm” has a distinct microbial pattern and may serve as endoscopic evidence of dysbiosis. Two hundred and twelve out of 1112 colonoscopies had biofilms. Half of those who had biofilms were patients with irritable bowel syndrome, a third were patients with Ulcerative colitis, and only 6% were healthy controls (P < 0.01). In-depth analysis was done in 117 of the samples for bacterial densities, bacterial composition, and metabolites. Biofilm-positive patients had tenfold more bacteria lying in close contact with the epithelium than biofilm-negative patients. More Escherichia/Shigella genera and Ruminococcus gnavus and less short-chain fatty acid-producing genera inhabited the biofilms. Biofilm-positive tissue and their corresponding feces had increased taurocholic acid levels than biofilm-negative samples (P = 0.05). This paper offers novel insights into the pathophysiology of luminal disease and the prospect of endoscopic diagnosis of gut dysbiosis.

 Do Nonalcoholic Fatty Liver Disease Patients with F3 Fibrosis Need Hepatocellular Carcinoma Screening?

Sanyal AJ, Van Natta ML, Clark J, Neuschwander-Tetri BA, Diehl A, Dasarathy S, et al. Prospective study of outcomes in adults with nonalcoholic fatty liver disease. N Engl J Med 2021;385:1559-69.

Sanyal et al., sought to find out actual outcomes of nonalcoholic fatty liver disease (NAFLD) in this prospective study of 1773 adults with biopsy-proven NAFLD with a median follow-up of 4 years. Seventy percent of the cohort had (Fibrosis) F0-F1, 36% had F3, and 9% constituted F4. All-cause mortality, hepatic and nonhepatic outcomes were measured. The death rate from any cause was highest in the cirrhosis group, followed by F3 and F0-F2, as one would expect. So were the occurrence rates of ascites, variceal haemorrhage, and hepatic encephalopathy. Surprisingly, hepatocellular carcinoma was higher in F3 than F4 (0.34 vs. 0.14 per 100 person-years). Lesser duration of follow-up, the possibility of sampling error in histological assessment may have contributed to this unexpected result.

 Are We Aware of Our Endoscopy Suites' Carbon Footprint?

Siau K, Hayee B, Gayam S. Endocsopy's current carbon footprint. Tech Innov Gastrointest Endosc 2022;23:344-52.

It is code red for human-driven global warming. Healthcare-associated emissions are no exception. Approximately eighteen million endoscopic procedures are performed annually in the US alone, emitting 85,768 metric tonnes of CO2, equating to 18,000 cars driving over a year. In this review, the authors identify potential sources of greenhouse gas emissions within the endoscopy room and estimate their carbon footprint. Single-use consumables from mouth guards to disposable scopes, equipment reprocessing, electricity usage, data storage, travel are significant carbon emission sources. Up to 13,500 tonnes of plastic, primarily nonrecyclable, is generated annually from the endoscopy sector. The authors also propose doable solutions focusing on reusability, recycling, and reduction. Globally, we are at the critical juncture to reflect on our carbon footprint and respond urgently to sustain a greener endoscopy. Earlier, Hernandez et al. garnered attention, comparing the life cycles of single-use duodenoscopes against duodenoscopes with disposable tips and reusable duodenoscopes. Carbon emission was higher for endoscopic retrograde cholangiopancreatography with disposable duodenoscopes in this study. Such shreds of evidence reinforce our responsibility of cutting down carbon emissions. Endoscopy bodies should drive the green initiative by encouraging more research, thereby contributing to the universal task of addressing the climate crisis.

 Cold Snare for Large Laterally Spreading Lesions

Van Hattem WA, Shahidi N, Vosko S, Hartley I, Britto K, Sidhu M, et al. Piecemeal cold snare polypectomy versus conventional endoscopic mucosal resection for large sessile serrated lesions: A retrospective comparison across two successive periods. Gut 2021;70:1691-7.

About a third of colorectal cancer evolves from serrated lesions. Laterally spreading lesions (LSL) constitute a tenth of these, for which endoscopic mucosal resection (EMR) is the standard procedure of choice. EMR is, however, associated with bleeding and deep mural injury. Cold snare polypectomy is limited chiefly to sub-centimetric lesions. It appears safer, though the completeness and safety of the procedure in LSLs remain questionable. The authors of this research performed a retrospective analysis of prospectively collected data, grouping into EMR (n = 353) and piecemeal cold snare polypectomy (pCSP) (n = 121). Postresection follow-up colonoscopies were done at 6 months and 18 months. Technical success was almost 100% in both procedures. Clinically and statistically significant postprocedure bleeding was noted in the EMR group (5%, P = 0.01), while none occurred in the pCSP. Deep mural injury and delayed perforation were noted in the EMR group, while cPSP had zero complications. There are significant limitations, as the median size of the lesion, presence of dysplasia were higher in the EMR group, which could explain the higher incidence of complications. pCSP appears equally efficacious and safer as EMR, but randomized controlled trials are needed to recommend this for large LSLs safely.

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Conflicts of interest

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