Network meta-analysis of prophylactic pancreatic stents and non-steroidal anti-inflammatory drugs in the prevention of moderate-to-severe post-ERCP pancreatitis.

BACKGROUND: There is an ongoing debate that non-steroidal anti-inflammatory drugs (NSAID) or prophylactic pancreatic stents (PPS) are more beneficial in preventing post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis (PEP). In our present network meta-analysis, we aimed to compare PPSs to rectal NSAIDs in the prevention of moderate and severe PEP in average- and high-risk patients. METHODS: We performed a systematic search for randomized controlled trials (RCT) from MEDLINE (via PubMed), Embase and Cochrane Central databases. RCTs using prophylactic rectal NSAIDs or PPSs in patients subjected to ERCP at average- and high-risk population were included. The main outcome was moderate and severe PEP defined by the Cotton criteria. Pairwise Bayesian network meta-analysis was performed, and interventions were ranked based on surface under cumulative ranking (SUCRA) values. RESULTS: Seven NSAID RCTs (2593 patients), and 2 PPS RCTs (265 patients) in the average-risk, while 5 NSAID RCTs (1703 patients), and 8 PPS RCTs (974 patients) in the high-risk group were included in the final analysis. Compared to placebo, only PPS placement reduced the risk of moderate and severe PEP in both patient groups (average-risk: RR = 0.07, 95% CI [0.002-0.58], high-risk: RR = 0.20, 95% CI [0.051-0.56]) significantly. Rectal NSAID also reduced the risk, but this effect was not significant (average-risk: RR = 0.58, 95% CI [0.22-1.3], high-risk: RR = 0.58, 95% CI [0.18-2.3]). Based on SUCRA, PPS placement was ranked as the best preventive method. CONCLUSION: Prophylactic pancreatic stent placement but not rectal NSAID seems to prevent moderate-to-severe PEP better both, in average- and high-risk patients.

ERCP is more challenging in cases of acute biliary pancreatitis than in acute cholangitis - Analysis of the Hungarian ERCP registry data.

BACKGROUND: Endoscopic retrograde cholangiopancreatography (ERCP) is an important therapeutic modality in acute biliary pancreatitis (ABP) cases with cholangitis or ongoing common bile duct obstruction. Theoretically, inflammation of the surrounding tissues would result in a more difficult procedure. No previous studies examined this hypothesis. OBJECTIVES: ABP and acute cholangitis (AC) without ABP cases were compared to assess difficulty of ERCP. METHODS: The rate of successful biliary access, advanced cannulation method, adverse events, cannulation and fluoroscopy time were compared in 240 ABP cases and 250 AC cases without ABP. Previous papillotomy, altered gastroduodenal anatomy, and cases with biliary stricture were excluded. RESULTS: Significantly more pancreatic guidewire manipulation (adjusted odds ratio (aOR) 1.921 [1.241-2.974]) and prophylactic pancreatic stent use (aOR 4.687 [2.415-9.098]) were seen in the ABP than in AC group. Average cannulation time in the ABP patients (248 vs. 185 s; p = 0.043) were longer than in AC cases. No difference was found between biliary cannulation and adverse events rates. CONCLUSION: ERCP in ABP cases seem to be more challenging than in AC. Difficult biliary access is more frequent in the ABP cases which warrants the involvement of an experienced endoscopist.

Effect of COVID-19 pandemic on workflows and infection prevention strategies of endoscopy units in Hungary: a cross-sectional survey.

BACKGROUND: Health care professionals in endoscopic labs have an elevated risk for COVID-19 infection, therefore, we aimed to determine the effect of current pandemic on the workflow and infection prevention and control strategies of endoscopy units in real-life setting. METHODS: All members of Hungarian Society of Gastroenterology were invited between 7 and 17 April 2020 to participate in this cross-section survey study and to complete an online, anonymous questionnaire. RESULTS: Total of 120 endoscopists from 83 institutes were enrolled of which 35.83% worked in regions with high cumulative incidence of COVID-19. Only 33.33% of them had undergone training about infection prevention in their workplace. 95.83% of endoscopists regularly used risk stratification of patients for infection prior endoscopy. While indications of examinations in low risk patients varied widely, in high-risk or positive patients endoscopy was limited to gastrointestinal bleeding (95.00%), removal of foreign body from esophagus (87.50%), management of obstructive jaundice (72.50%) and biliary pancreatitis (67.50%). Appropriate amount of personal protective equipment was available in 60.85% of endoscopy units. In high-risk or positive patients, surgical mask, filtering facepiece mask, protective eyewear and two pairs of gloves were applied in 30.83%, 76.67%, 90.00% and 87.50% of cases, respectively. Personal protective equipment fully complied with European guideline only in 67.50% of cases. CONCLUSIONS: Survey found large variability in indications of endoscopy and relative weak compliance to national and international practical recommendations in terms of protective equipment. This could be improved by adequate training about infection prevention.

