Patients With Unexplained Dilated Pancreatic Duct Have High Risk of Biliopancreatic Malignancy Detected by EUS.

INTRODUCTION: Patients with unexplained dilated common bile duct (CBD) and/or dilated main pancreatic duct (MPD) on noninvasive abdominal imaging tests are often referred for endoscopic ultrasound (EUS) in order to rule out biliopancreatic cancer. The aim of the study was to evaluate the diagnostic yield of EUS in this patient group. METHODS: A prospective study was conducted. Patients with unexplained dilated CBD and/or MPD on abdominal imaging, who underwent EUS, were enrolled. RESULTS: Fifty-four patients underwent EUS (CBD dilation n=38, MPD dilation n=5 or both n=11). In 31/54 patients (57.4%), EUS revealed pathologic findings. Sixteen patients (29.6%) had EUS evidence of biliopancreatic cancer and 15 patients (27.7%) had benign pathology. Ten (62.5%) of the patients with biliopancreatic cancer had MPD dilation. MPD dilation was significantly associated with malignancy (P=0.017). CONCLUSION: Patients with unexplained dilated MPD on noninvasive image have a high risk of biliopancreatic malignancy detected by EUS.

Utility of endoscopic ultrasound in idiopathic acute recurrent pancreatitis.

Idiopathic acute recurrent pancreatitis (IARP) is defined as at least two episodes of acute pancreatitis with the complete or near-complete resolution of symptoms and signs of pancreatitis between episodes, without an identified cause. There is a paucity of information about the usefulness of endoscopic ultrasound (EUS) in IARP. OBJECTIVES: To determine the diagnostic yield of EUS in IARP. DESIGN: A retrospective study was performed in patients with IARP evaluated by EUS between January 2009 and December 2016. Follow-up assessments of acute pancreatitis recurrence were carried out. RESULTS: Seventy-three patients with 102 EUS procedures were included. EUS was able to identify the cause of IARP in 55 patients (75.3%). The most common findings were chronic pancreatitis in 27 patients (49.1%), followed by lithiasic pathology in 24 patients (43.6%), and intraductal papillary mucinous neoplasm in four patients (7.3%). A directed treatment against EUS findings had a protective tendency associated with the final resolution of recurrence. There were no complications reported. CONCLUSION: EUS performed in patients with IARP helped to identify a possible cause in 2/3 of the cases. The majority of patients have a treatable disease.

EUS-guided biliary drainage in patients with distal malignant biliary obstruction requires fewer interventions and has a lower cost compared to ERCP biliary drainage.

INTRODUCTION: Endoscopic retrograde cholangiopancreatography (ERCP) biliary drainage is considered the reference standard in patients with biliary obstruction, but it is not free of complications. EUS-guided biliary drainage (EUS-BD) is considered an alternative in patients with failed ERCP; however, data are scarce as to whether EUS-BD could be considered a first option. OBJECTIVE: The aim of our study was to compare the need for reintervention and cost between ERCP biliary drainage vs. EUS-BD. MATERIAL AND METHODS: We conducted a retrospective and comparative study of patients with distal malignant biliary obstruction with biliary drainage with ERCP + plastic stent (ERCP-PS) vs. ERCP + metal stent (ERCP-MS) vs. EUS-BD. RESULTS: 124 patients were included, divided into three groups: ERCP-PS, 60 (48.3%) patients; ERCP-MS, 40 (32.2%) patients; and EUS-BD, 24 (19.3%) patients. The need for reinterventions (67 vs. 37 vs. 4%, respectively), the number of procedures [3 (1-10) vs. 2 (1-7) vs. 1 (1-2)], and the costs (4550 ± 3130 vs. 5555 ± 3210 vs. 2375 ± 1020 USD) were lower in the EUS-BD group. No differences in terms of complications were detected. CONCLUSION: EUS-BD requires fewer reinterventions and has a lower cost compared to drainage by ERCP with metal or plastic stents.

When Is Sentinel Node Biopsy Indicated in High-Risk Ductal Carcinoma in situ? Four Hundred Sixty-Eight Cases from Three Institutions.

