Incidental pancreatic lesions - A diagnostic and management challenge.

The term "incidental lesion" denotes any lesion that is diagnosed by chance, by happenstance, usually with imaging techniques for a different condition unrelated to it. The widespread use of imaging tests with ever increasing quality and availability has led to finding an ever increasing number of incidental lesions, in this case in the pancreas.

Hemostatic spray powder TC-325 for GI bleeding in a nationwide study: survival and predictors of failure via competing risks analysis.

BACKGROUND AND AIMS: TC-325 (Hemospray, Cook Medical, Winston-Salem, NC) is an inorganic hemostatic powder recently approved by the U.S. Food and Drug Administration. This study aimed to examine the effectiveness, safety, and predictors of TC-325 failure in a large real-life cohort. METHODS: This was a retrospective study conducted at 21 Spanish centers. All patients treated with TC-325 until September 2018 were included. The primary outcome was treatment failure, defined as failed intraprocedural hemostasis or recurrent bleeding within the first 30 postprocedural days. Secondary outcomes included safety and survival. Risk and predictors of failure were assessed via competing-risk models. RESULTS: The cohort comprised 261 patients, of whom 219 (83.9%) presented with upper gastrointestinal bleeding (GIB). The most common causes were peptic ulcer (28%), malignancy (18.4%), and therapeutic endoscopy-related GIB (17.6%). TC-325 was used as rescue therapy in 191 (73.2%) patients. The rate of intraprocedural hemostasis was 93.5% (95% confidence interval [CI], 90%-96%). Risks of TC-325 failure at postprocedural days 3, 7, and 30 were 21.1%, 24.6%, and 27.4%, respectively. On multivariate analysis, spurting bleeding (P = .004), use of vasoactive drugs (P = .02), and hypotension (P = .008) were independent predictors of failure. Overall 30-day survival was 81.9% (95% CI, 76%-86%) and intraprocedural hemostasis was associated with a better prognosis (adjusted hazard ratio, 0.29; P = .006). Two severe adverse events were noted. CONCLUSION: TC-325 was safe and effective for intraprocedural hemostasis in more than 90% of patients, regardless of the cause or site of bleeding and its use as rescue therapy. In this high-risk cohort treated with TC-325, the 30-day failure rate exceeded 25% and was highest with spurting bleeding or hemodynamic instability.

Is argon plasma coagulation an effective and safe treatment option for patients with chronic radiation proctitis after high doses of radiotherapy?

INTRODUCTION: In severe cases refractory to medical treatment, APC appears to be the preferred alternative to control persistent rectal bleeding of patients with chronic radiation proctitis. Although successful outcomes have been demonstrated in patients previously treated with moderate doses of radiotherapy, there is reluctance towards its indication due to the concern of severe adverse events in patients treated with high doses of radiation. OBJECTIVES: The aim of this study was to assess the efficacy and toxicity of APC in the management of bleeding radiationinduced proctitis in patients treated with high doses of radiation for prostate cancer. METHODS AND MATERIALS: Data from 30 patients were treated with APC due to chronic radiation proctitis, were reviewed retrospectively. All cases had prostate cancer and 9 of them (30 %) underwent previous radical prostatectomy. The median dose of conformal 3D External Beam Radiotherapy (EBRT) delivered was 74 Gy (range 46-76). Median rectal D1cc and D2cc was 72.5 and 72.4 Gy respectively. Median rectal V70, V60 and V40 was 12, 39.5 and 80 %. Cardiovascular and digestive disease, diabetes, smoking behaviour, lowest haemoglobin and transfusion requirements were recorded. Indications for treatment with APC were anemia and persistent bleeding despite medical treatment. Argon gas flow was set at 1.8 l/min with an electrical power setting of 50 W. RESULTS: Median age of all patients was 69.6 years. The median lowest haemoglobin level was 9.6 g/dL. Median time between completion of radiotherapy and first session of APC was 13 months. Ninety-four therapeutic sessions were performed (median 3 sessions). Median time follow-up was 14.5 months (range 2-61). Complete response with resolved rectal bleeding was achieved in 23 patients (77 %), partial response in 5 (16 %) and no control in 2 (6 %). No patients required transfusion following therapy. Two patients developed long-term (> 6 weeks) grade 2 rectal ulceration and grade 2 rectal incontinence, respectively. CONCLUSIONS: The argon plasma coagulation is an effective and safe management option in patients with medically refractory rectal bleeding after high doses of radiation for prostate cancer.