Hypertriglyceridemia-induced acute pancreatitis: A prospective, multicenter, international cohort analysis of 716 acute pancreatitis cases.

BACKGROUND: Hypertriglyceridemia is the third most common cause of acute pancreatitis (AP). It has been shown that hypertriglyceridemia aggravates the severity and related complications of AP; however, detailed analyses of large cohorts are contradictory. Our aim was to investigate the dose-dependent effect of hypertriglyceridemia on AP. METHODS: AP patients over 18 years old who underwent triglyceride measurement within the initial three days were included into our cohort analysis from a prospective international, multicenter AP registry operated by the Hungarian Pancreatic Study Group. Data on 716 AP cases were analyzed. Six groups were created based on the highest triglyceride level (<1.7 mmol/l, 1.7-2.19 mmol/l, 2.2-5.59 mmol/l, 5.6-11.29 mmol/l, 11.3-22.59 mmol/l, ≥22.6 mmol/l). RESULTS: Hypertriglyceridemia (≥1.7 mmol/l) presented in 30.6% of the patients and was significantly and dose-dependently associated with younger age and male gender. In 7.7% of AP cases, hypertriglyceridemia was considered as a causative etiological factor (≥11.3 mmol/l); however, 43.6% of these cases were associated with other etiologies (alcohol and biliary). Hypertriglyceridemia was significantly and dose-dependently related to obesity and diabetes. The rates of local complications and organ failure and maximum CRP level were significantly and dose-dependently raised by hypertriglyceridemia. Triglyceride above 11.3 mmol/l was linked to a significantly higher incidence of moderately severe AP and longer hospital stay, whereas triglyceride over 22.6 mmol/l was significantly associated with severe AP as well. CONCLUSION: Hypertriglyceridemia dose-dependently aggravates the severity and related complications of AP. Diagnostic workup for hypertriglyceridemia requires better awareness regardless of the etiology of AP.

Risk factors of post-ERCP pancreatitis in high-risk patients despite prevention with prophylactic pancreatic stents.

Objectives: To analyze risk factors of post-ERCP pancreatitis (PEP) in high risk patients in whom prophylactic pancreatic stents (PPSs) were intended to use to prevent endoscopic retrograde cholangiography (ERCP)-related complications.Patients and methods: Three hundred and seventeen high-risk patients for developing PEP were considered for preventive pancreatic stent placement in our endoscopy unit over 5 years. 5 Fr, 3-5 cm long PPSs were used. All data were collected in a predefined database. Development of PEP despite PPS placement was analyzed.Results: PEP occurred in 29 of 288 successfully stented patients (10.07%; 24 mild, four moderate, one severe). PPS was protective against all risks factors except for sphincter of Oddi dysfunction (SOD). PPS related complication rate was 2.78% (n = 8). Unsuccessful stenting occurred in 29 patients (9.15%), PEP developed in 41.38% (n = 12; seven mild, four moderate, one severe). Those patients who had more patient related risk factors were more likely to develop PEP despite preventive measures with PPS. On the contrary, PPS placement was less successful in patients who had more procedure related risk factors.Conclusions: PPS is protective against all risks factors of PEP except for SOD in high-risk patients. More vulnerable patients who have more patient-related risk factors are more likely to develop PEP despite PPS is used, while more complex procedures predispose to unsuccessful PPS placement in patients with more procedure-related risk factors. PPS insertion in high-risk patients is effective and safe preventive method and the procedure related complication rate is reasonably low.

Improved adenoma detection with linked color imaging technology compared to white-light colonoscopy.