INTRODUCTION: Sentinel lymph node biopsy (SLNB) in ductal carcinoma in situ (DCIS) is not indicated. However, in certain cases (size >3 cm, high grade, mass effect on mammography, or palpable mass), it may be possible to find incidental invasive carcinoma (IC) that requires an SLNB. We studied the correlation of the aforesaid factors with the probability of finding IC in the surgical specimen. METHODS: Data was collected from 3 different institutions between 2010 and 2016, recording characteristics such as, but not limited to: high grade, size >3 cm, mass effect on mammography, and palpable mass. RESULTS: On the whole, 468 "high-risk" DCIS cases were identified, 139 (29%) of which had IC. When the DCIS was high grade or the size was >3 cm, there was no significant difference in the probability of finding IC in the surgical specimen (OR = 1.13; 95% CI 0.84-1.51; OR = 1.2; 95% CI 0.85-1.40). Nevertheless, when a high grade and size (>3 cm) were combined, IC was more likely to exist (72.7 vs. 27.3%; p = 0.001). In addition, mass effect and palpation were independently associated with a significantly greater degree of IC (OR = 12.76; 95% CI 6.93-23.52). CONCLUSIONS: The results suggest that high-grade DCIS or DCIS with a size >3 cm, independently, does not require SLNB. Nonetheless, in the event that both factors are found in the same case, SLNB may be indicated. Additionally, SLNB is advisable for DCIS cases that are palpable or show a mass effect on mammography.

Cutaneous Manifestations of Zika in Peru.

This article aims to describe the cutaneous manifestations observed in the Zika epidemic in Peru during 2016 and 2017, as well as discuss the potential differential diagnoses. During the outbreak, the main reason for seeking medical advice was the development of a pruriginous maculopapular rash with a marked papular component, which started on the chest and later generalized to the rest of the body. Similar manifestations were noted in adults, children, and pregnant women. Other manifestations such as conjunctivitis, edema, or petechiae on the palate were rare. We suggest that in areas that are endemic for arboviral infections, in the differential diagnosis of a rash one must consider infections such as dengue, Zika, or chikungunya viruses. In nonendemic areas, the diagnosis is more difficult, as the rash may result from other viral infections not transmitted by arthropods and/or reactive or inflammatory diseases (urticaria, atopic dermatitis, systemic lupus erythematosus). We recommend that primary care health personnel are trained in the recognition of the mucocutaneous lesions caused by Zika virus infection, which could contribute to the identification of suspicious cases, particularly pregnant women.

Analysis of circulating blood and tissue biopsy PDX1 and MSX2 gene expression in patients with pancreatic cancer: A case-control experimental study.

Early diagnosis of pancreatic cancer (PC) is based on endoscopic ultrasound (EUS). However, EUS is invasive and requires a high level of technical skill. Recently, liquid biopsies have achieved the same sensitivity and specificity for the diagnosis of numerous pathologies, including cancer. Insulin-promoting factor 1 (PDX1) and Msh-homeobox 2 (MSX2), 2 homeotic genes, have been confirmed to be related to pancreatic oncogenesis.The aim of this study is to establish the diagnostic utility of circulating serum levels of MSX2 and PDX1 expression in patients with PC.A prospective study was conducted from January 2014 to February 2017. Patients with a suspected diagnosis of PC who underwent fine needle aspiration biopsy guided by EUS (EUS-FNA) were included in the study, in addition to non-PC control subjects. Both tissue and blood serum samples were submitted to histopathological analysis and measurement of PDX1 and MSX2 gene expression by means of qRT-PCR.Patients were divided into non-PC, malignant pathology (MP), or benign pathology (BP) groups. Significant differences in both MSX2 [2.05 (1.66-4.60) vs 0.83 (0.49-1.60), P = .006] and PDX1 [2.59 (1.28-10.12) vs 1.02 (0.81-1.17), P = .036] gene expression were found in blood samples of PC compared with non-PC subjects. We also observed a significant increase in MSX2 transcripts in tissue biopsy samples of patients diagnosed with MP compared with those with BP [1.98 (1.44-4.61) and 0.66 (0.45-1.54), respectively, P = .012]. The ROC curves indicate a sensitivity and specificity of 80% for PDX1 and 86% for MSX2.Gene expression of MSX2 in tissue samples obtained by EUS-FNA and serum expression of MSX2 and PDX1 were higher in patients with PC.

