Massive spontaneous portosystemic shunt is a solid, easily identifiable prognostic factor in patients with cirrhosis.

OBJECTIVES: Spontaneous portosystemic shunts (SPSSs) are associated with complications and death in cirrhosis. We evaluated chronic portosystemic encephalopathy (CPSE) and survival in cirrhotic patients with massive (>10 mm diameter) SPSS (MSPSS). METHODS: We have retrospectively compared 77 cirrhotic patients with MSPSS and 77 paired-matched patients without SPSS. RESULTS: More patients with MSPSS presented with CPSE (40.3% vs. 20.8%, P = 0.010) or died (33.8% vs. 18.2%, P = 0.039). Model for Endstage Liver Disease (MELD) score [hazard ratio (HR) 1.146, 95% confidence interval (CI) 1.099-1.195], follow-up (FU) ascites (HR 5.128, 95% CI 2.396-10.973) and age (HR 1.048, 95% CI 1.017-1.080) were associated with CPSE; and MELD score (HR 1.082, 95% CI 1.035-1.131), FU renal failure (HR 9.319, 95% CI 3.595-24.158), and FU ascites (HR 4.320, 95% CI 1.615-11.555) were associated with death. Liver function worsened faster in the MSPSS group. Among patients with better liver function (MELD < 11.5), MSPSS patients presented worse survival (P = 0.048, Breslow test). Comparing patients by the Child-Pugh group, we did not find differences in survival; in patients from Child-Pugh group B + C, the MSPSS group presented less time free of CPSE (P < 0.05, log-rank test). Patients with splenorenal MSPSS presented better survival (P = 0.04, log-rank test), and patients with umbilical MSPSS had shorter time free of CPSE (P < 0.016, log-rank test). CONCLUSION: MSPSS increased CPSE and death risks during long FU. Even with better liver function (MELD < 11.5), MSPSS was associated with lower survival. Splenorenal MSPSS presented better survival and the umbilical type was associated with shorter time free of CPSE.

Endoscopic ultrasonography-guided celiac plexus neurolysis in patients with unresectable pancreatic cancer: An update.

Pancreatic cancer produces disabling abdominal pain, and the pain medical management for pancreatic cancer is often challenging because it mainly relies on the use of narcotics (major opioids). However, opioids often provide suboptimal pain relief, and the use of opioids can lead to patient tolerance and several side effects that considerably reduce the quality of life of pancreatic cancer patients. Endosonography-guided celiac plexus neurolysis (EUS-CPN) is an alternative for pain control in patients with nonsurgical pancreatic cancer; EUS-CPN consists of the injection of alcohol and a local anesthetic into the area of the celiac plexus to achieve chemical ablation of the nerve tissue. EUS-CPN via the transgastric approach is a safer and more accessible technique than the percutaneous approach. We have reviewed most of the studies that evaluate the efficacy of EUS-CPN and that have compared the different approaches that have been performed by endosonographers. The efficacy of EUS-CPN varies from 50% to 94% in the different studies, and EUS-CPN has a pain relief duration of 4-8 wk. Several factors are involved in its efficacy, such as the onset of pain, previous use of chemotherapy, presence of metastatic disease, EUS-CPN technique, type of needle or neurolytic agent used, etc. According to this review, injection into the ganglia may be the best technique, and a good visualization of the ganglia is the best predictor for a good EUS-CPN response, although more studies are needed. However, any of the 4 different techniques could be used to perform EUS-CPN effectively with no differences in terms of complications between the techniques, but more studies are needed. The effect of EUS-CPN on pain improvement, patient survival and patient quality of life should be evaluated in well-designed randomized clinical trials. Further research also needs to be performed to clarify the best time frame in performing a EUS-CPN.

A combined endoscopy and laparoscopic approach for a gastric perforation due to intragastric balloon insertion.

We present a case report of a combined endoscopy and laparoscopy approach of gastric perforation secondary to an intragastric balloon insertion. Endoscopy approach may be useful in order to achieve balloon's extraction and to perform perforation delimitation for primary closure, thus avoiding total or partial gastrectomy.