Publications by authors named "Lars Aabakken"

117 Publications

The influence of disease activity on fatigue in patients with ulcerative colitis - a longitudinal study.

Scand J Gastroenterol 2021 Nov 30:1-8. Epub 2021 Nov 30.

Department of Internal Medicine, Stavanger University Hospital, Stavanger, Norway.

Objective: The relationship between the disease activity of ulcerative colitis and fatigue is unclear. We investigated how reaching deep remission versus remaining in active disease influenced the severity of fatigue.

Materials And Methods: We included 149 consecutive patients in a longitudinal study. Patients were re-examined after 3 months of conventional treatment and dichotomized into A: Active disease or B: Deep remission. The Partial Mayo Score (PMS) was recorded in all patients. Fatigue was rated using the fatigue visual analog scale (fVAS), Fatigue Severity Scale (FSS), and Short Form-36 Vitality Subscale (SF-36vs). A control group of 22 age and sex-matched healthy subjects were included as controls for patients reaching deep remission.

Results: After 3 months there were no significant differences in fVAS, FSS and SF-36vs scores in patients with active disease compared to patients reaching deep remission, when adjusting for baseline fatigue scores. Patients in remission based on MES-UC scores had no significant reduction in fatigue scores, whereas patients in remission based on PMS had all three fatigue scores reduced. However, patients reaching deep remission still had higher fVAS and lower SF-36vs scores compared to healthy control subjects.

Conclusions: After 3 months of conventional treatment there were no differences in fatigue severity in patients reaching deep remission compared with patients still having active disease. Fatigue was more pronounced in patients in deep remission than in healthy subjects, and was associated with subjective and not objective measures of disease activity. This indicates that other potent factors than inflammation influence fatigue in UC.
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http://dx.doi.org/10.1080/00365521.2021.2007281DOI Listing
November 2021

A novel intragastric balloon for treatment of obesity and type 2 diabetes. A two-center pilot trial.

Scand J Gastroenterol 2021 Oct 29:1-7. Epub 2021 Oct 29.

Clinical Effectiveness Research Group, University of Oslo, Oslo, Norway.

Background And Aims: Obesity with type-2 diabetes is a global challenge. Lifestyle interventions have limited effect for most patients. Bariatric surgery is highly effective, but resource-demanding, invasive and associated with serious complications. Recently, a new intragastric balloon was introduced, not requiring endoscopy for placement or removal (Elipse™, Allurion Inc., Natick, MA). The balloon is swallowed in a capsule and filled with water once in the stomach. The balloon self-deflates after 4 months and is naturally excreted. The present trial investigated balloon feasibility, safety and efficacy in patients with obesity and type-2 diabetes.

Patients And Methods: We treated 19 patients, with type-2 diabetes and body mass index (BMI) of 30.0-39.9 kg/m at two Norwegian centers with the Elipse balloon. Patient follow-up during balloon treatment mimicked real-world clinical practice, including dietary plan and outpatient visits. The primary efficacy endpoints were total body weight loss (TBWL) and HbA1c at weeks 16 and 52.

Results: All patients underwent balloon insertion uneventfully as out-patients. Mean TBWL and HbA1c reduction after 16 and 52 weeks of balloon insertion was 3.9% (95%CI 2.1-5.7) and 0.8% (95%CI 1.9-3.5); and 7 (95%CI 4-10), and 1 (95%CI -6 to 9) mmol/mol, respectively. Adverse events occurred in two patients (10.5%): one developed gastric outlet obstruction, managed by endoscopic balloon removal; the other excessive vomiting and dehydration, managed conservatively.

Conclusions: This first Scandinavian real-world clinical trial with a new minimally invasive intragastric balloon system demonstrated good feasibility, but did not confirm expected efficacy for weight loss and diabetes control.
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http://dx.doi.org/10.1080/00365521.2021.1994641DOI Listing
October 2021

Uniting the Global Gastroenterology Community to Meet the Challenge of Climate Change and Nonrecyclable Waste.

J Clin Gastroenterol 2021 Nov-Dec 01;55(10):823-829

Universiti Sains Malaysia, Gelugor, Penang, Malaysia.

Climate change has been described as the greatest public health threat of the 21st century. It has significant implications for digestive health. A multinational team with representation from all continents, excluding Antarctica and covering 18 countries, has formulated a commentary which outlines both the implications for digestive health and ways in which this challenge can be faced.
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http://dx.doi.org/10.1097/MCG.0000000000001619DOI Listing
October 2021

Early and accurate detection of cholangiocarcinoma in patients with primary sclerosing cholangitis by methylation markers in bile.