OBJECTIVES: Linked color imaging (LCI) is a new endoscopic technology that may increase colorectal adenoma detection rate (ADR) and polyp detection rate (PDR) by virtual chromoendoscopy. Aim of the present study was to evaluate the effectiveness of LCI in ADR and PDR compared to the HD white-light colonoscopy (WLC) technique. MATERIALS AND METHODS: Between October 2016 and June 2018, we enrolled consecutive outpatients prospectively. Eligible patients allocated randomly to undergo HD WLC or LCI colonoscopy technique during instrument withdrawal. Each colonoscopy was performed in a single center by the same three expert endoscopists (with expertise more than 5000 colonoscopies). RESULTS: A total of 1278 patients underwent colonoscopy in the study period. ADR and PDR were significantly higher in the LCI group compared to the WLC group (34.4% vs. 26.8%; p = .007; and 53.3% vs 46.4%; p = .023, respectively). Similarly, the mean number of adenomas per patient (MAP) was significantly higher with the LCI than WLC (0.64 vs 0.44, respectively; p = .002). The mean age of patients at the time of colonoscopy was 51.95 years (SD = 13.861) in the LCI group and 51.96 years (SD = 14.028) in the WLC group. No significant differences observed in patient demographic characteristics (there was no difference in gender and age distribution, p = .986), quality of colonoscopy preparation and withdrawal times (WT) between the two groups (WLC and the LCI groups, 493.9 (SD: 143.5) and 514.0 (SD: 139.5) sec, respectively). CONCLUSIONS: According to our results, LCI virtual chromoendoscopic technology was superior compared to conventional HD WLC in detecting colorectal polyps and adenomas.

Preventive pancreatic stents in the management of acute biliary pancreatitis (PREPAST trial): pre-study protocol for a multicenter, prospective, randomized, interventional, controlled trial.

BACKGROUND: The outcome of the most common biliary form of acute pancreatitis has not changed even with the better described indications for early endoscopic intervention. It may be due to the fact that this intrevention theoretically can cause further pancreatic injury or cannot always relieve the pancreatic duct obstruction. We hypothesize that maintaining the outflow of the pancreatic duct with preventive pancreatic stents at the early ERCP improves the outcome of acute biliary pancreatitis. METHODS/DESIGN: PREPAST is a prospective, randomized, controlled, multicenter trial. Patients with acute biliary pancreatitis with coexisting cholangitis are randomized to undergo urgent endoscopic intervention with or without pancreatic stenting within 48 h from the onset of pain, and in addition patients without signs of cholangitis but cholestasis are randomly allocated to recieve conservative treatment or early endoscopic intervention with or without pancreatic stenting within 48 h from the onset of pain. Patients without acute cholangitis and signs of cholestasis recieve conservative treatment. 230 patients are planned to be enrolled during a 48 months period from different centers. The primary endpoint is the outcome of acute biliary pancreatitis as described by the latest guidelines. Secondary endpoints include mortality data, and other variables not analyzed as a primary endpoint but related to the pancreatitis or the pancreatic stenting. DISCUSSION: The PREPAST trial is designed to show whether early endoscopic intervention with the usage of preventive pancreatic stenting improves the outcome of acute biliary pancreatitis. The study has been registered at the International Standard Randomised Controlled Trial Number (ISRCTN) Register (trial ID: ISRCTN13517695).

Genetic analysis of the bicarbonate secreting anion exchanger SLC26A6 in chronic pancreatitis.

BACKGROUND: Pancreatic ductal HCO3(-) secretion is critically dependent on the cystic fibrosis transmembrane conductance regulator chloride channel (CFTR) and the solute-linked carrier 26 member 6 anion transporter (SLC26A6). Deterioration of HCO3(-) secretion is observed in chronic pancreatitis (CP), and CFTR mutations increase CP risk. Therefore, SLC26A6 is a reasonable candidate for a CP susceptibility gene, which has not been investigated in CP patients so far. METHODS: As a first screening cohort, 106 subjects with CP and 99 control subjects with no pancreatic disease were recruited from the Hungarian National Pancreas Registry. In 60 non-alcoholic CP cases the entire SLC26A6 coding region was sequenced. In the Hungarian cohort variants c.616G > A (p.V206M) and c.1191C > A (p.P397=) were further genotyped by restriction fragment length polymorphism analysis. In a German replication cohort all exons were sequenced in 40 non-alcoholic CP cases and variant c.616G > A (p.V206M) was further analyzed by sequencing in 321 CP cases and 171 controls. RESULTS: Sequencing of the entire coding region revealed four common variants: intronic variants c.23 + 78_110del, c.183-4C > A, c.1134 + 32C > A, and missense variant c.616G > A (p.V206M) which were found in linkage disequilibrium indicating a conserved haplotype. The distribution of the haplotype did not show a significant difference between patients and controls in the two cohorts. A synonymous variant c.1191C > A (p.P397=) and two intronic variants c.1248 + 9_20del and c.-10C > T were detected in single cases. CONCLUSION: Our data show that SLC26A6 variants do not alter the risk for the development of CP.

