Publications by authors named "Mario Dinis-Ribeiro"

261 Publications

ESGE quality parameters in colonoscopy: How to ensure their adoption?

Endosc Int Open 2021 Oct 16;9(10):E1463-E1465. Epub 2021 Sep 16.

Gastroenterology Department, Portuguese Oncology Institute of Porto, Porto, Portugal.

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http://dx.doi.org/10.1055/a-1486-6788DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8445679PMC
October 2021

Endoscopic tissue sampling - Part 1: Upper gastrointestinal and hepatopancreatobiliary tracts. European Society of Gastrointestinal Endoscopy (ESGE) Guideline.

Endoscopy 2021 Sep 17. Epub 2021 Sep 17.

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

1: ESGE recommends that, where there is a suspicion of eosinophilic esophagitis, at least six biopsies should be taken, two to four biopsies from the distal esophagus and two to four biopsies from the proximal esophagus, targeting areas with endoscopic mucosal abnormalities. Distal and proximal biopsies should be placed in separate containers.Strong recommendation, low quality of evidence. 2: ESGE recommends obtaining six biopsies, including from the base and edge of the esophageal ulcers, for histologic analysis in patients with suspected viral esophagitis.Strong recommendation, low quality of evidence. 3: ESGE recommends at least six biopsies are taken in cases of suspected advanced esophageal cancer and suspected advanced gastric cancer.Strong recommendation, moderate quality of evidence. 4: ESGE recommends taking only one to two targeted biopsies for lesions in the esophagus or stomach that are potentially amenable to endoscopic resection (Paris classification 0-I, 0-II) in order to confirm the diagnosis and not compromise subsequent endoscopic resection.Strong recommendation, low quality of evidence. 5: ESGE recommends obtaining two biopsies from the antrum and two from the corpus in patients with suspected infection and for gastritis staging.Strong recommendation, low quality of evidence. 6: ESGE recommends biopsies from or, if endoscopically resectable, resection of gastric adenomas.Strong recommendation, moderate quality of evidence. 7: ESGE recommends fine-needle aspiration (FNA) and fine-needle biopsy (FNB) needles equally for sampling of solid pancreatic masses.Strong recommendation, high quality evidence. 8: ESGE suggests performing peroral cholangioscopy (POC) and/or endoscopic ultrasound (EUS)-guided tissue acquisition in indeterminate biliary strictures. For proximal and intrinsic strictures, POC is preferred. For distal and extrinsic strictures, EUS-guided sampling is preferred, with POC where this is not diagnostic.Weak recommendation, low quality evidence. 9: ESGE suggests obtaining possible non-neoplastic biopsies before sampling suspected malignant lesions to prevent intraluminal spread of malignant disease.Weak recommendation, low quality of evidence. 10: ESGE suggests dividing EUS-FNA material into smears (two per pass) and liquid-based cytology (LBC), or the whole of the EUS-FNA material can be processed as LBC, depending on local experience.Weak recommendation, low quality evidence.
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http://dx.doi.org/10.1055/a-1611-5091DOI Listing
September 2021

Efficacy and safety of primary, early and late needle-knife fistulotomy for biliary access.

Sci Rep 2021 Aug 17;11(1):16658. Epub 2021 Aug 17.

Department of Gastroenterology, Portuguese Oncology Institute of Porto, Porto, Portugal.

European Society of Gastrointestinal Endoscopy recommends needle-knife fistulotomy (NKF) as the preferred precut technique. However, there is little information on whether NKF performed at different times is associated with different success and adverse event rates. We compared the outcomes of 3 different timings of NKF. This was an observational study conducted at 4 institutions and this was a retrospective analysis of prospectively collected data. We included 330 consecutive patients submitted to NKF attempt for biliary access. Patients were divided into three groups: NKF as an initial procedure for biliary access (group A, n = 121); early NKF defined as after 5 min, 5 attempts, or 2 pancreatic passages (group B, n = 99); and late NKF: after at least 10 min of unsuccessful standard biliary cannulation (group C, n = 110). We assessed the success rate of biliary cannulation at initial ERCP, time to perform NKF until biliary cannulation, overall biliary cannulation rate (second ERCP when initial failure), adverse event rate, and predictors of post-ERCP pancreatitis (PEP). The initial cannulation rate was 98%, 91% and 94% for groups A, B and C respectively, p = 0.08, whereas overall biliary cannulation rate was 100%, 95% and 98%, p = 0.115. The adverse event rate/PEP was 4.1%/2.5%, 7.1%/4% and 10.9%/8.2%, for groups A, B and C respectively, (p = 0.197 and p = 0.190). Median time for creating the fistula was A = 4.0 min, B = 3.2 min, and C = 5.6 min, p < 000.1. Each additional minute spent attempting cannulation increased the odds ratio (OR) for PEP by 1.072, and patients with 3 or more risk factors for pancreatitis had a higher chance of PEP. In conclusion, the timing of NFK does not appear to influence success rates but late NFK is associated with a higher time to create a fistula and an increased risk of pancreatitis. Primary NFK is associated with a high rate of success and a low rate of PEP and deserves additional investigation.
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http://dx.doi.org/10.1038/s41598-021-96142-9DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8371017PMC
August 2021

Outcomes of single-endoscopist-performed needle-knife fistulotomy for selective biliary access in 842 consecutive patients: learning curve and changes over a 14-year period in a retrospective study.

Scand J Gastroenterol 2021 Aug 6:1-8. Epub 2021 Aug 6.

Department of Gastroenterology, Santa Luzia Hospital, Unidade Local de Saúde Alto Minho, Viana do Castelo, Portugal.

Background And Aims: Needle-knife fistulotomy (NKF) has emerged as the preferred precut technique. From a late strategy, NKF has shifted to an early rescue technique and has been used recently as a primary method for biliary access. It is unknown how these changes have affected NKF outcomes. We analyzed the outcomes of NKF over time in a large cohort of patients.

