Suk Pyo Shin

Recent Update on Microbiological Monitoring of Gastrointestinal Endoscopes after High-Level Disinfection.

Endoscopy-related infections are important contributors to nosocomial infections. Endoscope reprocessing according to standard guidelines ensures high-level disinfection and prevents endoscopy-related infections. Microbiological surveillance may help in monitoring the effectiveness of gastrointestinal endoscope disinfection. The process involves microbial cultures and non-culture methods such as bioburden assays, adenosine triphosphate (ATP) bioluminescence, and quantitative polymerase chain reactions (PCRs). Surveillance culturing to monitor endoscopes after reprocessing has been recommended by a majority of organizations. Bioburden assays, ATP bioluminescence, and quantitative PCRs provide rapid and reliable measures. Each institution will have to try to establish its own surveillance guidelines.

A double blind, placebo-controlled, randomized clinical trial that breast milk derived Lactobacillus gasseri BNR17 mitigated diarrhea-dominant irritable bowel syndrome

The exact pathogenesis of diarrhea-dominant irritable bowel syndrome (IBS) is not known, but the abnormal microbiota of the gastrointestinal tract is considered to be one of the important contributing factors as in other gastrointestinal diseases such as inflammatory bowel disease, antibiotic-associated diarrhea, and colorectal cancer as well as systemic diseases. Though diverse trials of probiotics had been continued in the treatment of diarrhea-IBS, only a few proved by randomized clinical trial. To prove the efficacy of Lactobacillus gasseri BNR17 isolated from breast milk in patients with diarrhea-IBS, prospective, randomized, placebo controlled clinical trial was done including health related-quality of life analysis, colon transit time, and the changes of fecal microbiota. BNR17 significantly improved the symptoms of diarrhea compared to control group. Health related-QOL analysis showed significant improvement of abdominal pain, distension, disturbed daily life, and mean defecation frequency with BNR17. On comparative CTT before and after BNR17, 6 out of 24 subjects showed significant correction of rapid colon transit pattern, while only 2 out of 24 in placebo (p<0.01). Upon fecal microbiota analysis, BNR17 significantly increased B. fecalis, E. rectale, C. aerofaciens, F. prausnitzil and B. steroris. Conclusively, Lactobacillus gasseri BNR17 can be a potential probiotics to ameliorate diarrhea-IBS.

Clinical impact of non-alcoholic fatty liver disease on the occurrence of colorectal neoplasm: Propensity score matching analysis

The effect of non-alcoholic fatty liver disease (NAFLD) on the occurrences of colorectal neoplasm (CRN) at surveillance colonoscopy is rarely evaluated. We retrospectively reviewed medical records of 1,023 patients who had both index and surveillance colonoscopy at a single institution. The cumulative occurrence rates of overall and advanced CRN at the time of surveillance colonoscopy were compared between patients with and without NAFLD using propensity score matching analysis. In an analysis of matched cohort of 441 patients, the cumulative rates of overall CRN occurrence at 3 and 5 years after index colonoscopy were higher in subjects with NAFLD than in those without NAFLD (9.1% vs. 5.0% & 35.2% vs. 25.3%, P = 0.01). Cox regression analysis showed that NAFLD independently increased the risk of overall CRN occurrence with marginal significance (adjusted hazard ratio [aHR]: 1.31 95% CI: 1.01–1.71, P = 0.05). Additionally, NAFLD was associated with the development of 3 or more adenomas at the time of surveillance colonoscopy (aHR: 2.49, 95% CI: 1.20–5.20, P = 0.02). In subgroup analysis based on index colonoscopy risk categories, the effect of NAFLD on the overall CRN occurrence at the time of surveillance colonoscopy was confined to the normal group (aHR: 1.47, 95% CI: 1.05–2.06, P = 0.02). Regarding advanced CRN occurrences at the time of surveillance colonoscopy, age was the only significant risk factor (aHR: 1.06, 95% CI: 1.02–1.10, P = 0.001). NAFLD was associated with overall CRN occurrence, especially in patients with no adenoma at the index colonoscopy. NAFLD may be considered for the determination of the time-interval for surveillance colonoscopy, especially the patients with negative index colonoscopy findings.

Communicating Tubular Esophageal Duplication Combined with Bronchoesophageal Fistula

Esophageal duplication (ED) is rarely diagnosed in adults and is usually asymptomatic. Especially, ED that is connected to the esophagus through a tubular communication and combined with bronchoesophageal fistula (BEF) is extremely rare and has never been reported in the English literature. This condition is very difficult to diagnose. Although some combinations of several modalities, such as upper gastrointestinal endoscopy, esophagography, computed tomography, magnetic resonance imaging, and endoscopic ultrasonography, can be used for the diagnosis, the results might be inconclusive. Here, we report on a patient with communicating tubular ED that was incidentally diagnosed on the basis of endoscopy and esophagography during the postoperational evaluation of BEF.