[Acute pancreatitis. Evidence-based practice guidelines, prepared by the Hungarian Pancreatic Study Group]. / Akut pancreatitis. A Magyar Hasnyálmirigy Munkacsoport bizonyítékon alapuló kezelési irányelvei.

Acute pancreatitis is one of the most common diseases of the gastrointestinal tract associated with significant morbidity and mortality that requires up-to-date and evidence based treatment guidelines. The Hungarian Pancreatic Study Group proposed to prepare evidence based guideline for the medical and surgical management of acute pancreatitis based on the available international guidelines and evidence. The preparatory and consultation task force appointed by the Hungarian Pancreatic Study Group translated and, if it was necessary, complemented and/or modified the international guidelines. All together 42 relevant clinical questions were defined in 11 topics (Diagnosis and etiology, Prognosis, Imaging, Fluid therapy, Intensive care management, Prevention of infectious complications, Nutrition, Biliary interventions, Post-endoscopic retrograde cholangio-pancreatography pancreatitis, Indication, timing and strategy for intervention in necrotizing pancreatitis, Timing of cholecystectomy [or endoscopic sphincterotomy]). Evidence was classified according to the UpToDate® grading system. The draft of the guideline was presented and discussed at the consensus meeting on September 12, 2014. 25 clinical questions with almost total (more than 95%) and 17 clinical questions with strong (more than 70%) agreement were accepted. The present guideline is the first evidence based acute pancreatitis guideline in Hungary. The guideline may provide important help for tuition, everyday practice and for establishment of proper finance of acute pancreatitis. Therefore, the authors believe that these guidelines will widely become as basic reference in Hungary.

[Chronic pancreatitis. Evidence based management guidelines of the Hungarian Pancreatic Study Group]. / Krónikus pancreatitis. A Magyar Hasnyálmirigy Munkacsoport bizonyítékon alapuló kezelési irányelvei.

Chronic pancreatitis is an inflammatory disease associated with structural and functional damage of the pancreas. In most cases pain, maldigestion and weight loss are the leading symptoms, which significantly worsen the quality of life. Correct diagnosis and differential diagnosis of chronic pancreatitis and treatment of these patients requires up-to-date and evidence based treatment guidelines. The Hungarian Pancreatic Study Group proposed to prepare an evidence based guideline based on the available international guidelines and evidence. The preparatory and consultation task force appointed by the Hungarian Pancreatic Study Group translated and complemented and/or modified the international guidelines if it was necessary. 123 relevant clinical questions in 11 topics were defined. Evidence was classified according to the UpToDate® grading system. The draft of the guidelines were presented and discussed at the consensus meeting in September 12, 2014. All clinical questions were accepted with total or strong agreement. The present guideline is the first evidence based guideline for chronic pancreatitis in Hungary. This guideline provides very important and helpful data for tuition, everyday practice and proper financing of chronic pancreatitis. Therefore, the authors believe that these guidelines will widely become a basic reference in Hungary.

[Autoimmune pancreatitis. Evidence based management guidelines of the Hungarian Pancreatic Study Group]. / Autoimmun pancreatitis. A Magyar Hasnyálmirigy Munkacsoport bizonyítékon alapuló kezelési irányelvei.