Methods: Multicenter retrospective cohort study of 842 patients who underwent NKF for biliary access between 2006 and 2019. Patients were divided into four study periods according to a late or early cannulation strategy and to the use of post-ERCP pancreatitis prophylaxis (Period 1-Period 4). We assessed outcomes of NKF, learning curves and shifts over time.

Results: Bile duct access was obtained in 88.0% of the patients. The initial cannulation rate increased significantly from 77.5% in P1 to 92.0% in P4 ( < .001). An endoscopist can obtain 80% success rate after performing 100 NKF procedures (95% CI: 0.79-0.86) and a 95% success rate after 830 procedures (95% CI: 0.92-0.98). Adverse events and pancreatitis were observed in 6.5% and 4.9% of patients respectively. The rate of pancreatitis was not significantly different during the 4 periods ( = .190). A decline in the pancreatitis rate was observed from 2006 until 2016 (no trainees) and then an increase until 2019 (trainees involved). The presence of trainees increased the rate of pancreatitis in the last period by 9.9%.

Conclusions: The success of NKF has increased significantly over the years, initially in a rapid manner and then more slowly. It is associated with a low rate of complications, which tend to decrease with experience. The involvement of trainees is associated with an increased rate of pancreatitis.
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http://dx.doi.org/10.1080/00365521.2021.1958369DOI Listing
August 2021

Curriculum for ERCP and endoscopic ultrasound training in Europe: European Society of Gastrointestinal Endoscopy (ESGE) Position Statement.

Endoscopy 2021 Oct 26;53(10):1071-1087. Epub 2021 Jul 26.

Department of Gastroenterology and Hepatology, University Hospitals Leuven, and TARGID, KU Leuven, Leuven, Belgium.

The European Society of Gastrointestinal Endoscopy (ESGE) has recognized the need to formalize and enhance training in endoscopic retrograde cholangiopancreatography (ERCP) and endoscopic ultrasound (EUS). This manuscript represents the outcome of a formal Delphi process resulting in an official Position Statement of the ESGE and provides a framework to develop and maintain skills in ERCP and EUS. This curriculum is set out in terms of the prerequisites prior to training; recommended steps of training to a defined syllabus; the quality of training; and how competence should be defined and evidenced before independent practice. 1: Trainees should be competent in gastroscopy prior to commencing training. Formal training courses and the use of simulation in training are recommended. 2: Trainees should keep a contemporaneous logbook of their procedures, including key performance indicators and the degree of independence. Structured formative assessment is encouraged to enhance feedback. There should be a summative assessment process prior to commencing independent practice to ensure there is robust evidence of competence. This evidence should include a review of a trainee's procedure volume and current performance measures. A period of mentoring is strongly recommended in the early stages of independent practice. 3: Specifically for ERCP, all trainees should be competent up to Schutz level 2 complexity (management of distal biliary strictures and stones > 10 mm), with advanced ERCP requiring a further period of training. Prior to independent practice, ESGE recommends that a trainee can evidence a procedure volume of > 300 cases, a native papilla cannulation rate of ≥ 80 % (90 % after a period of mentored independent practice), complete stones clearance of ≥ 85 %, and successful stenting of distal biliary strictures of ≥ 90 % (90 % and 95 % respectively after a mentored period of independent practice). 4: The progression of EUS training and competence attainment should start from diagnostic EUS and then proceed to basic therapeutic EUS, and finally to advanced therapeutic EUS. Before independent practice, ESGE recommends that a trainee can evidence a procedure volume of > 250 cases (75 fine-needle aspirations/biopsies [FNA/FNBs]), satisfactory visualization of key anatomical landmarks in ≥ 90 % of cases, and an FNA/FNB accuracy rate of ≥ 85 %. ESGE recognizes the often inadequate quality of the evidence and the need for further studies pertaining to training in advanced endoscopy, particularly in relation to therapeutic EUS.
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http://dx.doi.org/10.1055/a-1537-8999DOI Listing
October 2021

Colorectal Screening Program in Northern Portugal: First Findings.

Acta Med Port 2021 Jul 20. Epub 2021 Jul 20.

Departamento de Gastroenterologia. Instituto Português de Oncologia do Porto. Porto. Portugal.

Introduction: In Portugal, a colorectal cancer screening program based on faecal immunochemical test followed by colonoscopy was shown to be cost-effective for individuals between 50 and 74 years old. We report the first findings of the implementation of a population-based program In Northern Portugal.

Material And Methods: In the pilot phase, eligible subjects were allocated either to a direct mailing invitation or to primary care centers. In the first year of program implementation, we assessed the uptake rate, the faecal immunochemical test -positivity rate, the diagnostic yield of advanced neoplasia, and the quality parameters for post-faecal immunochemical test + colonoscopy.

Results: We invited 100 501 eligible subjects (49% male with a median age of 55 years). Of these, 5228 participated in the pilot phase and 95 273 participated in the first year of the program. In the first year of the program, the adherence was 29%, with a positivity rate of 5% and a 60% compliance to colonoscopy. The faecal immunochemical test-detection rate of advanced neoplasia was 0.35/1000 subjects, and the positive predictive value at post- faecal immunochemical test + colonoscopy was 44% and 2% for advanced adenoma and invasive cancer, respectively. No major adverse events were reported after colonoscopy.

Discussion: The suboptimal adherence to faecal immunochemical test and post-faecal immunochemical test + colonoscopy remains the most urgent step to be addressed.

Conclusion: A centralized invitation system based on direct mailing was feasible and both colonoscopy quality and diagnostic yield were adequate antecipating the success of the programme.
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http://dx.doi.org/10.20344/amp.15904DOI Listing
July 2021

Original Article: MicroRNA Dysregulation in the Gastric Carcinogenesis Cascade: Can We Anticipate Its Role in Individualized Care?