Endoscopic Ultrasound in Pediatric Patients With Pancreatobiliary Disease.

BACKGROUND: Endoscopic ultrasound (EUS) is one of the greatest advances of the last few decades for the diagnostic and therapeutic approach of gastrointestinal diseases in adults. However, there are limitations to the application of the procedure in the pediatric population. The aim of this study was to describe the diagnostic yield and therapeutic role of EUS in pediatric patients with pancreatobiliary disease. MATERIALS AND METHODS: A retrospective study was performed on a prospective database of pediatric patients who underwent diagnostic and therapeutic endosonographic procedures. All patients seen in a 12-year period were included. RESULTS: A total of 54 patients were included, including 32 (59.3%) female individuals, with an average age of 16 (9 to 17) years. EUS was abnormal in 46 (85%) patients. Of the abnormal procedures, 4 (7.4%) corresponded to therapeutic ones. The main indication of the study was recurrent acute pancreatitis in 29 (54%). The main endosonographic findings were microlithiasis in 14 (25.9%), chronic pancreatitis in 9 (16.7%), and pancreatic tumors in 6 (11.1%) patients. Follow-up was performed in 31 (57.4%) patients, 19/31 patients underwent surgery, and 4/31 patients had endoscopic retrograde cholangiopancreatography. The median follow-up was 910 (2 to 3916) days. In 100% of the patients with follow-up, the initial diagnosis of EUS was confirmed. CONCLUSION: EUS is a useful and safe tool in the pediatric population with pancreatobiliary diseases.

Gastric responses to acute psychological stress in climacteric women: a pilot study.

OBJECTIVE: Women exhibit reduced ovarian sex hormones during the menopausal period that result in well-known physical and psychological symptoms. However, symptoms related to gastric motility (GM) have not been thoroughly investigated. We hypothesized that stress response gastric motility (SRGM) is lower in postmenopausal (PM) and perimenopausal (PERIM) women than in premenopausal (PREM) women. Estrogenic decline leads to neuroendocrine changes in different areas of the brain. These changes can result in hypothalamic vasomotor symptoms, disorders in eating behaviours, and altered blood pressure, in addition to psychological disorders such as stress, anxiety, depression, and irritability related to alterations in the limbic system. METHODS: In this pilot study, 55 PREM, PERIM, and PM women were clinically evaluated using the Nowack stress profile (SP) and State-Trait Anxiety Inventory (STAI). GM was assessed via electrical bioimpedance using two psychological stress tests (Stroop and Raven tests). RESULTS: Basal SP and STAI-anxiety test scores were similar among the three groups of women (P > 0.05). PERIM women had lower GM in the basal state (P < 0.05) than did other women. PREM and PM women had significantly decreased GM during the stress tests (P < 0.05). However, PERIM did not exhibit GM changes during stress tests (P > 0.05). CONCLUSION: Changes in sex hormones during PERIM may affect GM and SRGM.

Biliary Drainage in Patients With Failed ERCP: Percutaneous Versus EUS-guided Drainage.

AIM: The goal of the study is to compare the efficacy and safety of bile duct drains guided by endoscopic ultrasound-guided biliary drainage (EGBD) versus percutaneous transhepatic biliary drainage (PTBD). MATERIALS AND METHODS: Retrospective comparative study. Patients with obstruction of the bile duct who underwent the EGBD or PTBD procedure and had at least 1 previous endoscopic retrograde cholangiopancreatography that failed or was inaccessible to the second duodenal portion were included. RESULTS: A total of 90 patients were initially evaluated and 28 were excluded. There were 39 (62.9%) women, with a median age of 55.6 years (range, 22 to 88 y). The etiology of biliary obstruction was malignancy in 35 (56.4%) patients. Differences between EGBD versus PTBD groups were in technical success (90% vs. 78%; P=0.3), clinical success (96% vs. 63%; P=0.04), complications (6.6% vs. 28%; P=0.04), length of stay [6.5 d (range, 0 to 11 d) vs. 12.5 d (range, 6.2 to 25 d)] (P=0.009), and costs 1440.15±240.94 versus 2165.87±241.10 USD (P=0.03). CONCLUSIONS: EGBD is associated with a higher clinical success rate and safety, shorter hospital stays, and lower cost compared with PTBD.

