MiR-200b categorizes patients into pancreas cystic lesion subgroups with different malignant potential.

Extracellular vesicles (EV) carry their cargo in a membrane protected form, however, their value in early diagnostics is not well known. Although pancreatic cysts are heterogeneous, they can be clustered into the larger groups of pseudocysts (PC), and serous and mucinous pancreatic cystic neoplasms (S-PCN and M-PCN, respectively). In contrast to PCs and S-PCNs, M-PCNs may progress to malignant pancreatic cancers. Since current diagnostic tools do not meet the criteria of high sensitivity and specificity, novel methods are urgently needed to differentiate M-PCNs from other cysts. We show that cyst fluid is a rich source of EVs that are positive and negative for the EV markers CD63 and CD81, respectively. Whereas we found no difference in the EV number when comparing M-PCN with other pancreatic cysts, our EV-based biomarker identification showed that EVs from M-PCNs had a higher level of miR-200b. We also prove that not only EV-derived, but also total cyst fluid miR-200b discriminates patients with M-PCN from other pancreatic cysts with a higher sensitivity and specificity compared to other diagnostic methods, providing the possibility for clinical applications. Our results show that measuring miR-200b in cyst fluid-derived EVs or from cyst fluid may be clinically important in categorizing patients.

A preoperative ultrasound-based protocol for optimisation of fluid therapy to prevent early intraoperative hypotension: a randomised controlled study.

BACKGROUND: Intraoperative hypotension is a risk factor for postoperative complications. Preoperative dehydration is a major contributor, although it is difficult to estimate its severity. Point-of-care ultrasound offers several potential methods, including measurements of the inferior vena cava. The addition of lung ultrasound may offer a safety limit. We aimed to evaluate whether the implication of an ultrasound-based preoperative fluid therapy protocol can decrease the incidence of early intraoperative hypotension. METHODS: Randomised controlled study in a tertiary university department involves elective surgical patients of ASA 2-3 class, scheduled for elective major abdominal surgery under general anaesthesia with intubation. We randomised 40-40 patients; 38-38 were available for analysis. Conventional fluid therapy was ordered on routine preoperative visits. Ultrasound-based protocol evaluated the collapsibility index of inferior vena cava and lung ultrasound profiles. Scans were performed twice: 2 h and 30 min before surgery. A high collapsibility index (≥ 40%) indicated a standardised fluid bolus, while the anterior B-profile of the lung ultrasound contraindicated further fluid. The primary outcome was the incidence of postinduction and early intraoperative (0-10 min) hypotension (MAP < 65 mmHg and/or ≥ 30% of decrease from baseline). Secondary endpoints were postoperative lactate level, urine output and lung ultrasound score at 24 h. RESULTS: The absolute criterion of postinduction hypotension was fulfilled in 12 patients in the conventional group (31.6%) and 3 in the ultrasound-based group (7.9%) (p = 0.0246). Based on composite criteria of absolute and/or relative hypotension, we observed 17 (44.7%) and 7 (18.4%) cases, respectively (p = 0.0136). The incidence of early intraoperative hypotension was also lower: HR for absolute hypotension was 2.10 (95% CI 1.00-4.42) in the conventional group (p = 0.0387). Secondary outcome measures were similar in the study groups. CONCLUSION: We implemented a safe and effective point-of-care ultrasound-based preoperative fluid replacement protocol into perioperative care. TRIAL REGISTRATION: The study was registered to ClinicalTrials.gov on 10/12/2021, registration number: NCT05171608 (registered prospectively on 10/12/2021).

Efficacy and safety of endoscopic drainage of peripancreatic fluid collections: a retrospective multicenter European study.