Pathobiology 2021 Jul 16:1-13. Epub 2021 Jul 16.

Gastroenterology Department, Portuguese Oncology Institute of Porto (IPO-Porto), Porto, Portugal.

Background: Gastric carcinogenesis progresses from normal mucosa, atrophic/metaplastic gastritis, and dysplasia to adenocarcinoma. MicroRNAs (miRNAs) regulate DNA expression and have been implicated; however, their role is not fully established.

Aims: The aim of this study was to characterize plasma and tissue expression of several miRNAs in gastric carcinogenesis stages.

Methods: Single-center cross-sectional study in 64 patients: 19 controls (normal mucosa); 15 with extensive atrophic/metaplastic gastritis; and 30 with early gastric neoplasia (EGN). Seven miRNAs (miR-21, miR-146a, miR-181b, miR-370, miR-375, miR 181b, and miR-490) were quantified by real time-qPCR in peripheral blood and endoscopic biopsy samples.

Results: We found a significant upregulation of miR-181b, miR-490, and miR-21 in the EGN mucosa (overexpression 2-14-times higher than controls). We observed a significant underexpression of miR-146a and miR-370 in atrophic/metaplastic gastritis (86 and 66% decrease, p = 0.008 and p = 0.001) and in EGN (89 and 62% reduction, p = 0.034 and p = 0.032) compared with controls. There were no differences between lesions and nonneoplastic mucosa and no dysregulation of plasma miRNAs.

Conclusion: We found significant dysregulation of 5 miRNAs in gastric carcinogenesis, suggesting a tumor suppressor role for miR-146a and miR-370 and oncogenic potential for miR-21, miR-181, and miR-490. These changes happen diffusely in the gastric mucosa, suggesting a high-risk field defect, which may influence these patients' surveillance.
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http://dx.doi.org/10.1159/000515548DOI Listing
July 2021

Artificial Intelligence for gastrointestinal endoscopy: When technology meets our needs!

Best Pract Res Clin Gastroenterol 2021 Jun-Aug;52-53:101725. Epub 2021 Jan 31.

III Medizinische Klinik, Universitatsklinikum Augsburg, Augsburg, Germany.

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http://dx.doi.org/10.1016/j.bpg.2021.101725DOI Listing
January 2021

Early gastric cancer and Artificial Intelligence: Is it time for population screening?

Best Pract Res Clin Gastroenterol 2021 Jun-Aug;52-53:101710. Epub 2020 Nov 10.

Department of Gastroenterology, Portuguese Oncology Institute of Porto, Porto, Portugal.

Gastric cancer is a common cause of death worldwide and its early detection is crucial to improve its prognosis. Its incidence varies throughout countries, and screening has been found to be cost-effective at least in high-incidence regions. Identification of individuals harbouring preneoplastic lesions and their surveillance or of those with early gastric cancer are extremely important processes and endoscopy play a key role for this purpose. Unfortunately, also quality and accuracy for endoscopic detection varies among centres and endoscopists. Recent studies about Artificial Intelligence applied to endoscopic imaging show that these technologies perform very well and could be extremely useful for endoscopists to achieve the accuracy needed for gastric cancer screening. Nonetheless, as its introduction in this field is very recent, most studies are carried out offline and its results in clinical practice need to be further validated namely by incorporating all the components/dimensions of endoscopy from pre to post-assessment.
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http://dx.doi.org/10.1016/j.bpg.2020.101710DOI Listing
July 2021

Live endoscopy events (LEEs): European Society of Gastrointestinal Endoscopy Position Statement - Update 2021.

Endoscopy 2021 08 10;53(8):842-849. Epub 2021 Jun 10.

Serviço de Gastrenterologia, Instituto Português de Oncologia, Porto, Portugal.

The European Society of Gastrointestinal Endoscopy (ESGE) is dedicated to improving the quality of gastrointestinal endoscopy, including through educational activities such as live endoscopy events (LEEs). The primary goal of LEEs should be to facilitate the improvement of endoscopic patient care through the acquisition of best endoscopic practice. Patients should not expect additional benefit from being treated during a LEE compared to a routine setting. There is limited available evidence on LEE safety but to date there is no indication that patients are at increased risk from participation. Pre-recorded cases with live facilitation can also be used to fulfill learning outcomes. Establishing an endoscopic curriculum with clear learning outcomes is important to structure attendees' learning, assess course outcomes, and allow appropriate targeting of courses to learner experience. Increasingly, LEEs are streamed online and therefore the necessary measures should be taken to ensure that patients have given appropriate consent and that their anonymity has been safeguarded. ESGE recommends that an endoscopist who is not participating in the live demonstrations is named as patient advocate, and that patient safety should must be prioritized throughout. In all ESGE-organized LEEs the intended learning outcomes, procedural indications and descriptions, attendee feedback, and adverse events should be recorded and submitted in a post-event report to ESGE.
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http://dx.doi.org/10.1055/a-1511-1657DOI Listing
August 2021

Second-generation thrombopoietin receptor agonists: New players in the management of cirrhotic patients undergoing therapeutic endoscopy?

Dig Liver Dis 2021 Jun 1. Epub 2021 Jun 1.

Gastroenterology Unit, Department of Medical and Surgical Sciences, S.Orsola-Malpighi Hospital, University of Bologna, Bologna, Italy.

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http://dx.doi.org/10.1016/j.dld.2021.05.007DOI Listing
June 2021

PqqE is a new virulence factor that cleaves junctional adhesion molecule A and disrupts gastric epithelial integrity.