Treatment of achalasia by injection of sclerosant substances: a long-term report.

BACKGROUND: Endoscopic sclerotherapy (EST) with ethanolamine oleate (EO) was proposed as a treatment for achalasia, based on the well-known necrotizing effect against the esophageal muscle layers. The aim of this study is to evaluate long-term efficacy of EST. METHODS: Four consecutive series of patients with achalasia were treated according to different schedules over a period of 20 years, by using EO or polidocanol (PD). The primary outcome was dysphagia relief. Secondary outcomes were lower esophageal sphincter pressure, esophagogram, gastroesophageal reflux and endoscopic ultrasonography (EUS). Patients not responding to EST were treated with 30 mm dilation. RESULTS: A total of 103 patients completed the treatment. On medium-term evaluation, 75 patients who completed the treatment reached a clinical response labeled as "good," 23 were assessed as "fair," and 5 were assessed as failures. EUS has become a very informative tool to guide the treatment. The overall follow-up lasted for 87.9 ± 66.7 months. Twelve patients experienced a late failure. The cumulative expectancy of being free of recurrence was 90 % at 50 months with EO, but it was only 65 % with PD. Those patients who responded to rescue measures remained in good or fair clinical condition during the remaining follow-up. Young age, PD, and the so-called fusiform pattern on esophagogram proved to be significant predictors of poor prognosis. CONCLUSION: EST with EO is a promising alternative to classic therapies for achalasia. In contrast, PD-treated patients showed an important trend to fibrosis and clinical recurrence. Dilation seems particularly effective after EST, when this technique has failed.

The role of endoscopic ultrasound guided fine needle aspiration (EUS-FNA) in non small cell lung cancer (NSCLC) patients: SEED-SEPD-AEG Joint Guideline.

Lung cancer is one of the most frequent neoplasms in our environment, and represents the first cause of cancer related death in western countries. Diagnostic and therapeutic approach to these patients may be complicated, with endoscopic ultrasound guided fine needle aspiration (EUS-FNA), classically performed by gastroenterologists, playing a very important role. As this disease is not closely related to the "digestive tract", gastroenterologists have been forced to update their knowledge on this field o adequately diagnose this significant group of patients. The recent advent of modern and promising techniques like endobronchial ultrasound guided fine needle aspiration (EBUS-FNA) have prompted new approaches for diagnosis and staging of this type of patients. In this clinical guideline, the "Sociedad Española de Endoscopia Digestiva" (SEED), "Sociedad Española de Patología Digestiva" (SEPD) and the "AsociaciónEspañola de Gastroenterología", have jointed efforts to update the existing knowledge on the field and provide their members with evidence based recommendations.

Initial experience with EUS-guided cholangiopancreatography for biliary and pancreatic duct drainage: a Spanish national survey.