Autoimmune pancreatitis is a rare disease which can even mimic pancreatic tumor, however, unlike the latter, it requires not surgical but conservative management. Correct diagnosis and differential diagnosis of autoimmune pancreatitis and treatment of these patients requires up-to-date and evidence based management guidelines. The Hungarian Pancreatic Study Group proposed to prepare an evidence based guideline based on the available international guidelines and evidences. The preparatory and consultation task force appointed by the Hungarian Pancreatic Study Group translated and complemented and/or modified the international guidelines if it was necessary. 29 relevant clinical questions in 4 topics were defined (Basics; Diagnosis; Differential diagnostics; Therapy). Evidence was classified according to the UpToDate(®) grading system. The draft of the guidelines was presented and discussed at the consensus meeting on September 12, 2014. All clinial questions were accepted with almost total (more than 95%) agreement. The present guideline is the first evidence based autoimmune pancreatitis guideline in Hungary. The guideline may provide very important and helpful data for tuition of autoimmune pancreatitis, for everyday practice and for establishing proper finance. Therefore, the authors believe that these guidelines will widely become a basic reference in Hungary.

[Pediatric pancreatitis. Evidence based management guidelines of the Hungarian Pancreatic Study Group]. / Gyermekkori pancreatitis. A Magyar Hasnyálmirigy Munkacsoport bizonyítékon alapuló kezelési irányelvei.

Pediatric pancreatitis is a rare disease with variable etiology. In the past 10-15 years the incidence of pediatric pancreatitis has been increased. The management of pediatric pancreatitis requires up-to-date and evidence based management guidelines. The Hungarian Pancreatic Study Group proposed to prepare an evidence based guideline based on the available international guidelines and evidences. The preparatory and consultation task force appointed by the Hungarian Pancreatic Study Group translated and complemented and/or modified the international guidelines if it was necessary. In 8 clinical topics (diagnosis; etiology; prognosis; imaging; therapy; biliary tract management; complications; chronic pancreatitis) 50 relevant questions were defined. Evidence was classified according to the UpToDate(®) grading system. The draft of the guidelines was presented and discussed at the consensus meeting on September 12, 2014. All clinical statements were accepted with total (more than 95%) agreement. The present Hungarian Pancreatic Study Group guideline is the first evidence based pediatric pancreatitis guideline in Hungary. The present guideline is the first evidence-based pancreatic cancer guideline in Hungary that provides a solid ground for teaching purposes, offers quick reference for daily patient care in pediatric pancreatitis and guides financing options. The authors strongly believe that these guidelines will become a standard reference for pancreatic cancer treatment in Hungary.

[Pancreatic cancer. Evidence based management guidelines of the Hungarian Pancreatic Study Group]. / Pancreasrák. A Magyar Hasnyálmirigy Munkacsoport bizonyítékon alapuló kezelési irányelvei.

Pancreatic cancer is a disease with a poor prognosis usually diagnosed at a late stage. Therefore, screening, diagnosis, treatment and palliation of pancreatic cancer patients require up-to-date and evidence based management guidelines. The Hungarian Pancreatic Study Group proposed to prepare an evidence based guideline based on the available scientific evidence and international guidelines. The preparatory and consultation board appointed by the Hungarian Pancreatic Study Group translated and complemented/modified the recent international guidelines. 37 clinical statements in 10 major topics were defined (Risk factors and genetics, Screening, Diagnosis, Staging, Surgical care, Pathology, Systemic treatment, Radiation therapy, Palliation and supportive care, Follow-up and recurrence). Evidence was graded according to the National Comprehensive Cancer Network (NCCN) grading system. The draft of the guideline was presented and discussed at the consensus meeting in September 12, 2014. Statements were accepted with either total (more than 95% of votes, n = 15) or strong agreement (more than 70% of votes, n = 22). The present guideline is the first evidence-based pancreatic cancer guideline in Hungary that provides a solid ground for teaching purposes, offers quick reference for daily patient care and guides financing options. The authors strongly believe that these guidelines will become a standard reference for pancreatic cancer treatment in Hungary.

[The role of endoscopic ultrasound in the diagnosis and therapy of gastrointestinal disorders]. / Az endoszkópos ultrahang alkalmazása a gastrointestinalis betegségek diagnosztikájában és terápiájában.

Endoscopic ultrasound is one of those diagnostic methods in gastrointestinal endoscopy which has developed rapidly in the last decade and has became exceedingly available to visualize the walls of the internal organs in details corresponding to histological layers, or analyze the adjacent structures. Fine needles and other endoscopic accessories can be introduced into the neighbouring tissues under the guidance of endoscopic ultrasound, and diagnostic and minimally invasive therapeutic interventions can be performed. The endoscopic ultrasound became more widely available in Hungary in recent years. This review focuses on the indications, benefits and complications of diagnostic and therapeutic endoscopic ultrasound. We recommend this article to gastroenterologists, surgeons, internists, pulmonologists, and to specialists in oncology and radiology. This recommendation was based on the consensus of the Board members of the Endoscopic Ultrasound Section of the Hungarian Gastroenterological Society.