Gut Microbes 2021 Jan-Dec;13(1):1-21

i3S - Instituto de Investigação e Inovação em Saúde, Universidade do Porto, Porto, Portugal.

infects approximately half of the world's population and is the strongest risk factor for peptic ulcer disease and gastric cancer, representing a major global health concern. persistently colonizes the gastric epithelium, where it subverts the highly organized structures that maintain epithelial integrity. Here, a unique strategy used by to disrupt the gastric epithelial junctional adhesion molecule-A (JAM-A) is disclosed, using various experimental models that include gastric cell lines, primary human gastric cells, and biopsy specimens of infected and non-infected individuals. preferentially cleaves the cytoplasmic domain of JAM-A at Alanine 285. Cells stably transfected with full-length JAM-A or JAM-A lacking the cleaved sequence are used in a range of functional assays, which demonstrate that the cleaved region is critical to the maintenance of the epithelial barrier and of cell-cell adhesion. Notably, by combining chromatography techniques and mass spectrometry, PqqE (HP1012) is purified and identified as the virulence factor that cleaves JAM-A, uncovering a previously unreported function for this bacterial protease. These findings propose a novel mechanism for to disrupt epithelial integrity and functions, breaking new ground in the understanding of the pathogenesis of this highly prevalent and clinically relevant infection.
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http://dx.doi.org/10.1080/19490976.2021.1921928DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8115454PMC
May 2021

Endoscopists' diagnostic accuracy in detecting upper gastrointestinal neoplasia in the framework of artificial intelligence studies.

Endoscopy 2021 May 5. Epub 2021 May 5.

Gastroenterology Department, Portuguese Oncology Institute of Porto, Porto, Portugal.

Background:  Estimates on miss rates for upper gastrointestinal neoplasia (UGIN) rely on registry data or old studies. Quality assurance programs for upper GI endoscopy are not fully established owing to the lack of infrastructure to measure endoscopists' competence. We aimed to assess endoscopists' accuracy for the recognition of UGIN exploiting the framework of artificial intelligence (AI) validation studies.

Methods:  Literature searches of databases (PubMed/MEDLINE, EMBASE, Scopus) up to August 2020 were performed to identify articles evaluating the accuracy of individual endoscopists for the recognition of UGIN within studies validating AI against a histologically verified expert-annotated ground-truth. The main outcomes were endoscopists' pooled sensitivity, specificity, positive and negative predictive value (PPV/NPV), and area under the curve (AUC) for all UGIN, for esophageal squamous cell neoplasia (ESCN), Barrett esophagus-related neoplasia (BERN), and gastric adenocarcinoma (GAC).

Results:  Seven studies (2 ESCN, 3 BERN, 1 GAC, 1 UGIN overall) with 122 endoscopists were included. The pooled endoscopists' sensitivity and specificity for UGIN were 82 % (95 % confidence interval [CI] 80 %-84 %) and 79 % (95 %CI 76 %-81 %), respectively. Endoscopists' accuracy was higher for GAC detection (AUC 0.95 [95 %CI 0.93-0.98]) than for ESCN (AUC 0.90 [95 %CI 0.88-0.92]) and BERN detection (AUC 0.86 [95 %CI 0.84-0.88]). Sensitivity was higher for Eastern vs. Western endoscopists (87 % [95 %CI 84 %-89 %] vs. 75 % [95 %CI 72 %-78 %]), and for expert vs. non-expert endoscopists (85 % [95 %CI 83 %-87 %] vs. 71 % [95 %CI 67 %-75 %]).

Conclusion:  We show suboptimal accuracy of endoscopists for the recognition of UGIN even within a framework that included a higher prevalence and disease awareness. Future AI validation studies represent a framework to assess endoscopist competence.
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http://dx.doi.org/10.1055/a-1500-3730DOI Listing
May 2021

Gastric microbiome profile throughout gastric carcinogenesis: beyond helicobacter.

Scand J Gastroenterol 2021 Jun 29;56(6):708-716. Epub 2021 Apr 29.

Department of Gastroenterology, Portuguese Oncology Institute - Porto, Porto, Portugal.

Background: Gastric dysbiosis has been hinted as a potential cause of gastric cancer. However, changes in microbiome throughout the major stages of gastric carcinogenesis remain mostly unknown.

Objective: To describe gastric microbiome at different stages, analysing for the first time dysbiosis specifically in patients with early gastric cancer (EGC).

Methods: Cross-sectional study including patients ( = 77) with endoscopically and histologically confirmed normal stomachs (controls;  = 25), advanced atrophic gastritis with intestinal metaplasia (IM;  = 18) and EGC ( = 34). Endoscopic biopsies from antrum and corpus ( = 154) were analyzed. Next-generation sequencing was performed characterizing microbial communities down to the species level based on full-length 16SrRNA gene profiling.

Results: Significant differences were found in the microbiome profile between the groups. Firmicutes were more frequent ( = .012) and Proteobacteria were less frequent ( = .04) both in the IM and EGC when comparing to controls. Relative frequency of , when present, was much higher in the controls (83%) when comparing to the other groups (IM 1%, EGC 27%;  = .006), being the dominant bacteria only in the controls. Dysbiosis was present already and more significantly at the IM stage, with two bacteria progressively increasing from controls to IM then to cancer: from 1.48 to 3.9% ( = .014); and from 19.3 to 33.7% ( = .04), being the EGC dominant bacteria.

Conclusions: Our results confirm dominancy in non-atrophic stomachs and progressive dysbiosis throughout gastric carcinogenesis. but particularly is significantly increased in patients with EGC. Specific modulation of these bacteria may change gastric cancer risk.
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http://dx.doi.org/10.1080/00365521.2021.1902560DOI Listing
June 2021

Revising the European Society of Gastrointestinal Endoscopy (ESGE) research priorities: a research progress update.