Hepatology 2021 Aug 26. Epub 2021 Aug 26.

Department of Molecular Oncology, Institute for Cancer Research, Oslo University Hospital - the Norwegian Radium Hospital, Oslo, Norway.

Background & Aims: Primary sclerosing cholangitis (PSC) is associated with increased risk of cholangiocarcinoma (CCA). Early and accurate CCA detection represents an unmet clinical need, as the majority of PSC patients are diagnosed at advanced stage of malignancy. In the present study, we aimed at establishing robust DNA methylation biomarkers in bile for early and accurate diagnosis of CCA in PSC.

Approach & Results: Droplet digital PCR (ddPCR) was used to analyze 344 bile samples from 273 patients with sporadic- and PSC-associated CCA, PSC, and other non-malignant liver diseases for promoter methylation of CDO1, CNRIP1, SEPT9 and VIM. Receiver operating characteristics (ROC) curve analyses revealed high area under the ROC curves (AUCs) for all four markers (0.77-0.87) for CCA detection among patients with PSC. Including only samples from PSC patients diagnosed with CCA ≤12 months following bile collection increased the accuracy for cancer detection, with a combined sensitivity of 100% (28/28) and a specificity of 90% (20/203). The specificity increased to 93% when only including PSC patients with long time follow-up (>36 months) as controls, and remained high (83%) when only including PSC patients with dysplasia as controls (n=23). Importantly, the bile samples from the CCA-PSC ≤12 patients, all positive for the biomarkers, included both early- and late stage CCA, different tumor growth patterns, anatomical locations, and CA 19-9 levels.

Conclusions: By using highly sensitive ddPCR to analyze robust epigenetic biomarkers, CCA in PSC was accurately detected in bile, irrespective of clinical and molecular features, up to 12 months before CCA diagnosis. The findings suggest a potential for these biomarkers to complement current detection and screening methods for CCA in patients with PSC.
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http://dx.doi.org/10.1002/hep.32125DOI Listing
August 2021

Defining Primary Sclerosing Cholangitis: Results From an International Primary Sclerosing Cholangitis Study Group Consensus Process.

Gastroenterology 2021 Dec 10;161(6):1764-1775.e5. Epub 2021 Aug 10.

Institute of Immunology and Immunotherapy, University of Birmingham and, Department of Cellular Pathology, Queen Elizabeth Hospital, Birmingham, United Kingdom.

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http://dx.doi.org/10.1053/j.gastro.2021.07.046DOI Listing
December 2021

Promotion of gastrointestinal endoscopy in Sub-Saharan Africa: What is needed, and how can ESGE and WEO help?

Endosc Int Open 2021 Jul 17;9(7):E1001-E1003. Epub 2021 Jun 17.

Department of Transplantation Medicine, Faculty of Medicine, Oslo University Hospital - Rikshospitalet, Oslo, Norway. Co-chair of the Committee of Activities to Reach Africa - World Endoscopy Organization.

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http://dx.doi.org/10.1055/a-1495-5215DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8211488PMC
July 2021

Gastroparesis Symptoms Associated with Intestinal Hypomotility: An Explorative Study Using Wireless Motility Capsule.

Clin Exp Gastroenterol 2021 28;14:133-144. Epub 2021 Apr 28.

Norwegian Competence Centre for Functional Gastrointestinal Disorders, Department of Medicine, Haukeland University Hospital, Bergen, Norway.

Objective: Gastric emptying measurements are mandatory in gastroparesis diagnostics, but the association between delayed emptying and symptoms is questionable. It is imperative to find biomarkers better correlated to symptom generation. Hence, we examined the association between symptom severity and gastrointestinal motility measured by wireless motility capsule.

Patients And Methods: In this prospective single-centre study, patients with gastroparesis symptoms were simultaneously investigated with gastric emptying scintigraphy and wireless motility capsule, measuring regional transit times and contractility parameters. Symptom severity was assessed with the Patient Assessment of Upper Gastrointestinal Symptom Severity Index (PAGI-SYM), including the Gastroparesis Cardinal Symptom Index (GCSI).

