Suction versus slow-pull for endoscopic ultrasound-guided fine-needle aspiration of pancreatic tumors: a prospective randomized trial.

BACKGROUND: Suction (S) is commonly used to improve cell acquisition during endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA). Slow-pull (SP) sampling is another technique that might procure good quality specimens with less bloodiness. We aimed to determine if SP improves the diagnostic yield of EUS-FNA of pancreatic masses. METHODS: Patients with pancreatic solid masses were randomized to four needle passes with both techniques in an alternate fashion. Sensitivity, specificity, positive, and negative predictive values were calculated. Cellularity and bloodiness of cytological samples were assessed and compared according to the technique. RESULTS: Sensitivity, specificity, and accuracy of suction vs. SP were 95.2% vs. 92.3%; 100% vs. 100; 95.7% vs. 93%, respectively. As to the association of methods, they were 95.6, 100 and 96%, respectively. Positive predictive values for S and SP were 100%. There was no difference in diagnostic yield between S and SP (p = 0.344). Cellularity of samples obtained with SP and Suction were equivalent in both smear evaluation (p = 0.119) and cell-block (0.980). Bloodiness of SP and suction techniques were similar as well. CONCLUSIONS: S and SP techniques provide equivalent sensitivity, specificity, and accuracy. Association of methods seems to improve diagnostic yield. Suction does not increase the bloodiness of samples compared to slow-pull.

EUS-FNA versus ERCP for tissue diagnosis of suspect malignant biliary strictures: a prospective comparative study.

BACKGROUND AND STUDY AIMS: Biliary strictures are frequently a challenging clinical scenario and the anatomopathological diagnosis is essential in the therapeutic management, whether for curative or palliative purposes. The acquisition of specimens is necessary since many benign diseases mimic biliopancreatic neoplasms. Endscopic retrograde cholangiopancreatography (ERCP) is the traditionally used method despite the low sensitivity of biliary brush cytology and forceps biopsy. On the other hand, several studies reported good accuracy rates using endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA). The aim of this prospective study was to compare, the accuracy of EUS-FNA and ERCP for tissue sampling of biliary strictures. PATIENTS AND METHODS: After performing the sample size calculation, 50 consecutive patients with indeterminate biliary strictures were included to undergo ERCP and EUS on the same sedation.The gold-standard was surgery or 6 months' follow-up. Evaluation of the diagnostic indices (sensitivity, specificity, positive and negative predictive value, positive and negative likelihood ratio), concordance and adverse events among the methods were performed. Also, subtype analyses of the techniques, anatomical localization and size of the lesion were included. RESULTS: The final diagnoses reported in 50 patients were 47 malignant, 1 suspicious and 2 benign lesions. 31 lesions were extraductal and 19 intraductal, 35 were distal and 15 proximal strictures. In the intention-to-treat analysis, the sensitivity and accuracy of EUS-FNA were superior than ERCP tissue sampling (93,8 %, 94 % vs. 60,4 %, 62 %, respectively) ( P  = 0.034), with similar adverse events. There was no concordance between the methods and combining both methods improved the sensitivity and accuracy for 97.9 % and 98 %, respectively. In the subtype analyses, the EUS-FNA was superior, with a higher accuracy than ERCP tissue sampling in evaluating extraductal lesions (100 % vs. 54.8 %, P  = 0.019) and in those larger than 1.5 cm (95.8 % vs. 61.9 %, P  = 0.031), but were similar in evaluating intraductal lesions and lesions smaller than 1.5 cm. There was no significant difference between the methods in the analyzes of proximal, distal and pancreatic lesions. CONCLUSION: EUS-FNA is better than ERCP with brush cytology and intraductal forceps biopsy in diagnosing malignant biliary strictures, mainly in the assessment of extraductal lesions and in those larger than 1.5 cm. Combining ERCP with tissue sampling and EUS-FNA is feasible, the techniques have similar complication rates, and the combination greatly improves diagnostic accuracy.