Efficacy, drug sustainability, and safety of ustekinumab treatment in Crohn's disease patients over three years.

Long-term data on ustekinumab in real-life Crohn's disease patients are still missing, though randomized controlled trials demonstrated it as a favorable therapeutic option. We aimed to evaluate ustekinumab's clinical efficacy, drug sustainability, and safety in a prospective, nationwide, multicenter Crohn's disease patient cohort with a three-year follow-up. Crohn's disease patients on ustekinumab treatment were consecutively enrolled from 9 Hungarian Inflammatory Bowel Disease centers between January 2019 and May 2020. Patient and disease characteristics, treatment history, clinical disease activity (Harvey Bradshaw Index (HBI)), biomarkers, and endoscopic activity (Simple Endoscopic Score for Crohn's Disease (SES-CD)) were collected for three-years' time. A total of 148 patients were included with an overall 48.9% of complex behavior of the Crohn's disease and 97.2% of previous anti-TNF exposure. The pre-induction remission rates were 12.2% (HBI), and 5.1% (SES-CD). Clinical remission rates (HBI) were 52.2%, 55.6%, and 50.9%, whereas criteria of an endoscopic remission were fulfilled in 14.3%, 27.5%, and 35.3% of the subjects at the end of the first, second, and third year, respectively. Dose intensification was high with 84.0% of the patients on an 8-weekly and 29.9% on a 4-weekly regimen at the end of year 3. Drug sustainability was 76.9% during the follow-up period with no serious adverse events observed. Ustekinumab in the long-term is an effective, sustainable, and safe therapeutic option for Crohn's disease patients with severe disease phenotype and high previous anti-TNF biological failure, requiring frequent dose intensifications.

[The effect of endoscopic sphincterotomy on the motility of the gallbladder and of the sphincter of Oddi in patients with acalculous biliary pain syndrome]. / Endoszkópos sphincterotomia hatása az epehólyag és az Oddi-sphincter motilitására, valamint az epeürülés dinamikájára acalculosus biliaris fájdalom szindrómás betegekben.

INTRODUCTION: Sphincter of Oddi dysfunction usually occurs after cholecystectomy, but it can sometimes be detected in patients with intact gallbladder too. The diagnostic value of the non-invasive functional tests is not established in this group of patients and the effects of sphincterotomy on transpapillary bile outflow and gallbladder motility are unknown. AIMS: The aim of this study was to determine the effect of endoscopic sphincterotomy on the gallbladder ejection fraction, transpapillary bile outflow and the clinical symptoms of patients with acalculous biliary pain syndrome. PATIENTS AND METHODS: 36 patients with acalculous biliary pain syndrome underwent quantitative hepatobiliary scintigraphy, and all of them had decreased cholecytokinin-induced gallbladder ejection fraction. The endoscopic manometry of the sphincter of Oddi showed abnormal sphincter function in 26 patients who were enrolled the study. Before and after endoscopic sphincterotomy all patients had ultrasonographic measurement of cholecystokinin-induced gallbladder ejection fraction with and without nitroglycerin pretreatment and scintigraphy was repeated as well. The effects of sphincterotomy on gallbladder ejection fraction and transpapillary biliary outflow were evaluated. In addition, changes in biliary pain score with a previously validated questionnaire were also determined. RESULTS: All 26 patients had decreased gallbladder ejection fraction before sphincterotomy measured with scintigraphy (19+18%) and ultrasound (16+9.7%), which was improved after nitroglycerin pretreatment (48.2+17%; p<0.005). Detected with both methods, the ejection fraction was in the normal range after sphincterotomy (52+37% and 40.8+16.5%), but nitroglycerin pretreatment failed to produce further improvement (48.67+22.2%, NS). Based on scintigraphic examination sphincterotomy significantly improved transpapillary biliary outflow (common bile duct half time 63±33 min vs. 37±17 min; p<0.05). According to results obtained from questionneries, 22 of the 26 patients gave an account of significant symptom improvement after sphincterotomy. CONCLUSIONS: Endoscopic sphincterotomy improves cholecystokinin-induced gallbladder ejection fraction, transpapillary biliary outflow as well as biliary symptoms in patients with acalculous biliary pain syndrome and sphincter of Oddi dysfunction. Cholecystokinin-induced gallbladder ejection fraction with nitroglycerin pretreatment, measured with ultrasonography can be useful to select a subgroup of patients who can benefit from sphincterotomy.