Forward-viewing endoscope for ERCP in patients with Billroth II gastrectomy: a systematic review and meta-analysis

BackgroundThe forward-viewing endoscope has been increasingly used to perform endoscopic retrograde cholangiopancreatography (ERCP) in patients who underwent Billroth II gastrectomy. This study intended to assess efficacy and safety of the forward-viewing endoscope for ERCP in Billroth II gastrectomy patients compared with conventional side-viewing endoscope using a systematic review and meta-analysis.MethodsA systematic review was conducted for studies that evaluated the outcomes of ERCP for patients with Billroth II gastrectomy. Random-effect model meta-analyses with subgroup analyses were conducted. The methodological quality of the included publications was evaluated using the risk of bias assessment tool for non-randomized studies. The publication bias was assessed.ResultsIn total, 25 studies (1 randomized, 18 retrospective, 1 prospective, and 5 case series studies) with 2446 patients (499 forward-viewing and 1947 side-viewing endoscopes) were analyzed. The pooled afferent loop intubation rate was higher with the forward-viewing endoscope (90.3%, 95% confidence interval (CI) 85.6–93.6 vs. 86.8%, 95% CI 82.8–89.9%). The pooled selective cannulation rate was higher with the side-viewing endoscope (92.3%, 95% CI 88.0–95.2 vs. 91.1%, 95% CI 87.2–93.9%). The pooled bowel perforation rate was higher with the side-viewing endoscope (3.6%, 95% CI 2.3–5.7 vs. 3.0%, 95% CI 1.7–5.3%). The pooled pancreatitis rate was higher with the forward-viewing endoscope (5.4%, 95% CI 3.6–8.0 vs. 2.5%, 95% CI 2.3–5.7%). The pooled bleeding rate was higher with the forward-viewing endoscope (3.0%, 95% CI 1.6–5.5 vs. 2.0%, 95% CI 1.4–3.0%). The heterogeneity among the studies was not significant. The publication bias was minimal.ConclusionThis meta-analysis indicates that the forward-viewing endoscope is as safe and effective as conventional side-viewing endoscope for ERCP in patients with Billroth II gastrectomy.

Sessile Serrated Adenoma; the Hard-to-Catch Culprit of Interval Cancer

Colonoscopic screening and surveillance programs have been implemented in many countries and they have reduced colorectal cancer (CRC)-related deaths. However, this reduction was significantly noted in distal CRC, not in proximal CRC, and some patients may develop unexpected CRC within 3–5 years of colonoscopy. Interval CRCs, which have a prevalence ranging from 1.8% to 9.0%, are CRCs that are diagnosed after a screening or surveillance examination and before the date of the next recommended exam. It is known that interval CRCs are more common in the proximal colon than in the distal colon. Research regarding the molecular profiles of interval CRCs and serrated lesions have identified a molecular similarity between the interval CRCs and the pathway for serrated adenoma carcinogenesis. Due to the sessile or flat features associated with these lesions, preference for right colon and molecular features of sessile serrated adenomas/polyps (SSA/Ps), SSA/Ps have been getting attention for their clinical importance in interval CRCs. Despite advancement in imaging systems and some known endoscopic features characteristic of SSA/Ps, the detection and accurate identification of SSA/Ps during colonoscopy is challenging to the colonoscopist. In this issue of Clinical Endoscopy, Yang et al. validated previously reported endoscopic features of SSA/Ps and identified features that can be reliably used for SSA/P prediction by experts and trainees. The endoscopic features of SSA/Ps in this study are: indistinct borders, irregular shape, rim of debris, cloud-like surface, mucous cap, nodular surface, absence of surface vessels, and dark spots. Among these eight features, four included independent predictive features for SSA/P histology (indistinctive borders, mucous cap, cloudlike surface and dark spots). Additionally, three of these four features showed moderate interobserver agreement among experts and trainees (the exception being dark sports). These three characteristics rendered 79.0% sensitivity and 81.4% specificity for SSA prediction using high resolution white light endoscopy. With regards to the method of this study, I noticed an interesting point. Yang et al. held a training session and consensus meeting before the validation of the endoscopic features. This process might be the major reason why the interobserver agreement among trainees was not inferior to that of experts. Therefore, setting up courses that include a training session and consensus meeting might be helpful for trainees, not only for SSA/Ps but also for other lesions. Although the suitable degree of interobserver agreement in trainees in this study could not be applied to other medical centers which have not set-up the courses, the three simple endoscopic features could easily be used and prove to be helpful for colonoscopy training elsewhere. Received: April 1, 2017 Accepted: April 26, 2017 Correspondence: Suk Pyo Shin Department of Internal Medicine, Chuncheon Sacred Heart Hospital, Hallym University College of Medicine, 77 sakju-ro, Chuncheon 24253, Korea Tel: +82-33-240-5823, Fax: +82-33-255-4291, E-mail: ppyo1029@gmail.com