Gastrointestinal ischemia: endoscopic findings in the context of vascular insufficiency

Gastrointestinal ischemia may result from different causes: hemodynamic shock, thromboembolism, endoscopic or surgical complications, among other causes. Its symptoms are pain, vomiting, bleeding and bloating. Endoscopic findings are pale or blackened mucosa, and exudative and confluent ulcerative lesions. This paper aims to report a case of gastroduodenal ischemia associated with hemodynamic shock and disseminated intravascular coagulation (DIC). This is a case of a 56-yearsold male with multiple comorbidities, presenting with refractory septic shock and DIC. He underwent an upper gastrointestinal endoscopy (UGE) for investigation of melena, which revealed an extensive deep and exudative gastric ulcer, associated with edematous purplish duodenal mucosa. Due to the severity of the underlying condition, the patient evolved to death, evidencing septic shock as cause of death. Gastroduodenal ischemia is associated with a poor prognosis, in which early diagnosis by UGE is fundamental to guide potential interventions.

La isquemia gastroduodenal puede resultar por diferentes causas: shock hemodinámico, tromboembolismo, complicaciones post-procedimientos endoscópicos o quirúrgicos, entre otras. Sus síntomas son dolor, vómito, hemorragia y distensión abdominal. Los hallazgos endoscópicos son mucosa pálida o ennegrecida, lesiones ulcerativas exudativas y confluentes. Este trabajo relata un caso de isquemia gastrointestinal, asociada a choque hemodinámico y coagulación intravascular diseminada (CID). Este es un caso de un hombre de 56 años de edad, con múltiples comorbilidades, que presenta con shock séptico refractario a tratamiento y CID. El paciente se sometió a una endoscopia digestiva alta (EDA) para la investigación de melena, que reveló una extensa úlcera gástrica exudativa y profunda, asociada con mucosa duodenal violácea e inflamada. Debido a la gravedad de la enfermedad de base, el paciente evolucionó a la muerte, siendo el shock séptico como causa principal. La isquemia gastrointestinal es asociada a un mal pronóstico, en el que el diagnóstico precoz por EDA es fundamental para orientar las posibles intervenciones.

Upper gastrointestinal endoscopy applied in pediatrics: endoscopic and histological findings, including Helicobacter pylori / Endoscopia digestiva alta aplicada em pediatria: hallazgos endoscópicos e histológicos incluyendo al Helicobacter pylory

Objective: To present and discuss the endoscopic and histological results, as well as the incidence of Helicobacter pylori and other diseases, indications and characteristics of upper digestive endoscopies performed in children. Material and methods: Twenty-five endoscopies were performed in children aged six months to 11 years (mean 7.69 years), from February 2013 to January 2016. In 200 patients, endoscopies were diagnostic and serial biopsies were performed (esophagus, stomach and duodenum), in 120 of them. Results: The indication of endoscopy was diagnosed in 88.89% of the patients, and in 26 patients, a therapeutic procedure was performed. The most frequent endoscopic findings were esophagitis in 49 patients, gastritis in 84 and duodenitis in 16 patients. Four duodenal ulcers were diagnosed. In the therapeutic endoscopies, six gastrostomies were performed, 14 foreign body withdrawals, five nasoenteral tube passages and esophageal dilatation. The H. pylori survey was performed by anatomopathological method and was positive in 26 (13%) of the 200 patients in whom it was searched. Conclusion: pediatric endoscopy is an important niche of the digestive endoscopy, where it is important to emphasize the relevance of the institutional structure that performs these procedures, in order to conduct them safely, being able to treat possible and feasible complications

Objetivo: Presentar y discutir los hallazgos endoscópicos e histológicos, así como la incidencia de Helicobacter pylori y otras enfermedades, indicaciones y características de endoscopia digestiva alta realizada en niños. Material y métodos: Fueron realizadas 225 endoscopias en niños de seis meses a 11 años (media de 7,69 años) a partir de febrero de 2013 hasta enero de 2016. En 200 pacientes, en las endoscopias diagnósticas se llevan a cabo biopsias seriadas (esófago, estómago y duodeno) en 120 de ellos. Resultados: La indicación de endoscopia fue diagnóstica en el 88,89% de los pacientes y en 26 pacientes se realizaron un procedimiento terapéutico. Los hallazgos endoscópicos más frecuentes fueron esofagitis en 49 pacientes, gastritis y duodenitis 84 y en 16 pacientes se diagnosticaron cuatro úlceras duodenales. En endoscopias terapéuticas fueron realizadas seis gastrostomías, catorce extracciones de cuerpos extraños, cinco pasajes de sonda nasogástrica y una dilatación esofágica. El estudio de H. pylori se realizó por el método histopatológico y fué positivo en 26 (13%) de 200 pacientes en los que se han buscado. Conclusión: La endoscopía pediátrica es un nicho importante de la endoscopía digestiva donde es importante enfatizar la relevancia de la estructura institucional que realiza estos procedimientos para conducirlos con seguridad y ser capaces de tratar las complicaciones posibles