Results: We included 107 patients (70% women). In the whole patient group, nausea correlated with the gastric ( = -0.31, = 0.007), small bowel ( = -0.41, < 0.001) and colonic ( = -0.33, = 0.012) motility indices. In patients with idiopathic etiology, nausea correlated with small bowel motility index ( = -0.81, < 0.001) and mean stomach pressure ( = -0.64, = 0.013). We also found negative correlations between total GCSI score and maximum pressure of the small bowel ( = -0.77, < 0.001) and colon ( = -0.74, = 0.002). In diabetes patients, total PAGI-SYM score correlated with colonic motility index ( = -0.34, = 0.012), and mean pressure of the colon correlated with upper abdominal pain ( = -0.37, = 0.007). We found no association between symptoms, gastric emptying nor any other transit times.

Conclusion: In patients with gastroparesis symptoms, we found that symptom severity was associated with intestinal hypomotility. Based on these results, gastroparesis diagnostics should also include an evaluation of the small bowel and colon.
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http://dx.doi.org/10.2147/CEG.S304854DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8088984PMC
April 2021

Endoscopic retrograde cholangiopancreatography in infants and children.

Endosc Int Open 2021 Mar 18;9(3):E292-E296. Epub 2021 Feb 18.

Section for Gastroenterology, Department of Transplantation Medicine, Oslo University Hospital, Oslo, Norway.

 Previous reports have suggested that endoscopic retrograde cholangiopancreatography (ERCP) in pediatric patients are safe. However, the total number of cases presented in the literature remains small. We present results regarding safety and outcomes in pediatric patients undergoing ERCP at Oslo University Hospital.  Patients < 18 years who underwent ERCP between April 1999 and November 2017 were identified using procedure codes. Medical records were examined for age, gender, diagnosis, indications, type of sedation, findings, interventions, and complications.  A total of 244 procedures were performed in 158 patients. Fifty-six of these were in 53 infants (age ≤ 1 year). Mean age was 8.8 years. The youngest patient was 8 days old. Mean weight was 5.0 kg in infants, the smallest weighing 2.9 kg. Cannulation failed in 19 (7.8 %). The main indication in infants was suspicion of biliary atresia (n = 38). Six of the procedures (10.7 %) were therapeutic. In children the main indications were biliary stricture (n = 64) and investigation of primary sclerosing cholangitis (PSC) (n = 45). 119 (63.2 %) of these procedures were therapeutic. Complications were uncommon in infants; only two episodes of infection were registered. In children (> 1 year) post-ERCP pancreatitis were seen in 10.4 %.  Our retrospective series of ERCP procedures includes 56 procedures in infants, which is one of the largest series presented. Complications in infants are rare and post-ERCP pancreatitis was not seen. In older children 10.4 % experienced post-ERCP pancreatitis. In expert hands, ERCP was shown to be acceptably feasible and safe in infants and children.
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http://dx.doi.org/10.1055/a-1337-2212DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7892276PMC
March 2021

The effect of train-the-colonoscopy-trainer course on colonoscopy quality indicators.

Endoscopy 2021 Dec 23;53(12):1229-1234. Epub 2021 Feb 23.

Cancer Registry of Norway, Oslo, Norway.

Background:  Systematic training in colonoscopy is highly recommended; however, we have limited knowledge of the effects of "training-the-colonoscopy-trainer" (TCT) courses. Using a national quality register on colonoscopy performance, we aimed to evaluate the effects of TCT participation on defined quality indicators.

Methods:  This observational study compared quality indicators (pain, cecal intubation, and polyp detection) between centers participating versus not participating in a TCT course. Nonparticipating centers were assigned a pseudoparticipating year to match their participating counterparts. Results were compared between first year after and the year before TCT (pseudo)participation. Time trends up to 5 years after TCT (pseudo)participation were also compared. Generalized estimating equation models, adjusted for age, sex, and bowel cleansing, were used.

Results:  11 participating and 11 nonparticipating centers contributed 18 555 and 10 730 colonoscopies, respectively. In participating centers, there was a significant increase in detection of polyps ≥ 5 mm, from 26.4 % to 29.2 % ( = 0.035), and reduction in moderate/severe pain experienced by women, from 38.2 % to 33.6 % ( = 0.043); no significant changes were found in nonparticipating centers. Over 5 years, 20 participating and 18 nonparticipating centers contributed 85 691 and 41 569 colonoscopies, respectively. In participating centers, polyp detection rate increased linearly ( = 0.003), and pain decreased linearly in women ( = 0.004). Nonparticipating centers did not show any significant time trend during the study period.