BACKGROUND: EUS-guided cholangiopancreatography (ESCP) allows transmural access to biliopancreatic ducts when ERCP fails. Data regarding technical details, safety, and outcomes of ESCP are still unknown. OBJECTIVE: To evaluate outcomes of ESCP in community and referral centers at the initial development phase of this procedure, to identify the ESCP stages with higher risk of failure, and to evaluate the influence on outcomes of factors related to the endoscopist. DESIGN: Multicenter retrospective study. SETTING: Public health system hospitals with experience in ESCP in Spain. PATIENTS: A total of 125 patients underwent ESCP in 19 hospitals, with an experience of <20 procedures. INTERVENTION: ESCP. MAIN OUTCOME MEASUREMENTS: Technical success and complication rates in the initial phase of implantation of ESCP are described. The influence of technical characteristics and endoscopist features on outcomes was analyzed. RESULTS: A total of 125 patients from 19 hospitals were included. Biliary ESCP was performed in 106 patients and pancreatic ESCP was performed in 19. Technical success was achieved in 84 patients (67.2%) followed by clinical success in 79 (63.2%). Complications occurred in 29 patients (23.2%). Unsuccessful manipulation of the guidewire was responsible for 68.2% of technical failures, and 58.6% of complications were related to problems with the transmural fistula. LIMITATIONS: Retrospective study. CONCLUSION: Outcomes of ESCP during its implantation stage reached a technical success rate of 67.2%, with a complication rate of 23.2%. Intraductal manipulation of the guidewire seems to be the most difficult stage of the procedure.

Short article: Endoscopic ultrasound-guided fine-needle aspiration of portal vein thrombosis in patients with chronic liver disease and suspicion of hepatocellular carcinoma.

BACKGROUND: Differentiation between benign and malignant portal vein thrombosis (PVT) in the setting of a hepatocellular carcinoma (HCC) is of paramount importance. Histological analysis is usually not carried out because of potential severe side effects of the percutaneous approach. Endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) may be safer and may guide the clinical management of patients with HCC. OBJECTIVE: To describe the feasibility of the EUS-FNA in a series of patients with HCC and PVT. MATERIALS AND METHODS: A chart review of patients with PVT was performed from 2014 to 2016 in three tertiary care hospitals of Spain. Patients with chronic liver disease and PVT with a suspicion of HCC referred for EUS-FNA were included. The impact of the EUS-FNA was assessed by comparing staging following the Barcelona Clinic Liver Cancer algorithm (BCLC) before and after EUS-FNA. RESULTS: Of 104 patients with PVT and chronic liver disease, 23 were considered candidates for EUS-FNA. Eight patients were referred for EUS-FNA. The technique was feasible in seven patients and FNA was positive in six patients. No side effects were reported. EUS-FNA upstaged six out of seven (85.7%) patients: one patient BCLC stage B, two patients BCLC stage A, and three patients in whom the HCC was not diagnosed before EUS-FNA of the PVT. A benign PVT was found in the explant of the only patient with a negative PVT. CONCLUSION: EUS-FNA is a valuable technique in selected patients with chronic liver disease with PVT. It is feasible, safe, and may alter the clinical management in these patients.

Ultrasound-guided endoscopic fine needle aspiration cytology in pancreatic lesions: a series of 43 cases with histologic correlation from a single institution.

OBJECTIVE: To describe the usefulness of endoscopic ultrasound-guided fine needle aspiration cytology (EUS-FNAC) in pancreatic lesions. STUDY DESIGN: During a 5-year period (2007-2011) a total of 391 patients with pancreatic lesions have been studied using EUS-FNAC, with 43 of them having cytohistological correlation with core biopsy or surgical specimens. The diagnostic performance of this technique with and without the pathologist in the endoscopy room has been compared. RESULTS: On the cytological smears, adenocarcinoma was diagnosed in 13 (30.2%) cases and neuroendocrine neoplasm in 2 (4.6%). Six (13.9%) cases were considered suspicious for malignancy, 2 (4.6%) were solid pseudopapillary tumors, and 20 (46.5%) were negative. There were no mucin-producing cystic neoplasms in the cytological diagnostic approach. After the cytohistological correlation, 23 (53.5%) cases were true positive, 11 (25.5%) were true negative, and 9 (21%) were false negative. There were no false positive cases in the series. Diagnostic precision was 79%, sensitivity 71.18%, specificity 100%, positive predictive value 100%, and negative predictive value 55%. The diagnostic performance of this technique is significantly higher (p < 0.015) when the pathologist is present in the endoscopy room. CONCLUSION: Our data support the usefulness and reliability of EUS-FNAC in the diagnosis of pancreatic lesions. In our experience, significantly better results are obtained when the pathologist takes an active part in the procedure.