Secondary node analysis as an indicator for axillary lymphadenectomy in breast cancer patients. / Ganglio secundario como indicador de linfadenectomía axilar en pacientes afectas de cáncer de mama.

INTRODUCTION: Currently, there is no agreement regarding if it would be necessary to perform an axillary lymph node dissection (ALND) in patients who have macrometastases in the sentinel lymph node (SLN). We studied the utility of the secondary node analysis (SN), defined as the following node after the SLN in an anatomical and lymphatic pathway, as a sign of malignant axillary involvement. METHODS: An observational, retrospective and multicentre study was designed to assess the utility of the SN as a sign of axillary involvement. Among 2273 patients with breast cancer, a valid sample of 283 was obtained representing those who had the SN studied. Main endpoints of our study were: the SLN, the SN and the ALND histological pattern. Sensitivity, specificity and precision of the test were also calculated. RESULTS: SN test, in cases with positive SLN, has a sensitivity of 61.1%, a specificity of 78.7%, a positive predictive value of 45.8% and a negative predictive value of 87.3% with a precision of 74.7%. CONCLUSION: The study of the SN together with the technique of the SLN allows a more precise staging of the axillary involvement, in patients with breast cancer, than just the SLN technique.

Repeat endoscopic ultrasound fine needle aspiration after a first negative procedure is useful in pancreatic lesions.

BACKGROUND AND OBJECTIVES: There is no consensus about the ideal method for diagnosis in patients who have already undergone endoscopic ultrasound fine needle aspiration (EUS-FNA), and the inconclusive material is often obtained. The aim was to evaluate the diagnostic yield of the second EUS-FNA of pancreatic lesions. MATERIALS AND METHODS: A retrospective analysis of prospectively collected data of patients with EUS-FNA of pancreatic lesions is performed. All patients who underwent more than one EUS-FNA for the evaluation of suspected pancreatic cancer over a 7-year period were included in the analysis. RESULTS: A total of 296 EUS-FNAs of the pancreas were performed in 257 patients. The diagnostic yield with the first EUS-FNA was 78.6% (202/257). Thirty-nine (13.3%) FNAs were repeated in 34 patients; 17 (50%) patients were women. The mean ± standard deviation (SD) age was 58.8 ± 16.1 years. The location of the lesions in the pancreatic gland, from which the second biopsies were taken, was head of the pancreas, n = 28 (82.4%), body of the pancreas, n = 3 (8.8%), and tail, n = 3 (8.8%). The mean ± SD of the size of the lesion was 36.3 ± 14.6 mm. The second EUS-FNA was more likely to be positive for diagnosis in patients with an "atypical" histological result in the first EUS-FNA (odds ratio [OR]: 4.04; 95% confidence interval [CI]: 0.9-18.3), in contrast to patients with a first EUS-FNA reported as "normal" (OR: 0.21; 95% CI: 0.06-0.71). Overall, the diagnostic yield of the second EUS-FNA was 58.8% (20/34) with an increase to 86.3% overall (222/257). CONCLUSION: Repeat EUS-FNA in pancreatic lesions is necessary in patients with a negative first EUS-FNA because it improves the diagnostic yield.

EUS-guided drainage of pancreatic pseudocysts offers similar success and complications compared to surgical treatment but with a lower cost.

BACKGROUND AND AIM: Pancreatic pseudocysts (PPC) are a complication that occurs in acute and chronic pancreatitis. They comprise 75% of cystic lesions of the pancreas. There are scarce data about surgical versus endoscopic treatment on PPC. The aim of this study was to compare both treatment modalities regarding clinical success, complication rate, recurrence, hospital stay and cost. METHODS: Retrospectively, data obtained prospectively from 2000 to 2012 were analyzed. A PPC was defined as a fluid collection in the pancreatic or peripancreatic area that had a well-defined wall and contained no solid debris or recognizable parenchymal necrosis. Clinical success was defined as complete resolution or a decrease in size of the PPC to 2 cm or smaller. RESULTS: Overall, 64 procedures in 61 patients were included: 21 (33%) cases were drained endoscopically guided by EUS and 43 (67%) cases were drained surgically. The clinical success of the endoscopic group was 90.5 versus 90.7% for the surgical group (P = 0.7), with a complication rate of 23.8 and 25.6%, respectively (P = 0.8), and a mortality rate of 0 and 2.3% for each group, respectively (P = 0.4). The hospital stay was lower for the endoscopic group: 0 (0-10) days compared with 7 (2-42) days in the surgical group (P < 0.0001). Likewise, the cost was lower in the endoscopic group (P < 0.001). The recurrence rate was similar in both groups: 9.5 and 4.5% respectively (P = 0.59). The two recurrences found in the endoscopic group were associated with stent migration, and the recurrence in the surgical group was due to the type of surgery performed (open drainage). CONCLUSION: Endoscopic treatment of PPC offers the same clinical success, recurrence, complication and mortality rate as surgical treatment but with a shorter hospital stay and lower costs.