Conclusions:  Participation in a TCT course improved polyp detection rates and reduced pain experienced by women. These effects were maintained during a 5-year follow-up.
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http://dx.doi.org/10.1055/a-1352-4583DOI Listing
December 2021

Transpancreatic biliary sphincterotomy versus double guidewire in difficult biliary cannulation: a randomized controlled trial.

Endoscopy 2021 10 13;53(10):1011-1019. Epub 2021 Jan 13.

Division of Digestive Surgery and Urology, Turku University Hospital and University of Turku, Turku, Finland.

Background: Difficult biliary cannulation in endoscopic retrograde cholangiopancreatography (ERCP) increases the risk of post-ERCP pancreatitis (PEP). The purpose of this prospective, randomized, multicenter study was to compare two advanced rescue methods, transpancreatic biliary sphincterotomy (TPBS) and a double-guidewire (DGW) technique, in difficult common bile duct (CBD) cannulation.

Methods: Patients with native papilla and planned CBD cannulation were recruited at eight Scandinavian hospitals. An experienced endoscopist attempted CBD cannulation with wire-guided cannulation. If the procedure fulfilled the definition of difficult cannulation and a guidewire entered the pancreatic duct, randomization to either TPBS or to DGW was performed. If the randomized method failed, any method available was performed. The primary end point was the frequency of PEP and the secondary end points included successful cannulation with the randomized method.

Results: In total, 1190 patients were recruited and 203 (17.1 %) were randomized according to the study protocol (TPBS 104 and DGW 99). PEP developed in 14/104 patients (13.5 %) in the TPBS group and 16/99 patients (16.2 %) in the DGW group ( = 0.69). No difference existed in PEP severity between the groups. The rate of successful deep biliary cannulation was significantly higher with TPBS (84.6 % [88/104]) than with DGW (69.7 % [69/99];  = 0.01).

Conclusions: In difficult biliary cannulation, there was no difference in PEP rate between TPBS and DGW techniques. TPBS is a good alternative in cases of difficult cannulation when the guidewire is in the pancreatic duct.
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http://dx.doi.org/10.1055/a-1327-2025DOI Listing
October 2021

Toward real-time polyp detection using fully CNNs for 2D Gaussian shapes prediction.

Med Image Anal 2021 02 12;68:101897. Epub 2020 Nov 12.

Intervention Centre, Oslo University Hospital, Oslo, Norway; Department of Electronic Systems, Norwegian University of Science and Technology, Trondheim, Norway.

To decrease colon polyp miss-rate during colonoscopy, a real-time detection system with high accuracy is needed. Recently, there have been many efforts to develop models for real-time polyp detection, but work is still required to develop real-time detection algorithms with reliable results. We use single-shot feed-forward fully convolutional neural networks (F-CNN) to develop an accurate real-time polyp detection system. F-CNNs are usually trained on binary masks for object segmentation. We propose the use of 2D Gaussian masks instead of binary masks to enable these models to detect different types of polyps more effectively and efficiently and reduce the number of false positives. The experimental results showed that the proposed 2D Gaussian masks are efficient for detection of flat and small polyps with unclear boundaries between background and polyp parts. The masks make a better training effect to discriminate polyps from the polyp-like false positives. The proposed method achieved state-of-the-art results on two polyp datasets. On the ETIS-LARIB dataset we achieved 86.54% recall, 86.12% precision, and 86.33% F1-score, and on the CVC-ColonDB we achieved 91% recall, 88.35% precision, and F1-score 89.65%.
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http://dx.doi.org/10.1016/j.media.2020.101897DOI Listing
February 2021

A man in his thirties with right ventricular heart failure, jaundice and abdominal pain.

Tidsskr Nor Laegeforen 2020 11 19;140(17). Epub 2020 Nov 19.

Background: The combination of jaundice and acute abdominal pain is a common clinical problem associated with a broad array of aetiologies.

Case Presentation: A 36-year-old male with Down's syndrome and Eisenmenger's syndrome presented with abdominal pain, jaundice and acute liver failure. Initial transabdominal ultrasound and subsequent magnetic resonance cholangiopancreatography (MRCP) revealed gallbladder stones, but no common bile duct stones. During the course of the patient's hospital admission, his liver chemistries were consistently elevated. Thus, endoscopic retrograde cholangiography (ERC) with sphincterotomy was performed, despite the anaesthesiological risk associated with his chronic heart failure. However, the ERC and sphincterotomy did not relieve the patient's symptoms and had no apparent effect on his abnormal liver chemistries. By the end of his hospital stay, the patient recovered spontaneously and was discharged with no final conclusion having been reached. An unexpected turn of events led us to conclude upon a diagnosis a few weeks later.

