Endoscopic application of polysaccharide powder for hemostasis in anticoagulated pigs (with video)

BackgroundAcute GI bleeding remains a clinical problem of daily importance. Increasing numbers of patients with compromised coagulation challenge the established methods of endoscopic hemostasis. Therefore, new powders for the treatment of GI bleeding have been developed.ObjectiveTo clarify the efficacy of a newly available anticoagulant powder in stopping hemorrhage.DesignA randomized prospective comparative study regarding the potential of an endoscopically applicable polysaccharide powder in pigs receiving antithrombotic medication.SettingA professional veterinary animal laboratory.PatientsTwenty-two pigs were anticoagulated with heparin (n = 8), aspirin (n = 8), or no antithrombotic medication (n = 6), in a randomized order.InterventionsA bleeding ulcer with continuous bleeding (Forrest I b) was established in the stomach. Endoscopic hemostasis was performed using the powder.Main Outcome MeasurementsTime to hemostasis and the amount of powder used were recorded. Follow-up occurred for 3 days, final hemoglobin measurement, followed by autopsy with control for post-interventional bleeding.ResultsEndoscopic hemostasis was successful in all cases. Post-interventional bleeding was not recorded.LimitationsAnimal study, artificial superficial bleeding source.ConclusionPolysaccharide powder is able to stop active bleeding from Forrest I b lesions in pigs receiving antithrombotic therapy

Implementation of endoscopic submucosal dissection in Europe: survey after ten ESD expert training workshops 2009 – 2018

Background and aims Transfer of ESD technique for early gastrointestinal cancer from Japan requires expert-supervised experimental training before unsupervised implementation of clinical ESD. Aims To evaluate unsupervised implementation of ESD-intention-to-treat (-ITT). Methods ESD Workshops (in-vivo porcine model) lasted 3.3 days including one day theory for 177 participants from 135 Western referral centers. A questionnaire was sent to the senior participant of all 135 centers. Design Cross-sectional questionnaire survey. Main outcome measurements Performance, organ distribution, severe adverse events of ESD-ITT. Results Feedback was received from 113 centers (84%), i.e. 73 (54%) ESD centers and 40 centers (30%) with zero ESD; 10 (7%) had published ESD; no feedback from 12 (9%) centers with unknown status. Altogether, 83 centers (61.5%) perform ESD: 21 (16%) had >150 ESD (professional category), 33 (24%) had 31-150 ESD (competent category), and 29 (21.5%) had ≤ 30 ESD (initial learning category). Most implemented ESD centers (91%, 72 of 79) were analyzed: Centers on initial learning (420 ESD) compared to centers with >30 ESD (5676 ESD) performed en-bloc ESD in 64% vs. 84%, hybrid-ESD in 26% vs.11% and piecemeal-EMR in 10% vs. 5.2%. Majority of ESD (66-68%) were in colorectum, overall with low risk (30-day mortality 0.03%, surgical repair 3.5% vs. 1.7%) and satisfactory outcome (oncosurgery 7.4% vs. 5.2%, local recurrence 1.5% vs. 0.3%). Conclusions Beyond guideline recommendations, unsupervised implementation of ESD was successful in colorectum with step-up approach. Now, Western ESD centers have to aim for professional (i.e. >80%) curative ESD

3-Component synthesis of α-substituted sulfonamides via Brønsted acid-catalyzed C(sp3)–H bond functionalization of 2-alkylazaarenes

A Brønsted acid-catalyzed addition of 2-alkylazaarenes to in situ generated N-sulfonylimines through selective C(sp3)–H bond functionalization has been developed. This protocol provides an atom- and step-economic approach to α-substituted sulfonamides

EXPERIMENTAL ENDOSCOPIC SUBMUCOSAL DISSECTION TRAINING IN A PORCINE MODEL:LEARNING EXPERIENCE OF SKILLED WESTERN ENDOSCOPISTS

Background: Endoscopic submucosal dissection (ESD) demands a new level of endoscopic skill in Europe. A 2-day workshop was set up for trainees to carry out five ESD each in order to obtain the skill level required to perform ESD in the stomach or rectum. This study describes: (i) the workshop setup; (ii) the participant's performance; and (iii) the training effect on post-workshop clinical ESD performance. Methods: Eighteen very experienced European endoscopists participated in four half-day (4.5 h) training sessions, with everybody rotating daily through six separate training stations (two each with dual, hook, or hybrid knives) with expert tutors. One anesthetized piglet was used per station and session. After 1 year, the clinical ESD performance was surveyed to estimate the training effect of the workshop. Results: Overall, 74 ESD were performed, that is, 4.1 ESD per participant. On average ESD lasted 57 min for 6 cm(2) specimens. We detected a 22% rate of perforation (16 of 74 ESD with perforations), mostly attributable to participants with less experience in ESD. Those who started clinical ESD within 1 year after the workshop performed 144 clinical ESD (median 8 [0-20] per trainee) mostly in the stomach (40%) and large bowel (46%) with an acceptable rate of perforation (9.7%) and surgical repair (3.5%) without mortality or persistent morbidity. Conclusion: Intense skill training for ESD is needed to reduce the risk of perforation, as demonstrated by the results of this workshop. We show that experimental ESD training, however, enables skilled European endoscopists to perform ESD in standard locations with moderate risk of perforation during the clinical learning curve