Postoperative abdominal collections drainage: Percutaneous versus guided by endoscopic ultrasound.

BACKGROUND AND AIM: Postoperative fluid collections (POFC) have high mortality. Percutaneous drainage (PD) is the preferred treatment modality. Drainage guided by endoscopic ultrasound (EUS-GD) represents a good alternative. The aim of the present study was to compare clinical success and complication rates of EUS-GD versus PD. METHODS: Data collected prospectively were analyzed in a retrospective manner. Patients with POFC from October 2008 to November 2013 were included. All collections were drained percutaneously or by EUS-GD. RESULTS: Sixty-three procedures in 43 patients with POFC were analyzed; 13 patients were drained using EUS-GD and 32 patients with PD. Two patients assigned initially to the PD group were reassigned to EUS-GD. Surgery procedures most often related to the collections were intestinal reconnection, distal pancreatectomy, biliary-digestive bypass, and exploratory laparotomy. Technical success (100% vs 91%; P = 0.25), clinical success (100% vs 84%; P = 0.13), recurrence (31% vs 25%; P = 0.69), hospital stay days (median 22 vs 27; P = 0.35), total costs (8328 ± 1600 USD vs 11 047 ± 1206 USD; P = 0.21), complications (0% vs 6%; P = 0.3), and mortality (8% vs 6%; P = 0.9) were each evaluated in the EUS-GD and PD groups, respectively. In the PD group one death was related to the procedure. CONCLUSIONS: EUS-GD is as effective and safe as PD in patients with POFC. The advantage of not requiring external drainage and a trend to higher clinical success and lower total costs must be considered.

Diagnostic yield of endoscopic ultrasound in patients with hypoglicemia and insulinoma suspected.

BACKGROUND AND OBJECTIVES: Noninvasive imaging techniques have shown limitations to identify insulinomas. In few studies reported so far, endoscopic ultrasound (EUS) has proven to be able to locate lesions. The aim of this study was to compare the performance of computed tomography versus EUS for the detection of insulinomas. MATERIALS AND METHODS: In a retrospective manner prospectively collected data were analyzed. Patients with hypoglucemia and hyperinsulinemia were included. Diagnostic yield was measured in relationship to sensitivity, specificity, positive predictive value, negative predictive value and accuracy. Surgical specimens were considered the gold standard. RESULTS: Sensitivity, positive predictive value, and accuracy of EUS was 100%, 95.4% and 95.4%, respectively. In the case of CT the sensitivity was 60%, specificity 100%, positive predictive value 100%, negative predictive value 7%, and accuracy were 68%. CONCLUSIONS: EUS is useful in the preoperative assessment of patients with hypoglycemia and serum hyperinsulinemia.

Follow-up of patients with pseudotumoral chronic pancreatitis: outcome and surveillance.