Interpretation: This case illustrates the challenges of a multidisciplinary approach in a complex patient, and an overlooked detail that became a lesson to learn from.
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http://dx.doi.org/10.4045/tidsskr.20.0191DOI Listing
November 2020

Impact of the COVID-19 pandemic on gastrointestinal endoscopy in Africa.

Endosc Int Open 2020 Aug 7;8(8):E1097-E1101. Epub 2020 Aug 7.

Endoscopy Unit, Nuovo Regina Margherita Hospital, Rome, Italy.

As with all other fields of medical practice, gastrointestinal endoscopy has been impacted by the COVID-19 pandemic. However, data on the impact of the pandemic in Africa, especially sub-Saharan Africa are lacking. A web-based survey was conducted by the International Working Group of the European Society for Gastrointestinal Endoscopy and the World Endoscopy Organization to determine the impact and effects the COVID-19 pandemic has had on endoscopists in African countries. Thirty-one gastroenterologists from 14 countries in north, central, and sub-Saharan Africa responded to the survey. The majority of respondents reduced their endoscopy volume considerably. Personal protective equipment including FFP-2 masks were available in almost all participating centers. Pre-endoscopy screening was performed as well. The COVID-19 pandemic has had a substantial impact on gastrointestinal endoscopy in most African countries; however, the impact may not have been as devastating as expected.
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http://dx.doi.org/10.1055/a-1210-4274DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7413826PMC
August 2020

CD4 T cells persist for years in the human small intestine and display a T1 cytokine profile.

Mucosal Immunol 2021 03 22;14(2):402-410. Epub 2020 Jun 22.

Department of Pathology, Oslo University Hospital and University of Oslo, Oslo, Norway.

Studies in mice and humans have shown that CD8 T cell immunosurveillance in non-lymphoid tissues is dominated by resident populations. Whether CD4 T cells use the same strategies to survey peripheral tissues is less clear. Here, examining the turnover of CD4 T cells in transplanted duodenum in humans, we demonstrate that the majority of CD4 T cells were still donor-derived one year after transplantation. In contrast to memory CD4 T cells in peripheral blood, intestinal CD4 T cells expressed CD69 and CD161, but only a minor fraction expressed CD103. Functionally, intestinal CD4 T cells were very potent cytokine producers; the vast majority being polyfunctional T1 cells, whereas a minor fraction produced IL-17. Interestingly, a fraction of intestinal CD4 T cells produced granzyme-B and perforin after activation. Together, we show that the intestinal CD4 T-cell compartment is dominated by resident populations that survive for more than 1 year. This finding is of high relevance for the development of oral vaccines and therapies for diseases in the gut.
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http://dx.doi.org/10.1038/s41385-020-0315-5DOI Listing
March 2021

Determination of lower cut-off levels of adalimumab associated with biochemical remission in Crohn's disease.

JGH Open 2020 Jun 6;4(3):410-416. Epub 2019 Oct 6.

Gastroenterology Unit, Department of Internal Medicine Stavanger University Hospital Stavanger Norway.

Background And Aim: Adalimumab is administered and dosed using a standardized treatment regimen. Although therapeutic drug monitoring (TDM) may help optimize treatment efficacy, the lower cut-off concentration of adalimumab needed to retain disease remission has not been established. This cross-sectional study of patients with Crohn's disease on stable medication aimed to determine a lower therapeutic drug concentration threshold of adalimumab associated with biochemical disease remission.

Methods: C-reactive protein (CRP) and fecal calprotectin were used as established markers and albumin as an explorative marker of disease activity. Time since introduction, treatment interval, drug dosage, serum drug concentration and antidrug antibodies, disease duration, age, and sex were recorded.

Results: The study included 101 patients who were divided into "active disease" and "remission" groups for inflammatory markers based on cut-off levels of 5 mg/L for CRP and 50 mg/kg for fecal calprotectin. Cut-off levels for albumin of 36.5 and 41.5 g/L were also added as further indicatives of remission. Receiver operating characteristic analysis found optimal thresholds for adalimumab associated with remission at 6.8-7.0 mg/L for the combination of CRP and fecal calprotectin and when combining CRP, fecal calprotectin, and albumin.