Rendez-Vous laparoendoscopic after ERCP failure in patient with Billroth II gastrectomy / Laparoscopía por Rendez-Vous luego de falla de CPRE en un paciente con gastectomía Billroth II

Endoscopic retrograde cholangiopancreatography (ERCP) is the treatment of choice in patients with choledocholithiasis. However, despite its high success rate, in some cases it is not successful, requiring alternative therapy. Billroth II partial gastrectomy is a condition associated with an important failure rate of ERCP. When endoscopic treatment fails, surgical exploration of the bile duct is the most common approach. However, the surgery is related to a greater complexity of execution and morbimortality. We describe the case of a patient with choledocholithiasis and Billroth II partial gastrectomy, submitted to the combined treatment called rendez-vous laparoendoscopic, after failure of ERCP, which unites in a single stage the endoscopic treatment of choledocholithiasis and laparoscopic removal of the gallbladder. We conclude that this therapeutic approach was effective, safe, with low cost and without complications.

La colangiopancreatografía endoscópica retrógrada (CPRE) es el tratamiento de elección en pacientes portadores de coledocolitiasis. Sin embargo, a pesar de su elevada tasa de éxito, en algunos casos no es exitosa, exigiendo terapia alternativa. La gastrectomía parcial con reconstrucción a Billroth II es una condición asociada a la importante tasa de fracaso de la CPRE. Cuando el tratamiento endoscópico falla, la exploración quirúrgica de la vía biliar es un enfoque más común. Sin embargo, la cirugía se relaciona con una mayor complejidad de ejecución y morbimortalidad. Describimos el caso de un paciente con coledocolitiasis y gastrectomía parcial con reconstrucción a Billroth II, sometido al tratamiento combinado denominado rendez-vous laparoendoscópico tras fallo de la CPRE, que une en una sola etapa el tratamiento endoscópico de la coledocolitiasis y la retirada laparoscópica de la vesícula biliar. Llegamos a la conclusión de que este enfoque terapéutico fue eficaz, seguro, de bajo costo y sin complicaciones.

Guide wire-assisted cannulation versus conventional contrast to prevent pancreatitis: A systematic review and meta-analysis based on randomized control trials / Canulación asistida por alambre guía versus contraste convencional para prevenir la pancreatitis: Una revisión sistemática y meta-análisis basados en ensayos aleatorios controlados

Objective: Through this systematic review and meta-analysis, we aim to clarify the differences between these two techniques, thus improving primary success cannulation and reducing complications during endoscopic retrograde cholangiopancreatography, primarily pancreatitis. Methods: A comprehensive search was conducted to search for data available up until June2015from the most important databases available in the health field: EMBASE, MEDLINE (via PubMed), Cochrane, LILACS and CENTRAL (via BVS), SCOPUS, the CAPES database (Brazil), and gray literature. Results: Nine randomized clinical trialsincluding2583 people were selected from20,198 studies for meta-analysis. Choledocholithiasis had been diagnosed in mostly (63.8%) of the patients, who were aged an average of 63.15 years. In those patients treated using the guide wire-assisted cannulation technique, provided a significantly lower instance of pancreatitis (RD=0.03; 95% CI: 0.01-0.05; I2= 45%) and greater primary success cannulation (RD=0.07; 95% CI: 0.03-0.12; I2=12%) than conventional contrast cannulation. Conclusions: The guide wire-assisted technique, when compared to the conventional contrast technique, reduces the risk of pancreatitis and increases primary success cannulation rate. Thus, guide wire-assisted cannulation appears to be the most appropriate first-line cannulation technique