Endoscopy 2021 05 1;53(5):535-554. Epub 2021 Apr 1.

Gastroenterology Department, Portuguese Oncology Institute of Porto, Porto, Portugal.

Background: One of the aims of the European Society of Gastrointestinal Endoscopy (ESGE) is to encourage high quality endoscopic research at a European level. In 2016, the ESGE research committee published a set of research priorities. As endoscopic research is flourishing, we aimed to review the literature and determine whether endoscopic research over the last 4 years had managed to address any of our previously published priorities.

Methods: As the previously published priorities were grouped under seven different domains, a working party with at least two European experts was created for each domain to review all the priorities under that domain. A structured review form was developed to standardize the review process. The group conducted an extensive literature search relevant to each of the priorities and then graded the priorities into three categories: (1) no longer a priority (well-designed trial, incorporated in national/international guidelines or adopted in routine clinical practice); (2) remains a priority (i. e. the above criterion was not met); (3) redefine the existing priority (i. e. the priority was too vague with the research question not clearly defined).

Results: The previous ESGE research priorities document published in 2016 had 26 research priorities under seven domains. Our review of these priorities has resulted in seven priorities being removed from the list, one priority being partially removed, another seven being redefined to make them more precise, with eleven priorities remaining unchanged. This is a reflection of a rapid surge in endoscopic research, resulting in 27 % of research questions having already been answered and another 27 % requiring redefinition.

Conclusions: Our extensive review process has led to the removal of seven research priorities from the previous (2016) list, leaving 19 research priorities that have been redefined to make them more precise and relevant for researchers and funding bodies to target.
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http://dx.doi.org/10.1055/a-1397-3005DOI Listing
May 2021

Influence of a novel classification of the papilla of Vater on the outcome of needle-knife fistulotomy for biliary cannulation.

BMC Gastroenterol 2021 Apr 1;21(1):147. Epub 2021 Apr 1.

Cintesis - Center for Health Technology and Services Research, Porto, Portugal.

Background: Existing proposed classification systems for the Papilla of Vater (PV) suboptimally account for all relevant, encountered PV appearances, are too complex or have not been assessed for intra- or interobserver variability. We proposed a novel endoscopic classification system for PV, determined its inter- and intraobserver rates and used the classification system to assess whether the success and complications of needle-knife fistulotomy (NKF) are influenced by the morphology of the PV.

Methods: The classification system was developed by expert endoscopists. To evaluate the inter- and intraobserver agreement, an online questionnaire was sent to 20 endoscopists from several countries (10 experts and 10 nonexperts) that included 50 images of papillae of Vater divided among various categories. Four weeks later, a second survey, with the images from the first questionnaire randomly reordered, was sent to the same endoscopists. The inter- and intraobserver agreements among the experts and nonexperts was calculated. Using the proposed classification system, all 361 consecutive patients who underwent NKF for biliary access to a naïve papilla were prospectively enrolled in the study.

Results: The novel classification system comprises 7 categories: type I, flat type, lacking an oral protrusion; type IIA, prominent tubular nonpleated type, with an oral protrusion and < 1 transverse fold over the oral protrusion; type IIB, prominent tubular pleated type, with an oral protrusion and > 2 transverse folds over the oral protrusion; type IIC: prominent bulging type, with an enlarged and bulging oral protrusion; type IIIA, diverticular-intradiverticular type, with a papillary orifice inside the diverticulum; type IIIB: diverticular-diverticular border type, with a papillary orifice less than 2 cm from the diverticular border; type IV: unclassified papilla, with no morphology classified in the other categories. The interobserver agreement between experts was substantial (K = 0.611, 95% CI 0.498-0.709) and was higher than that between nonexperts (K = 0.516; 95% CI 0.410-0.636). The intraobserver agreement was substantial among both experts (K = 0,651; 95% CI 0.586-0.715) and nonexperts (K = 0.646, 95% CI 0.615-0.677). In a multivariate model, type IIIA and IIIB were the only independent risk factors for difficult rescue NKF biliary cannulation (P = 0.003 and P = 0.019, respectively), and type I and type IIB were the only independent risk factors for a prolonged cannulation time using NKF (P < 0.001 and P = 0.005, respectively).

Conclusions: The novel endoscopic classification system for PV is highly reproducible among experienced ERCPists according to the substantial level of agreement between experts. However, nonexperts require further training in its use. Using the novel classification system, we identified different types of papillae significantly associated with a lower efficacy of NKF and a prolonged time to obtain successful biliary cannulation using NKF.
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http://dx.doi.org/10.1186/s12876-021-01735-3DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8017832PMC
April 2021

Endoscopic ultrasound-guided sampling of gastrointestinal subepithelial lesions: just wet it.

Eur J Gastroenterol Hepatol 2021 Mar 12. Epub 2021 Mar 12.

Gastroenterology Department, Portuguese Oncology Institute Departamento de Medicina da Comunidade, Informação e Decisão em Saúde (MEDCIDS) Surgery and Physiology Department, Faculty of Medicine of the University of Porto, Porto, Portugal.

Introduction: Endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) is the main method for acquisition of tissue from gastrointestinal subepithelial lesions (SELs). Despite the development of new needles, diagnostic yield remains low. A new method of aspiration has been described, where the needle is filled with saline [wet-suction technique (WST)], with promising results in pancreatic lesions. This method has not been tested in SELs.

Aims And Methods: Prospective single center study to assess the diagnostic yield of EUS-FNA+WST in the diagnosis of SELs, without the use of rapid on-site evaluation. In mesenchymal tumors, the diagnosis was considered positive only when immunohistochemistry could differentiate between gastrointestinal stromal tumor and leiomyoma.