Conclusions: In patients with Crohn's disease, serum adalimumab of at least 6.8 mg/L was associated with biochemical disease remission based on CRP and fecal calprotectin, supporting the use of TDM to ensure disease control. Albumin should be further tested in this setting.
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http://dx.doi.org/10.1002/jgh3.12266DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7273736PMC
June 2020

Role of Endoscopy in Primary Sclerosing Cholangitis.

Clin Endosc 2021 Mar 8;54(2):193-201. Epub 2020 May 8.

Department of Transplantation Medicine, Oslo University Hospital, Oslo, Norway.

Primary sclerosing cholangitis (PSC) is a progressive disease of the bile ducts that usually results in chronic liver disease often requiring liver transplantation. Endoscopy remains crucial to the care of these patients, although magnetic resonance cholangiopancreatography has replaced endoscopic retrograde cholangiopancreatography (ERCP) as the primary imaging modality for diagnosis. For detection of dysplasia or cholangiocarcinoma, ERCP with intraductal sampling remains compulsory. Moreover, dominant strictures play an important part in the disease development, and management by balloon dilatation or stenting could contribute to long-term prognosis. In addition, endoscopy offers management for adverse events such as bile leaks and anastomotic strictures after liver transplantation. Finally, the special phenotype of inflammatory bowel disease associated with PSC as well as the frequent occurrence of portal hypertension mandates close follow-up with colonoscopy and upper endoscopy. With the emergence of novel techniques, the endoscopist remains a key member of the multidisciplinary team caring for PSC patients.
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http://dx.doi.org/10.5946/ce.2020.019-IDENDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8039754PMC
March 2021

Laparoscopy-assisted versus balloon enteroscopy-assisted ERCP after Roux-en-Y gastric bypass.

Endoscopy 2020 08 21;52(8):654-661. Epub 2020 Apr 21.

Clinical Effectiveness Research Group, Department of Health Management and Health Economics, University of Oslo, Oslo, Norway.

Background: Patients who have undergone Roux-en-Y gastric bypass (RYGB) are at increased risk of biliary disease necessitating endoscopic retrograde cholangiopancreatography (ERCP). The most widely used approaches to perform ERCP after RYGB are laparoscopy-assisted ERCP (LA-ERCP) and balloon enteroscopy-assisted ERCP (BEA-ERCP). There are few studies comparing these procedures. We aimed to compare the performance, benefits, and harms of LA-ERCP and BEA-ERCP in RYGB patients.

Methods: We identified all RYGB patients who underwent ERCP at two tertiary care endoscopy centers in Oslo, Norway between May 2013 and December 2017. One center performed BEA-ERCP, the other LA-ERCP. Procedure success was defined as fulfillment of the therapeutic or diagnostic aim, according to the procedure description. Adverse events were classified according to the Clavien-Dindo grading system.

Results: During the study period, 40 BEA-ERCP and 39 LA-ERCP procedures were performed in 68 patients. Procedure success rate was 72.5 % for BEA-ERCP and 87.2 % for LA-ERCP ( = 0.14). Adverse events occurred in 18 % of BEA-ERCP and 28 % of LA-ERCP ( = 0.23). Serious adverse events (Clavien-Dindo grade ≥ 3b) occurred in 2.5 % of BEA-ERCP and 7.7 % of LA-ERCP procedures ( = 0.36). Concomitant cholecystectomy was performed in 25 of the 39 LA-ERCP procedures. The median procedure times for LA-ERCP performed with and without concomitant cholecystectomy were 201 minutes and 140 minutes, respectively, and for BEA-ERCP was 125 minutes.

Conclusions: In experienced hands, both LA-ERCP and BEA-ERCP have high success rates after RYGB. The choice of approach should be individualized according to patient characteristics and available physician competence.
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http://dx.doi.org/10.1055/a-1139-9313DOI Listing
August 2020

Use of rapid reading software to reduce capsule endoscopy reading times while maintaining accuracy.

Gastrointest Endosc 2020 06 22;91(6):1322-1327. Epub 2020 Jan 22.

NIHR Nottingham Biomedical Research Centre, Nottingham University Hospitals NHS Trust and the University of Nottingham, Nottingham, United Kingdom; Nottingham Digestive Diseases Centre, The University of Nottingham, Nottingham, United Kingdom.