[Endoscopic ultrasound-guided fine needle aspiration cytology in the mediastinum]. / Endoszkópos ultrahang vezérelte finomtu-aspirációs citológia a mediastinumban.

INTRODUCTION: Endoscopic ultrasound and endoscopic ultrasound-guided fine needle aspiration in the posterior mediastinum is technically a relatively simple and safe procedure, and it can provide important information for the further management of patients. AIM: To analyze and compare the results of mediastinal endoscopic ultrasound-guided fine needle aspiration with the data available in the literature. PATIENTS AND METHODS: The authors retrospectively analyzed their prospective database on mediastinal endoscopic ultrasound-guided fine needle aspiration of 49 patients referred to their endoscopy centre between 1 November 2009 and 1 November 2012. For the fine needle aspiration 22 and 25 G needles were used. Two to six needle passes were performed in each patient. All slides were prepared at the endoscopy unit and analyzed at the cytology laboratory. RESULTS: The authors performed mediastinal endoscopic ultrasound-guided fine needle aspiration for enlarged lymph nodes or suspected mediastinal malignancy in all but 4 patients (2 suspected oesophageal cancers, 1 suspected benign oesophageal stenosis with wall thickening and 1 cardia tumour, all with non-diagnostic endoscopic biopsies). Five patients were excluded from the analysis since fine needle aspiration was not performed in them. Benign lesions were suspected based on the endoscopic ultrasound morphology in 7, and malignant disease in 37 patients. In 3 cases samples obtained by biopsy were not informative for cytological analysis. Cytology confirmed all benign lesions and showed malignancy in 28 cases. Cytology failed to reveal malignancy in 6 patients, although it was suspected based upon endoscopic ultrasound finding. Furthermore, endoscopic ultrasound-guided fine needle aspiration provided the diagnosis in 15 of the 17 patients when bronchoscopy was non-diagnostic. The diagnostic accuracy of the EUS-FNA was the following: sensitivity 82%, specificity 100%, positive predictive value 1.0, negative predictive value 0.54. Only one infectious complication was encountered after fine needle aspiration despite antibiotic prophylaxis. DISCUSSION: Endoscopic ultrasound-guided fine needle aspiration of mediastinal pathology is an accurate, safe and technically relatively easy procedure, however it requires practice and skills in mediastinal anatomy. It has an excellent positive predictive value, a very good sensitivity, but slightly poor negative predictive value. The results of this study are concordant with the literature data. The authors suggest that at least 4 needle passes in the absence of on-site pathologist should be performed in order to minimize the number of false-negative results.

[Cholangitis and cholecystitis: diagnostic criteria and management]. / Epeút- és epehólyag-gyulladás: diagnosztikus kritériumok és terápia.

In developed countries, diseases of the gallbladder and the biliary tract count as some of the most frequent gastrointestinal disorders. The inflammation of the gallbladder/biliary tree is a potentially severe, even lethal condition that requires rapid diagnosis and early multidisciplinary approach to be treated. Although the frequency of these diseases is high, the treatment is not unified in Hungary yet. The aim of the evidence-based recommendation is to clarify the diagnostic criteria and severity grading of these diseases and to highlight the indications and rules of proper application of the numerous available therapeutic interventions. The recent guideline is based on the consensus of the Board members of the Endoscopic Section of the Hungarian Gastroenterology Society in contribution with renown experts of surgery, infectology as well as interventional radiology and it counts as a clear and easy applicable guide during the all-day healthcare practice. Our guidelines are based on Tokyo guidelines established on the basis of the consensus reached in the International Consensus Meeting held in Tokyo which were revised in 2013 (TG13) and in 2018 (TG18). Orv Hetil. 2023; 164(20): 770-787.

Early ERCP and biliary sphincterotomy with or without small-caliber pancreatic stent insertion in patients with acute biliary pancreatitis: better overall outcome with adequate pancreatic drainage.