Results: Eighty-seven patients with SELs were included (55% male, mean age 66 years). Mean SEL size was 25 mm (min 10 mm, max 120 mm), mean number of passes was 3 (±0.8). A 22G needle was used in 72 patients (83%), 19G in 10 (12%) and 25G in 5 (6%). We obtained a conclusive cytopathological diagnosis in 74 cases (diagnostic yield of 85%) and immunohistochemistry was performed in 70 cases (81%). The most frequent diagnoses were gastrointestinal stromal tumor (n = 34, 37%), leiomyoma (n = 13, 15%) and metastases (n = 10, 11%).

Conclusion: Wet suction technique allowed an excellent diagnostic yield in the EUS-guided evaluation of SELs. We suggest that, after proper replication of these results, WST may become the first-line method in the management of these lesions.
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http://dx.doi.org/10.1097/MEG.0000000000002108DOI Listing
March 2021

Complete endoscopic removal of a large appendiceal orifice polyp.

Endoscopy 2021 Mar 15. Epub 2021 Mar 15.

Gastroenterology Department, Portuguese Oncology Institute of Porto, Porto, Portugal.

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http://dx.doi.org/10.1055/a-1374-9793DOI Listing
March 2021

Anal cancer and precancerous lesions: a call for improvement.

Lancet Gastroenterol Hepatol 2021 04;6(4):327-334

CINTESIS - Center for Health Technology and Services Research, Medical Research Center, University of Porto, Porto, Portugal; Gastroenterology Department, Portuguese Oncology Institute of Porto, Porto, Portugal.

Anal squamous cell carcinoma is the most common type of anal cancer and is largely associated with anal human papillomavirus infection. The incidence of anal squamous cell carcinoma is increasing, and although still uncommon in the general population, a high incidence has been noted in specific population groups (eg, patients with HIV, men who have sex with men [MSM], recipients of solid organ transplants, women with genital neoplasia, and patients with systemic lupus erythematosus or inflammatory bowel disease). The higher incidence among individuals who are HIV-positive makes anal squamous cell carcinoma one of the most common non-AIDS-defining cancers among HIV-positive individuals. Anal cancer screening in high-risk groups aims to detect high-grade squamous intraepithelial lesions, which are considered anal precancerous lesions, and for which identification can provide an opportunity for prevention. A blind anal cytology is normally the first screening method, and for patients with abnormal results, this approach can be followed by an examination of the anal canal and perianal area under magnification, along with staining-a technique known as high-resolution anoscopy. Digital anorectal examination can enable early anal cancer detection. Several societies are in favour of screening for HIV-positive MSM and recipients of transplants. There are no current recommendations for screening of anal precancerous lesions via endoscopy, but in high-risk groups, a careful observation of the squamocolumnar junction should be attempted. Several treatments can be used to treat high-grade squamous intraepithelial lesions, including argon plasma coagulation or radiofrequency ablation, which are largely limited by high recurrence rates. Gastroenterologists need to be aware of anal squamous cell carcinoma and anal precancerous lesions, given that patients at high risk are frequently encountered in the gastroenterology department. We summarise simple procedures that can help in early anal squamous cell carcinoma detection.
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http://dx.doi.org/10.1016/S2468-1253(20)30304-6DOI Listing
April 2021

Endoscopic diagnosis and management of nonvariceal upper gastrointestinal hemorrhage (NVUGIH): European Society of Gastrointestinal Endoscopy (ESGE) Guideline - Update 2021.

Endoscopy 2021 Mar 10;53(3):300-332. Epub 2021 Feb 10.

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

1: ESGE recommends in patients with acute upper gastrointestinal hemorrhage (UGIH) the use of the Glasgow-Blatchford Score (GBS) for pre-endoscopy risk stratification. Patients with GBS ≤ 1 are at very low risk of rebleeding, mortality within 30 days, or needing hospital-based intervention and can be safely managed as outpatients with outpatient endoscopy.Strong recommendation, moderate quality evidence. 2: ESGE recommends that in patients with acute UGIH who are taking low-dose aspirin as monotherapy for secondary cardiovascular prophylaxis, aspirin should not be interrupted. If for any reason it is interrupted, aspirin should be re-started as soon as possible, preferably within 3-5 days.Strong recommendation, moderate quality evidence. 3: ESGE recommends that following hemodynamic resuscitation, early (≤ 24 hours) upper gastrointestinal (GI) endoscopy should be performed. Strong recommendation, high quality evidence. 4: ESGE does not recommend urgent (≤ 12 hours) upper GI endoscopy since as compared to early endoscopy, patient outcomes are not improved. Strong recommendation, high quality evidence. 5: ESGE recommends for patients with actively bleeding ulcers (FIa, FIb), combination therapy using epinephrine injection plus a second hemostasis modality (contact thermal or mechanical therapy). Strong recommendation, high quality evidence. 6: ESGE recommends for patients with an ulcer with a nonbleeding visible vessel (FIIa), contact or noncontact thermal therapy, mechanical therapy, or injection of a sclerosing agent, each as monotherapy or in combination with epinephrine injection. Strong recommendation, high quality evidence. 7 : ESGE suggests that in patients with persistent bleeding refractory to standard hemostasis modalities, the use of a topical hemostatic spray/powder or cap-mounted clip should be considered. Weak recommendation, low quality evidence. 8: ESGE recommends that for patients with clinical evidence of recurrent peptic ulcer hemorrhage, use of a cap-mounted clip should be considered. In the case of failure of this second attempt at endoscopic hemostasis, transcatheter angiographic embolization (TAE) should be considered. Surgery is indicated when TAE is not locally available or after failed TAE. Strong recommendation, moderate quality evidence. 9: ESGE recommends high dose proton pump inhibitor (PPI) therapy for patients who receive endoscopic hemostasis and for patients with FIIb ulcer stigmata (adherent clot) not treated endoscopically. (A): PPI therapy should be administered as an intravenous bolus followed by continuous infusion (e. g., 80 mg then 8 mg/hour) for 72 hours post endoscopy. (B): High dose PPI therapies given as intravenous bolus dosing (twice-daily) or in oral formulation (twice-daily) can be considered as alternative regimens.Strong recommendation, high quality evidence. 10: ESGE recommends that in patients who require ongoing anticoagulation therapy following acute NVUGIH (e. g., peptic ulcer hemorrhage), anticoagulation should be resumed as soon as the bleeding has been controlled, preferably within or soon after 7 days of the bleeding event, based on thromboembolic risk. The rapid onset of action of direct oral anticoagulants (DOACS), as compared to vitamin K antagonists (VKAs), must be considered in this context.Strong recommendation, low quality evidence.
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http://dx.doi.org/10.1055/a-1369-5274DOI Listing
March 2021