Backgrounds And Aims: A typical capsule endoscopy (CE) case generates tens of thousands of images, with abnormalities often confined to a just few frames. Omni Mode is a novel EndoCapsule software algorithm (Olympus, Tokyo, Japan) that proposes to intelligently remove duplicate images while maintaining accuracy in lesion detection.

Methods: This prospective multicenter study took place across 9 European centers. Consecutive, unselected CE cases were read conventionally in normal mode, with every captured frame reviewed. Cases were subsequently anonymized and randomly allocated to another center where they were read using Omni Mode. Detected lesions and reading times were recorded, with findings compared between both viewing modes. The clinical significance of lesions was described according to the P classification (P0, P1, and P2). Where a discrepancy in lesion detection in either mode was found, expert blinded review at a consensus meeting was undertaken.

Results: The patient population undergoing CE had a mean age of 49.5 years (range, 18-91), with the investigation of anemia or GI bleeding accounting for 71.8% of cases. The average small-bowel transit time was 4 hours, 26 minutes. The mean reading time in normal mode was 42.5 minutes. The use of Omni Mode was significantly faster (P < .0001), with an average time saving of 24.6 minutes (95% confidence interval, 22.8-26.9). The 2127 lesions were identified and classified according to the P classification as P0 (1234), P1 (656), and P2 (237). Lesions were identified using both reading modes in 40% (n = 936), and 1186 lesions were identified by either normal or Omni Mode alone. Normal mode interpretation was associated with 647 lesions being missed, giving an accuracy of .70. Omni Mode interpretation led to 539 lesions being missed, with an accuracy of .75. There was no significant difference in clinical conclusions made between either reading mode.

Conclusions: This study shows that CE reading times can be reduced by an average of 40%, without any reduction in clinical accuracy.
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http://dx.doi.org/10.1016/j.gie.2020.01.026DOI Listing
June 2020

ERCP-related adverse events: European Society of Gastrointestinal Endoscopy (ESGE) Guideline.

Endoscopy 2020 02 20;52(2):127-149. Epub 2019 Dec 20.

Department of Gastroenterology and Hepatology, Amsterdam University Medical Centers, University of Amsterdam, The Netherlands.

Prophylaxis: 1:  ESGE recommends routine rectal administration of 100 mg of diclofenac or indomethacin immediately before endoscopic retrograde cholangiopancreatography (ERCP) in all patients without contraindications to nonsteroidal anti-inflammatory drug administration.Strong recommendation, moderate quality evidence. 2:  ESGE recommends prophylactic pancreatic stenting in selected patients at high risk for post-ERCP pancreatitis (inadvertent guidewire insertion/opacification of the pancreatic duct, double-guidewire cannulation).Strong recommendation, moderate quality evidence. 3:  ESGE suggests against routine endoscopic biliary sphincterotomy before the insertion of a single plastic stent or an uncovered/partially covered self-expandable metal stent for relief of biliary obstruction.Weak recommendation, moderate quality evidence. 4:  ESGE recommends against the routine use of antibiotic prophylaxis before ERCP.Strong recommendation, moderate quality evidence. 5:  ESGE suggests antibiotic prophylaxis before ERCP in the case of anticipated incomplete biliary drainage, for severely immunocompromised patients, and when performing cholangioscopy.Weak recommendation, moderate quality evidence. 6:  ESGE suggests tests of coagulation are not routinely required prior to ERCP for patients who are not on anticoagulants and not jaundiced.Weak recommendation, low quality evidence.

Treatment: 7:  ESGE suggests against salvage pancreatic stenting in patients with post-ERCP pancreatitis.Weak recommendation, low quality evidence. 8:  ESGE suggests temporary placement of a biliary fully covered self-expandable metal stent for post-sphincterotomy bleeding refractory to standard hemostatic modalities.Weak recommendation, low quality evidence. 9:  ESGE suggests to evaluate patients with post-ERCP cholangitis by abdominal ultrasonography or computed tomography (CT) scan and, in the absence of improvement with conservative therapy, to consider repeat ERCP. A bile sample should be collected for microbiological examination during repeat ERCP.Weak recommendation, low quality evidence.
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http://dx.doi.org/10.1055/a-1075-4080DOI Listing
February 2020

Heat-shock protein 90 in plasma reflects severity of fatigue in patients with Crohn's disease.

Innate Immun 2020 02 10;26(2):146-151. Epub 2019 Oct 10.