Background: Endoscopic ultrasound (EUS)-guided transmural drainage allows treatment of symptomatic peripancreatic fluid collections (PFCs), with lumen-apposing metal stents (LAMS) and double pigtail plastic stents (DPPS) being the 2 most frequently used modalities. Methods: Consecutive patients undergoing PFC drainage in 10 European centers were retrospectively retrieved. Technical success (successful deployment), clinical success (satisfactory drainage), rate and type of early adverse events, drainage duration and complications on stent removal were evaluated. Results: A total of 128 patients-92 men (71.9%), age 57.2±11.9 years-underwent drainage, with pancreatic pseudocyst (PC) and walled-off necrosis (WON) in 92 (71.9%) and 36 (28.1%) patients, respectively. LAMS were used in 80 (62.5%) patients and DPPS in 48 (37.5%). Technical success was achieved in 124 (96.9%) of the cases, with no difference regarding either the type of stent (P>0.99) or PFC type (P=0.07). Clinical success was achieved in 119 (93%); PC had a better response than WON (91/92 vs. 28/36, P<0.001), but the type of stent did not affect the clinical success rate (P=0.29). Twenty patients (15.6%) had at least one early complication, with bleeding being the most common (n=7/20, 35%). No difference was detected in complication rate per type of stent (P=0.61) or per PFC type (P=0.1). Drainage duration was significantly longer with DPPS compared to LAMS: 88 (70-112) vs. 35 (29-55.3) days, P<0.001. Conclusions: EUS-guided drainage of PFCs achieves high percentages of technical and clinical success. Drainage using LAMS is of shorter duration, but the complication rate is similar between the 2 modalities.

Quantitative Software Analysis of Endoscopic Ultrasound Images of Pancreatic Cystic Lesions.

Endoscopic ultrasonography (EUS) is the most accurate imaging modality for the evaluation of different types of pancreatic cystic lesions. Our aim was to analyze EUS images of pancreatic cystic lesions using an image processing software. We specified the echogenicity of the lesions by measuring the gray value of pixels inside the selected areas. The images were divided into groups (serous cystic neoplasm /SCN/, intraductal papillary mucinous neoplasms and mucinous cystic neoplasms /Non-SCN/ and Pseudocyst) according to the pathology results of the lesions. Overall, 170 images were processed by the software: 81 in Non-SCN, 30 in SCN and 59 in Pseudocyst group. The mean gray value of the entire lesion in the Non-SCN group was significantly higher than in the SCN group (27.8 vs. 18.8; p < 0.0005). The area ratio in the SCN, Non-SCN and Pseudocyst groups was 57%, 39% and 61%, respectively; significantly lower in the Non-SCN group than in the SCN or Pseudocyst groups (p < 0.0005 and p < 0.0005, respectively). The lesion density was also significantly higher in the Non-SCN group compared to the SCN or Pseudocyst groups (4186.6/mm2 vs. 2833.8/mm2 vs. 2981.6/mm2; p < 0.0005 and p < 0.0005, respectively). The EUS image analysis process may have the potential to be a diagnostic tool for the evaluation and differentiation of pancreatic cystic lesions.

Diagnostic sensitivity of endoscopic ultrasonography in patients with suspected choledocholithiasis / Az endoszkópos ultrahangvizsgálat diagnosztikus érzékenysége epeúti kövesség gyanúja esetén.