Endoscopic submucosal dissection (ESD): how do Western endoscopists value animal models?

Scand J Gastroenterol 2021 Apr 8;56(4):492-497. Epub 2021 Feb 8.

Department of Gastroenterology, Portuguese Oncology Institute of Porto, Porto, Portugal.

Introduction: Endoscopic Submucosal Dissection (ESD)was introduced in the West later than in the East. Our aim was to assess how Western endoscopists performing ESD have been trained and how they value animal models for training.

Material And Methods: An online survey regarding training in ESD was sent to Western endoscopists who published articles on advanced resection techniques.

Results: From 279 endoscopists, 58 (21%) completed the questionnaire, of which 50 confirmed performance of clinical ESD. Endoscopists had a median of 15 years of endoscopic experience (IQR 9.75-20.25) and all of them were performing conventional EMR, before starting ESD. Prior to clinical ESD, 74% ( = 37) underwent training with models, 84% ( = 42) with live animal models and 92% ( = 46) with at least, one of the two models. After starting clinical ESD, as trainers, 52% ( = 26) were involved with and 60% ( = 30) with live animal models. Personal usefulness of and live animal models was rated with a median of 9 (IQR 8-10) and 10 (IQR 8-10), out of 10, respectively. Courses with and live animal models were considered a prerequisite before clinical practice by 84% ( = 42) and 78% ( = 39), respectively.

Conclusions: Western endoscopists have extensive endoscopic experience before starting ESD. The majority had pre-clinical training with and live animal models and more than half are acting as trainers of other endoscopists with these models. Animal models are considered very useful and deemed a prerequisite before clinical practice by the majority of the endoscopists.
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http://dx.doi.org/10.1080/00365521.2021.1879251DOI Listing
April 2021

Genetic Variations in Prostaglandin E Pathway Identified as Susceptibility Biomarkers for Gastric Cancer in an Intermediate Risk European Country.

Int J Mol Sci 2021 Jan 11;22(2). Epub 2021 Jan 11.

CINTESIS-Center for Health Technology and Services Research, University of Porto, Rua Dr. Plácido da Costa, 4200-450 Porto, Portugal.

The cyclooxygenase-2 (COX-2)/prostaglandin E (PGE) pathway exerts deleterious pleiotropic effects in inflammation-induced gastric carcinogenesis. We aimed to assess the association of genetic variants in prostaglandin-endoperoxide synthase 2 (), ATP binding cassette subfamily C member 4 (), hydroxyprostaglandin dehydrogenase 15-(NAD) ), and solute carrier organic anion transporter family member 2A1 () PGE pathway-related genes with gastric cancer (GC) risk in a European Caucasian population. A hospital-based case-control study gathering 260 GC cases and 476 cancer-free controls was implemented. Using a tagSNP approach, 51 single nucleotide polymorphisms (SNPs) were genotyped through MassARRAY iPLEX Gold Technology or allelic discrimination by real-time polymerase chain reaction (PCR). Homozygous carriers of the minor allele for both rs689466 and rs10935090 SNPs were associated with a 2.98 and 4.30-fold increased risk for GC, respectively (95% confidence interval (CI): 1.14-7.74, = 0.027; 95% CI: 1.22-15.16, = 0.026), with the latter also being associated with an anticipated diagnosis age. A multifactor dimensionality reduction analysis identified an overall three-factor best interactive model composed of age, rs689466, and rs1678374 that was associated with a 17.6-fold GC increased risk (95% CI: 11.67-26.48, < 0.0001, (cross-validation) CV consistency of 8/10 and accuracy of 0.807). In this preliminary study, several tagSNPs in PGE pathway-related genes were identified as risk biomarkers for GC development. This approach may help to identify higher-risk individuals and may contribute to the tailoring screening of GC in intermediate-risk European countries.
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http://dx.doi.org/10.3390/ijms22020648DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7827533PMC
January 2021

Overcoming the barriers to dissemination and implementation of quality measures for gastrointestinal endoscopy: European Society of Gastrointestinal Endoscopy (ESGE) and United European Gastroenterology (UEG) position statement.

Endoscopy 2021 Feb 7;53(2):196-202. Epub 2021 Jan 7.

Center for Health Technology and Services Research (CINTESIS), Faculty of Medicine, University of Porto, Portugal.

The European Society of Gastrointestinal Endoscopy (ESGE) has developed performance measures and established a framework for quality assessment for gastrointestinal endoscopy in Europe. Most national societies actively undertake initiatives to implement and explicitly endorse these quality indicators. Given this, ESGE proposes that, at a national level, strong leadership should exist to disseminate and implement quality parameters. Thus, understanding the potential barriers that may vary locally is of paramount importance. ESGE suggests that each national society should prioritize quality and standards of care in gastrointestinal endoscopy in their activities and should survey/understand which measures are a local priority to their members and make measuring quality intrinsic to daily endoscopy practice.
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http://dx.doi.org/10.1055/a-1312-6389DOI Listing
February 2021

Where Did the Colon Cancer Go?