Department of Internal Medicine, Stavanger University Hospital, Norway.

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http://dx.doi.org/10.1177/1753425919879988DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7016405PMC
February 2020

Plastic or metal stents for biliary duct-to-duct anastomotic strictures - Is the jury still out?

Liver Int 2019 07;39(7):1197-1198

Department of Transplantation Medicine, Oslo University Hospital, Oslo, Norway.

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http://dx.doi.org/10.1111/liv.14045DOI Listing
July 2019

Small-bowel endoscopy.

Endoscopy 2019 05 25;51(5):399-400. Epub 2019 Apr 25.

OUS-Rikshospitalet University Hospital, GI endoscopy, Oslo, Norway.

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http://dx.doi.org/10.1055/a-0879-1823DOI Listing
May 2019

Improving Automatic Polyp Detection Using CNN by Exploiting Temporal Dependency in Colonoscopy Video.

IEEE J Biomed Health Inform 2020 01 1;24(1):180-193. Epub 2019 Apr 1.

Automatic polyp detection has been shown to be difficult due to various polyp-like structures in the colon and high interclass variations in polyp size, color, shape, and texture. An efficient method should not only have a high correct detection rate (high sensitivity) but also a low false detection rate (high precision and specificity). The state-of-the-art detection methods include convolutional neural networks (CNN). However, CNNs have shown to be vulnerable to small perturbations and noise; they sometimes miss the same polyp appearing in neighboring frames and produce a high number of false positives. We aim to tackle this problem and improve the overall performance of the CNN-based object detectors for polyp detection in colonoscopy videos. Our method consists of two stages: a region of interest (RoI) proposal by CNN-based object detector networks and a false positive (FP) reduction unit. The FP reduction unit exploits the temporal dependencies among image frames in video by integrating the bidirectional temporal information obtained by RoIs in a set of consecutive frames. This information is used to make the final decision. The experimental results show that the bidirectional temporal information has been helpful in estimating polyp positions and accurately predict the FPs. This provides an overall performance improvement in terms of sensitivity, precision, and specificity compared to conventional false positive learning method, and thus achieves the state-of-the-art results on the CVC-ClinicVideoDB video data set.
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http://dx.doi.org/10.1109/JBHI.2019.2907434DOI Listing
January 2020

Endoscopic management of common bile duct stones: European Society of Gastrointestinal Endoscopy (ESGE) guideline.

Endoscopy 2019 05 3;51(5):472-491. Epub 2019 Apr 3.

Department of Gastroenterology and Hepatology, Amsterdam University Medical Center, University of Amsterdam, Amsterdam, The Netherlands.

ESGE recommends offering stone extraction to all patients with common bile duct stones, symptomatic or not, who are fit enough to tolerate the intervention.Strong recommendation, low quality evidence.ESGE recommends liver function tests and abdominal ultrasonography as the initial diagnostic steps for suspected common bile duct stones. Combining these tests defines the probability of having common bile duct stones.Strong recommendation, moderate quality evidence.ESGE recommends endoscopic ultrasonography or magnetic resonance cholangiopancreatography to diagnose common bile duct stones in patients with persistent clinical suspicion but insufficient evidence of stones on abdominal ultrasonography.Strong recommendation, moderate quality evidence.ESGE recommends the following timing for biliary drainage, preferably endoscopic, in patients with acute cholangitis, classified according to the 2018 revision of the Tokyo Guidelines:- severe, as soon as possible and within 12 hours for patients with septic shock- moderate, within 48 - 72 hours- mild, elective.Strong recommendation, low quality evidence.ESGE recommends endoscopic placement of a temporary biliary plastic stent in patients with irretrievable biliary stones that warrant biliary drainage.Strong recommendation, moderate quality of evidence.ESGE recommends limited sphincterotomy combined with endoscopic papillary large-balloon dilation as the first-line approach to remove difficult common bile duct stones. Strong recommendation, high quality evidence.ESGE recommends the use of cholangioscopy-assisted intraluminal lithotripsy (electrohydraulic or laser) as an effective and safe treatment of difficult bile duct stones.Strong recommendation, moderate quality evidence.ESGE recommends performing a laparoscopic cholecystectomy within 2 weeks from ERCP for patients treated for choledocholithiasis to reduce the conversion rate and the risk of recurrent biliary events. Strong recommendation, moderate quality evidence.
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http://dx.doi.org/10.1055/a-0862-0346DOI Listing
May 2019
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