Objetivo: A través de esta revisión sistemática y meta-análisis, nuestro objetivo es aclarar las diferencias entre estas dos técnicas, mejorando así la canulación de éxito primario y reducir las complicaciones durante la colangiopancreatografía retrógrada endoscópica, principalmente la pancreatitis. Métodos: Una búsqueda exhaustiva se realizó para buscar datos disponibles hasta junio de 2015, desde las bases de datos más importantes disponibles en el campo de la salud: EMBASE, MEDLINE (vía PubMed), Cochrane, LILACS y CENTRAL (a través de la BVS), SCOPUS, la base de datos CAPES (Brasil), y la literatura gris. Resultados: Nueve ensayos clínicos aleatorios incluyendo 2583 personas fueron seleccionados de 20198 estudios de meta- análisis. Coledocolitiasis había sido diagnosticada en su mayoría (63,8%) de los pacientes, que tenían entre un promedio de 63,15 años. En los pacientes tratados con la técnica de canulación guiada, proporcionado una instancia significativamente menor de pancreatitis (RD=0,03; IC del 95%: 0,01-0,05; I2=45%) y una mayor canalización de éxito primario (RD=0,07; IC del 95%: 0,03-0.12; I2=12%) que la canulación por contraste. Conclusiones: La técnica canulación con alambre guía, en comparación a la técnica de contraste convencional, reduce el riesgo de pancreatitis y aumenta la tasa de canulación con éxito primario. Por lo tanto, canulación con alambre guía parece ser la técnica de canulación de primera línea y la más adecuada

Estudio comparativo entre el uso de manitol y el picosulfato sódico como preparación para colonoscopía / Comparison of colon-cleansing methods in preparation for colonoscopy- comparative of solutions of mannitol and sodium picosulfate

Objetivos: El objetivo del presente estudio es comparar la preparación adecuada del colon con manitol y picosulfato sódico. Evaluar la aceptación de los pacientes, los efectos secundarios y la capacidad de limpieza. Materiales y métodos: Este es un estudio no aleatorio, prospectivo, ciego, en que el evaluador no tenía información sobre la preparación aplicada. La muestra obtenida se dividió en dos grupos de acuerdo con la preparación adecuada del colon, con 153 pacientes preparados con manitol al 10% y 84 pacientes con picosulfato sódico. La evaluación de la preparación se realizó usando la Escala de Boston (Boston Bowel Preparation Scale - BBP) a través de un sistema de puntuación para cada región del colon puntuada con 3 puntos: derecha, izquierda y colon transverso. Resultados: De los 237 pacientes que fueron evaluados, 146 (61,60%) eran mujeres y 91 (38,4%) eran hombres. En el grupo que utilizó manitol, 98 (64,05%) eran mujeres y 55 (35,95%) eran varones. Entre los pacientes que utilizaron picosulfato sódico, 48 (57,14%)eran mujeres y 36 (42,86%) eran hombres, sin diferencias estadísticas de ambos grupos (p>0,32). Teniendo en cuenta que con la adecuada preparación del colon y con puntuación de 6 puntos en la Escala de Boston, la preparación intestinal fue satisfactoria en ambos grupos. El 93% de los pacientes que utilizaron manitol y el 81% de los pacientes que utilizaron picosulfato sódico tenían preparación adecuada (puntuación de 6). La puntuación media en la preparación con manitol fue de 9 y en la preparación con picosulfato sódico fue de 7. No hubo diferencias significativas entre ambos grupos. Conclusión: Ambas preparaciones, demostraron ser seguras y eficaces para la limpieza del intestino, de acuerdo con la Escala de Boston, así como, la aceptabilidad de los pacientes y libre de complicaciones