OBJECTIVE: To analyze the efficacy of pancreatic duct (PD) stenting following endoscopic sphincterotomy (EST) compared with EST alone in reducing complication rate and improving overall outcome in acute biliary pancreatitis (ABP). METHODS: Between 1 January 2009 and 1 July 2010, 141 nonalcoholic patients with clinical, laboratory and imaging evidence of ABP were enrolled. Emergency endoscopic retrograde cholangiopancreatography (ERCP) was performed within 72 h from the onset of pain. Seventy patients underwent successful ERCP, EST, and stone extraction (control group); 71 patients (PD stent group) had EST, stone extraction and small-caliber (5 Fr, 3-5 cm) pancreatic stent insertion. All patients were hospitalized for medical therapy and jejunal feeding and were followed up. RESULTS: The mean age, Glasgow score, symptom to ERCP time, mean amylase and CRP levels at initial presentation were not significantly different in the PD stent group compared to the control group: 60.6 vs. 64.3, 3.21 vs. 3.27, 34.4 vs. 40.2, 2446.9 vs. 2114.3, 121.1 vs. 152.4, respectively. Complications (admission to intensive care unit, pancreatic necrosis with septicemia, large (>6 cm) pseudocyst formation, need for surgical necrosectomy) were less frequent in the PD stent group resulting in a significantly lower overall complication rate (9.86% vs. 31.43%, p < 0.002). Mortality rates (0% vs. 4.28%) were comparable, reasonably low and without any significant differences. CONCLUSIONS: Temporary small-caliber PD stent placement may offer sufficient drainage to reverse the process of ABP. Combined with EST the process results in a significantly less complication rate and better clinical outcome compared with EST alone during the early course of ABP.

[Endoscopic submucosal dissection in our practice -- new possibilities in the endoscopic treatment of neoplastic changes in the alimentary canal]. / Endoszkópos submucosus dissectio saját gyakorlatunkban -- új lehetoség a tápcsatorna korai neoplasztikus elváltozásainak endoszkópos kezelésében.

UNLABELLED: Endoscopic submucosal dissection is a promising new endoscopic technique for en block resection of early, superficial, flat, and laterally spreading gastrointestinal neoplasms. The primary aims of this prospective study were to summarize the first Hungarian experience with endoscopic submucosal dissection, and to compare the experimental in vivo procedures in pigs with the human application of this technique in two academic centers. METHODS: The ex vivo Erlangen pig model was used until initial competence was achieved. Thereafter 15 endoscopic submucosal dissection procedures were performed in up to 5 sessions in living pigs under general anesthesia. After submucosal injection with saline Fujinone ball tip, a Flush knife was used with a transparent hood for circumferential incision and submucosal dissection. The following variables were analyzed: specimen size, complete and en bloc resection rate, total duration of the procedure, and complications. Furthermore, between 2009 and 2012, 14 endoscopic submucosal dissections were carried out in humans; 1 duodenal, 3 gastric and 10 colorectal interventions were performed due to large laterally spreading intramucosal neoplasms. The specimen size, en bloc resection rate, total duration of the procedure and complications were next analyzed. RESULTS: 87% complete resection rate, 29.4 ± 19.5 cm2 specimen size and 136.2 ± 26.8 min of procedure duration were achieved in the live pig models. Nontransmural damages of the muscular layer occurred in 3/15 (20%) cases which were successfully closed with hemoclips, except in one pig that died due to fatal esophageal perforation. All bleedings were easily managed with hot biopsy forceps coagulation and hemoclips without hemodynamic instability. In humans, endoscopic submucosal dissection was accomplished with an 11/14 (79%) en block resection rate, with average resected specimen size of 11.56 ± 4.9 cm2 and with 157 ± 55 min of operating time. Two cases of bleeding and 2 cases of perforation occurred (14%), all of which were managed endoscopically. After 1.5 year of average follow up, local recurrence occurred in one case only. In addition, due to the 3 incomplete resections and unsuccessful endoscopic submucosal dissection, surgical intervention was required in 4 cases altogether. CONCLUSIONS: This study demonstrates the first Hungarian experience with endoscopic submucosal dissection. Training in live pig models could help endoscopists to overcome the learning curve and minimize the risk of complications before starting the procedure in humans. Reduction in the resection time and low risk of complications, especially bleeding, could be achieved by the application of a flush knife.