Am J Gastroenterol 2021 01;116(1):10

Department of Gastroenterology, Portuguese Oncology Institute of Porto, Portugal.

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http://dx.doi.org/10.14309/ajg.0000000000000644DOI Listing
January 2021

Clipping a gastric lesion before resection: not a contraindication for endoscopic submucosal dissection.

Endoscopy 2020 Dec 17. Epub 2020 Dec 17.

Gastroenterology Department, Portuguese Oncology Institute of Porto, Portugal.

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http://dx.doi.org/10.1055/a-1308-0814DOI Listing
December 2020

Overcoming the barriers to dissemination and implementation of quality measures for gastrointestinal endoscopy: European Society of Gastrointestinal Endoscopy (ESGE) and United European Gastroenterology (UEG) position statement.

United European Gastroenterol J 2021 Feb 10;9(1):120-126. Epub 2021 Feb 10.

Center for Health Technology and Services Research (CINTESIS), University of Porto, Porto, Portugal.

The European Society of Gastrointestinal Endoscopy (ESGE) has developed performance measures and established a framework for quality assessment for gastrointestinal endoscopy in Europe. Most national societies actively undertake initiatives to implement and explicitly endorse these quality indicators. Given this, the ESGE proposes that, at a national level, strong leadership should exist to disseminate and implement quality parameters. Thus, understanding the potential barriers that may vary locally is of paramount importance. The ESGE suggests that each national society should prioritise quality and standards of care in gastrointestinal endoscopy in their activities and should survey/understand which measures area local priority to their members and make measuring quality intrinsic to daily endoscopy practice.
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http://dx.doi.org/10.1177/2050640620981366DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8259235PMC
February 2021

The Colon Endoscopic Bubble Scale (CEBuS): a two-phase evaluation study.

Endoscopy 2020 Dec 7. Epub 2020 Dec 7.

Department of Gastroenterology, Portuguese Oncology Institute of Coimbra, Coimbra, Portugal.

Background: To date, no scale has been validated to assess bubbles associated with bowel preparation. This study aimed to develop and assess the reliability of a novel scale - the Colon Endoscopic Bubble Scale (CEBuS).

Methods: This was a multicenter, prospective, observational study with two online evaluation phases of 45 randomly distributed still colonoscopy images (15 per scale grade). Observers assessed images twice, 2 weeks apart, using CEBuS (CEBuS-0 - no or minimal bubbles, covering < 5 % of the surface; CEBuS-1 - bubbles covering 5 %-50 %; CEBuS-2 - bubbles covering > 50 %) and reporting the clinical action (do nothing; wash with water; wash with simethicone).

Results: CEBuS provided high levels of agreement both in evaluation Phase 1 (4 experts) and Phase 2 (6 experts and 13 non-experts), with almost perfect intraobserver reliability: kappa 0.82 (95 % confidence interval 0.75-0.88) and 0.86 (0.85-0.88); interobserver agreement - intraclass correlation coefficient (ICC) 0.83 (0.73-0.89) and 0.90 (0.86-0.94). Previous endoscopic experience had no influence on agreement among experts vs. non-experts: kappa 0.86 (0.80-0.91) vs. 0.87 (0.84-0.89) and ICC 0.91 (0.87-0.94) vs. 0.90 (0.86-0.94), respectively. Interobserver agreement on clinical action was ICC 0.63 (0.43-0.78) in Phase 1 and 0.77 (0.68-0.84) in Phase 2. Absolute agreement on clinical action per scale grade was 85 % (82-88) for CEBuS-0, 21 % (16-26) for CEBuS-1, and 74 % (70-78) for CEBuS-2.

Conclusion: CEBuS proved to be a reliable instrument to standardize the evaluation of colonic bubbles during colonoscopy. Assessment in daily practice is warranted.
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http://dx.doi.org/10.1055/a-1331-4325DOI Listing
December 2020

Covered Metal Stent after Dysfunction of Uncovered Stents for Palliation of Gastrointestinal Malignant Obstruction.

GE Port J Gastroenterol 2020 Nov 13;27(6):383-390. Epub 2020 May 13.

Gastroenterology Department, Portuguese Oncology Institute of Porto, Porto, Portugal.

Background: Self-expanding metal stents (SEMS) have been used for the palliative treatment of malignant gastrointestinal tract obstruction. However, restenosis or incomplete expansion of a first stent is a frequent complication, and the effectiveness of reintervention with placement of a second stent is still controversial.

Objective: To evaluate the clinical outcomes of covered SEMS (cSEMS) placement after dysfunction of uncovered SEMS (uSEMS) by the stent-in-stent technique.

Patients And Methods: We retrospectively studied a consecutive series of patients receiving palliative treatment for malignant gastrointestinal obstruction with cSEMS placement after uSEMS dysfunction in a tertiary center from January 2013 to August 2018. Technical and clinical success, time of patency, and adverse events were analyzed.

Results: Twelve patients were included; their mean age was 60 ± 9 years. Eleven patients had gastric outlet obstruction, and 1 patient had compression of the transverse colon due to gastric neoplasia. In 5 cases, there was absence of early clinical success with uSEMS and stent dysfunction in 7 cases (median patency time: 81 days). There was 100% technical success and 91.7% clinical success after cSEMS placement. There were no adverse events nor need for reintervention. The median patency time after placement of both stents was 163 days (vs. 71 days with the initial stent).

Conclusion: cSEMS placement after uSEMS dysfunction is technically feasible and a clinically effective treatment for patients with recurrent malignant gastrointestinal obstruction, with good stent patency in the medium/long term. This approach seems to be safe and without increase in adverse effects.
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http://dx.doi.org/10.1159/000507200DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7670366PMC
November 2020
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