Objectives: The purpose of the present study is to compare intestinal preparation with mannitol and sodium picosulphate, assessing patient’s acceptance, side effects and cleaning capacity. Material and methods: This is a prospective, nom randomized, blind study, in which the evaluator had no information about the preparation applied. The sample obtained was divided into two groups according to the bowel preparation applied, with 153 patients prepared with 10% mannitol and 84 patients with sodium picosulfate. The evaluation of colon preparation was done using the Boston Scale (Boston Bowel Preparation Scale - BBP) through a three-point scoring system for each of the three regions of the colon: right, left and transverse colon. Results: Of the 237 patients that were evaluated, 146 (61.60%) were female and 91 (38.4%) were male. Regarding the group that used mannitol, 98 were female (64.05%) and 55 were male (35.95%). Among the patients who used sodium picosulfate, 48 were female (57.14%) and 36 were male (42.86%), with no statistical differences between both groups (p> 0.32). Considering that an adequate preparation scores ≥ 6 in the Boston Scale, the bowel cleansing preparation was satisfactory in both groups. 93% of the patients who used mannitol and 81% of the patients who used sodium picosulfate had adequate preparation (score of ≥ 6). Moreover, we consider that the average score in the preparation with Mannitol was 9, while the sodium picosulfate score was 7. There were no significant differences between the two groups. Conclusion: There is consensus among authors who state that colonoscopy’s safety and success are highly related to the cleansing outcome, regardless of the method used. The same can be observed in the present study, on which both preparations were proved safe and effective for bowel cleansing, according to the Boston scale, as well as accepted by patients and free of complications

Endoscopic ultrasonography-guided common bile duct stone removal.

Endoscopic ultrasonography has become an important diagnostic and therapeutic tool in endoscopy units. It has a great impact on biliary and pancreatic disease management and its application to retrograde cholangiopancreatography is appealing, although very challenging with current devices. In this article we describe our initial experience with this technique.

Dilataciones endoscópicas del tracto gastrointestinal / Endoscopic dilation of the gastrointestinal tract

Las dilataciones en el tracto gastrointestinal se llevan a cabo para aliviar la obstrucción sintomática, ya sea funcional u orgánica, secundarias a una variedad de patologías tanto benignas como malignas. Con el advenimiento de las nuevas tecnologías, virtualmente toda estenosis digestiva puede ser manejada en forma mínimamente invasiva. Pese a su amplia difusión en la práctica actual, existen pocos estudios controlados que comparen las diferentes modalidades de dilatación. En el presente artículo realizamos una revisión de esta técnica, así como de la evidencia disponible para su aplicación en los diferentes segmentos del tracto gastrointestinal. El futuro de la dilatación incluye el desarrollo de dilatadores que permitan evaluar la dilatación durante su realización. Estos advenimientos, así como la ejecución de estudios controlados prospectivos van a mejorar las indicaciones, beneficios y riesgos para cada uno de los sistemas de dilatación existentes.

The endoscopic dilation of the gastrointestinal tract is carried out to relieve either functional or organic disorders, secondary to a variety of both benign and malignant diseases. With the advent of new technologies, virtually all digestive stenosis can be managed in a minimally invasive way. Despite its wide dissemination in actual practice, there are few controlled studies comparing the different forms of endoscopic dilation. In this article, we review this technique and the evidence available for application in different segments of the gastrointestinal tract. The future of the dilations includes the development of dilators to assess dilation during the procedure. These advents and the implementation of prospective controlled studies will improve the indications, benefits and risks for each of the existing systems of dilations.

Difficult cannulation: what should I do before EUS guided access? / Canulación difícil: ¿qué hacer antes de acceso guiado por EUS?

Selective cannulation of the common bile duct can be difficult, so multiple strategies have been developed to overcome the situation. In this review we analize the different strategies that can be used like different papillotome instead of the standard catheter, precut papillotomy using precut needle knives or precut papillotome, transpancreatic papillary septotomy, and stenting of the pancreatic duct. Bile duct cannulation remains an important benchmark of successful ERCP. Alternative biliary access indication and its use is very important If biliary cannulation remains unsuccessful.The suprapapillary puncture is a promissory technique. It´s important to have in mind that the goal of all techniques is to provide acute pancreatitis decrease.