AIM: To follow up patients with pseudotumoral chronic pancreatitis (PCP) to assess their outcome and identify an optimal surveillance interval. METHODS: Data obtained prospectively were analyzed in a retrospective manner. Patients with clinical evidence of chronic pancreatitis (abdominal pain in the epigastrium, steatorrhea, and diabetes mellitus), endoscopic ultrasound (EUS) criteria > 4, and EUS-fine needle aspiration (FNA) were included. A pseudotumor was defined as a non-neoplastic space-occupying lesion, a cause of chronic pancreatitis that may mimic changes typical of pancreatic cancer on CT or endoscopic ultrasound but without histological evidence. A real tumor was defined as a neoplastic space-occupying lesion because of pancreatic cancer confirmed by histology. RESULTS: Thirty-five patients with chronic pancreatitis were included, 26 (74.2%) of whom were men. Nine (25.7%) patients were diagnosed with pseudotumoral chronic pancreatitis and two (2/35; 5.7%) patients with pseudotumoral chronic pancreatitis were diagnosed with pancreatic cancer on follow-up. The time between the diagnosis of pseudotumoral chronic pancreatitis and pancreatic adenocarcinoma was 35 and 30 d in the two patients. Definitive diagnosis of pancreatic adenocarcinoma was made by surgery. In the remaining six patients with pseudotumoral chronic pancreatitis, the median of follow-up was 11 mo (range 1-22 mo) and they showed no evidence of malignancy on surveillance. In the follow-up of patients without pseudotumoral chronic pancreatitis but with chronic pancreatitis, none were diagnosed with pancreatic cancer. According to our data, older patients with chronic pancreatitis are at risk of pseudotumoral chronic pancreatitis. CONCLUSION: According to characteristics of patient, detection of PCP should lead a surveillance program for pancreatic cancer with EUS-FNA in < 1 mo or directly to surgical resection.

El pirofosfato de tiamina reduce el daño celular inducido por hipoxia en el cerebro de ratas neonatas / Thiamine pyrophosphate reduces hypoxia-induced cellular damage in neonatal rat brain

La encefalopatía por hipoxia es causa de discapacidad y requiere de nuevas estrategias terapéuticas. El pirofosfato de tiamina (PPT) es un cofactor esencial de enzimas fundamentales en el metabolismo de la glucosa, cuya disminución puede conducir a la falla en la síntesis de ATP y a la muerte celular. El objetivo de este estudio fue determinar si la administración de PPT, puede reducir el daño celular en un modelo de hipoxia neonatal en ratas. Animales de 11 días de edad fueron tratados con PPT (130 mg/kg) en dosis única o solución salina, una hora antes del protocolo de hipoxia o al término de ésta. Los cerebros fueron colectados para la evaluación del daño celular. Además, se tomaron muestras sanguíneas para evaluar los indicadores gasométricos de presión de dióxido de carbono (PaCO2) y de oxígeno (PaO2) en sangre arterial y pH. Los resultados muestran que la administración de PPT previa a la inducción de hipoxia, reduce el daño celular y restablece los indicadores gasométricos. Estos datos indican que el uso de PPT reduce el daño inducido por la hipoxia en animales neonatos.

Hypoxic encephalopathy is a leading cause of disability and requires new therapeutic strategies. Thiamine pyrophosphate (TPP) is an essential cofactor of fundamental enzymes involved in glucose metabolism. TPP reduction may lead to ATP synthesis failure and cell death. The objective of this study was to determine if TPP administration can reduce cellular damage in a model of neonatal hypoxia in rats. Eleven day old animals were treated with TPP (130 mg/kg) as a single dose or with saline solution one hour before the hypoxia protocol or after ending the protocol. The brains were collected to evaluate cellular damage. Blood samples were also collected to evaluate arterial oxygen tension (PaO2), carbon dioxide tension (PaCO2) and acidity (pH). The results showed that TPP administration previous to hypoxia induction reduces cellular damage and reestablishes arterial blood gases. These data indicate that TPP use reduces the damage induced by hypoxia in neonatal animals.

Use of a novel covered self-expandable metal stent with an anti-migration system for endoscopic ultrasound-guided drainage of a pseudocyst.

The development of pseudocysts in patients with chronic pancreatitis has been reported in 23%-60% of cases and drainage is indicated when they become symptomatic. Endoscopic ultrasound-guided drainage with the placement of plastic or metallic stents to create a cystogastric anastomosis has been shown to be a reliable and efficacious maneuver. Metallic stent use appears to be a safe and effective alternative that shortens the length of time of the procedure and maintains a greater diameter in the cystogastric communication. However, important migration rates have been reported. The use of new metallic stents that are specially designed to prevent migration represents a promising development in the treatment of these group of patients that appears to be safe and effective for pseudocyst drainage and could importantly reduce migration rates, while at the same time having the advantage of a single step procedure and a larger fistula diameter in the endoscopic cystogastric anastomosis.