Összefoglaló. Bevezetés: Az epeúti kövesség meglétének valószínusége különbözo klinikai prediktorok alapján megbecsülheto, e faktorok szenzitivitása és specificitása azonban nem kielégíto. Az endoszkópos ultrahangvizsgálat az epeúti kövesség diagnosztizálásának szemiinvazív precíz eszköze. Célkituzés: Célunk az endoszkópos ultrahangvizsgálat diagnosztikus érzékenységének vizsgálata gyanított epeúti kövesség esetén. Módszer: A prospektív vizsgálat során a betegeket az Amerikai Emésztoszervi Endoszkópos Társaság (ASGE) ajánlása szerint meghatározott prediktorok alapján közepes és magas valószínuségi csoportokba osztottuk, és endoszkópos ultrahangvizsgálatot, valamint amennyiben szükséges volt, endoszkópos retrográd kolangiopankreatográfiát (ERCP) végeztünk. Eredmények: Összesen 95 beteget vizsgáltunk. Az endoszkópos ultrahangvizsgálat 53 (56%) beteg esetében írt le epeúti kövességet: 55%-ban (39/71) a közepes valószínuségi és 58%-ban (14/24) a magas valószínuségi csoportban. Az ERCP mindegyik choledocholithiasisos esetet megerosítette. A két valószínuségi csoport között nem volt szignifikáns különbség (p = 0,56) az ERCP által igazolt epeúti kövesség tekintetében. Az ERCP csupán 1 esetben detektált epeúti kövességet a negatív endoszkópos ultrahangvizsgálat ellenére. Az endoszkópos ultrahangvizsgálat specificitása 100%, szenzitivitása 98%, míg pozitív és negatív prediktív értéke 100%, valamint 98% volt. Megbeszélés: Az epeúti kövesség meglétének becslése különbözo klinikai prediktorok alapján kihívást jelenthet. Következtetés: Az endoszkópos ultrahangvizsgálat szenzitív és pontos diagnosztikus eszköz a choledocholithiasis kimutatására és értékelésére, olyan esetekben is, amelyeknél az elozetes képalkotók nem találtak kövességet. Orv Hetil. 2022; 163(10): 400-406. INTRODUCTION: The likelihood of common bile duct stones can be prognosticated by various clinical predictors, however, the sensitivity and specificity of these factors are moderate. Endoscopic ultrasonography has been shown to be a semi-invasive precise test for the detection of common bile duct stones. OBJECTIVE: Our aim was to assess the diagnostic accuracy of endoscopic ultrasonography in patients with suspected choledocholithiasis. METHOD: Patients of this prospective study were categorized and divided into intermediate likelihood and high likelihood groups according to the clinical predictors defined by the American Society of Gastrointestinal Endoscopy (ASGE) guidelines and referred for linear endosonography. Endoscopic retrograde cholangiopancreatography (ERCP) was performed if needed. RESULTS: A total of 95 patients were assessed. Common bile duct stones were detected by endoscopic ultrasonography overall in 53 (56%) patients: 55% (39/71) in the intermediate likelihood and 58% (14/24) in the high likelihood group of patients. The detected common bile duct stones in all patients were confirmed by ERCP. There was no significant difference (p = 0.56) in the detection of stones by ERCP between the two likelihood groups. ERCP confirmed choledocholithiasis only in one patient whose preceding endosonography did not detect stone. The specificity and sensitivity of endoscopic ultrasonography were 100% and 98%, the positive predictive value and negative predictive value were 100% and 98%, respectively. DISCUSSION: Estimating the likelihood of choledocholithiasis based on various clinical predictors might be challenging. CONCLUSION: Endoscopic ultrasonography is a highly sensitive and accurate diagnostic tool for the detection and evaluation of common bile duct stones also in patients with previous normal imaging findings. Orv Hetil. 2022; 163(10): 400-406.

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.

Treatment of bile duct injuries during cholecystectomy / Cholecystectomia során bekövetkezo epeútsérülések ellátása

Biliary injury is a rare but a very serious complication of laparoscopic cholecystectomy (LC). Our aim was to analyse the incidence of the biliary injuries and its therapeutic outcome on patients who underwent LC or converted LC. Our research was conducted at the 1st Department of Surgery, Semmelweis University, Budapest between 2006 and 2016, retrospectively. We analysed the LCs and converted LCs performed at our Department and as well as cases where the primary operations were conducted at other institutions but they were unable to provide the adequate therapy for the injury, thus the patients were transferred to our institution. At the 1st Department of Surgery complications occurred in 0,66% (30/4885) of all LCs. 327 converted LCs were done, complications occurred in 26 (7.95%) times. 22 patients were transferred to the 1st Department of Surgery from other institutions. Bilio-vascular injuries occurred in 61% (41/78). ERCP was performed in 25 cases with a 92% success rate. Reoperation was needed in 41% (28/41). Biliary reconstruction during the reoperation was performed via hepaticojejunostomy in 82% of all reoperations. The therapeutic solutions of LC's complications are complex. Therefore, the treatment is recommended only in institutions with appropriate experience.