La canulación selectiva del conducto biliar común puede ser difícil por eso se han desarrollado diferentes estrategias para disminuir esta dificultad. La presente revisión analiza el uso de papilótomos diferentes en lugar del catéter estándar, la papilotomía con pre corte usando cuchillos o papilótomos, la septotomía papilar transpancreática y el uso de stents. La canulación biliar sigue siendo el factor más importante para considerar una ERCP como exitosa. Las indicaciones de accesos biliares alternativos y su uso es muy importante si esta falla. La punción suprapapilar es una técnica promisoria. Es importante tener en cuenta que la meta de todas las técnicas es disminuir la ocurrencia de pancreatitis aguda.

A review on endoscopic palliation of obstructive jaundice before surgery / Una revisión de la paliación endoscópica de la ictericia obstructiva antes de la cirugía

Since its development, endoscopic retrograde cholangiopancreatography (ERCP) has evolved from a simple diagnostic technique to an important therapeutic procedure. Obstructive jaundice is often the first and most common complication in patients with malignant disease of the extrahepatic biliary tract. Although preoperative biliary drainage (PBD) may be instituted in many centers, different studies have reported divergent results regarding its benefits in reducing the complications of hepatopancreatobiliary surgery, especially with regard to pancreatoduodenectomy for pancreatic cancer. In this review, we will summarize the current literature of PBD and describe its indications, possible benefits, and, when indicated, the appropriate interval before surgery.

Desde su desarrollo, la colangiopancreatografía retrógrada endoscópica ha evolucionado de una técnica puramente diagnóstica a un procedimiento netamente terapeútico. La ictericia obstructiva es a menudo la primera y más común de las complicaciones en los pacientes con enfermedad maligna de la vía biliar extrahepática. Aunque el drenaje biliar preoperatorio (DBP) puede ser realizado en múltiples centros, diferentes estudios han reportado resultados divergentes con respecto a sus beneficios en la reducción de las complicaciones de la cirugía biliopancreática, especialmente con respecto a duodenopancreatectomía para el cáncer de páncreas. En esta revisión, resumimos la literatura actual del DBP y describimos sus indicaciones, posibles beneficios y cuando esté indicado, el intervalo apropiado antes de la cirugía.

Metastasis of breast cancer to major duodenal papilla / Metástasis del cáncer de mama a la papila mayor duodenal

Metastasis is an infrequent cause of tumor involvement of the major duodenal papilla and of cholestasis. We report a case of obstructive jaundice due to a metastatic breast carcinoma to the major duodenal papilla, and assess curative and palliative treatment that interventional endoscopy can offer.

La metástasis es una causa infrecuente de compromiso de la papila mayor y colestasis. Reportamos una causa rara de ictericia causada por metástasis de cáncer de mama en la papilla mayor duodenal.

Prótesis metálica en paliación del cáncer avanzado del colon / Metal prosthesis for palliation of advanced colon cancer

La colocación de un stent de colon es una nueva herramienta que alcanza dos objetivos: crear un puente para preparar al paciente de forma segura con miras a un procedimiento quirúrgico y / o la paliación definitiva en los casos en que la condición clínica no permite otra intervención. El análisis de costo-beneficio favorece las ventajas de la intervención endoscópica con stent al evaluar los nuevos modelos de prótesis; sin embargo, otros factores deben tenerse en cuenta para adaptar localmente esta intervención como la infraestructura hospitalaria, la necesidad de personal entrenado, el seguimiento y el análisis costo-efectividad. En este contexto, un enfoque multidisciplinario y la aprobación de una Junta Institucional deben asegurarse en todos los casos. Evidentemente, los resultados a corto y largo plazo, así como el un adecuado seguimiento, se verán fortalecidos por el diseño de estudios prospectivos.

The colonic stent placement is a new tool reaching two intends: creating a bridge to prepare the patient safely to the surgical procedure and/or definite palliation in those cases in which the clinical condition is not feasible. The cost-benefit analysis push advantages to the endoscopic assess with new models of stents, however another endpoints should be raised such as Hospital structure, trained nurses, follow up and cost effectiveness conditions according to the regional policy. In this context, a multidisciplinary approach and Institutional review board approval should be stated in all cases. Obviously, short and long term results solidified by a follow up could be designing prospective studies.