RESUMEN
In patients with malignant distal biliary obstruction, drainage via Endoscopic Ultrasound-guided Choledochoduodenostomy (EUS-CDS) is indicated in clinical guidelines following a failed Endoscopic Retrograde Cholangiopancreatography (ERCP). However, current interest lies in evaluating its role as a first-line treatment. Through this letter, we present a case report that represents this clinical scenario, as well as a brief summary of the most recent literature supporting the use of EUS-CDS as a first-line treatment for malignant distal biliary obstruction.
RESUMEN
Acute pancreatitis is associated with significant morbidity and mortality. It can develop complications such as fluid collections and necrosis. Infection of necrosis occurs in about 20-40 % of patients with severe acute pancreatitis, and is associated with organ failure and worse prognosis. In the past few years the treatment of pancreatic collections has shifted from open surgery to minimally invasive techniques such as endoscopic ultrasound-guided drainage. These guidelines from a selection of experts among the Endoscopic Ultrasound Group, Spanish Society of Gastrointestinal Endoscopy (GSEED-USE) are intended to provide advice on the management of pancreatic collections based on a thorough review of the available scientific evidence. It also reflects the experience and clinical practice of the authors, who are advanced endoscopists or clinical pancreatologists with extensive experience in managing patients with acute pancreatitis.
Asunto(s)
Endosonografía , Pancreatitis , Humanos , Endosonografía/métodos , Pancreatitis/diagnóstico por imagen , Pancreatitis/terapia , Drenaje/métodos , Endoscopía del Sistema Digestivo/métodos , EspañaRESUMEN
Endoscopic retrograde cholangiopancreatography (ERCP) is the technique of choice for the treatment of biliopancreatic pathology. However, fluoroscopic imaging does not always allow an adequate diagnosis. On the other hand, some large stones cannot be removed by the usual methods. In these situations, cholangioscopy has proven to be an essential tool for the diagnosis of biliary strictures and the treatment of large stones. Its role in pancreatic pathology is also increasing. The development of a single-operator, disposable cholangioscope has made it possible to expand the technique to a large number of hospitals that perform ERCP. For this reason, the Spanish Society of Digestive Endoscopy has developed this consensus document on the use of the Spyglass-DS cholangioscope. The document has been prepared by a group of endoscopists with expertise in cholangioscopy, reviewing the scientific evidence on the main current indications for cholangiopancreatoscopy.
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Colangiopancreatografia Retrógrada Endoscópica , Colestasis , Humanos , Consenso , Colangiopancreatografia Retrógrada Endoscópica/métodos , Endoscopía Gastrointestinal , PáncreasRESUMEN
BACKGROUND AND AIMS: over-the-scope-clips (OTSC®) have been proposed as a rescue treatment for bleeding peptic ulcers. However, their effectiveness has not been evaluated in Spain. METHODS: this retrospective and single-center study (January 2018-December 2021) assessed the technical success, clinical success and safety of the device within 30 days. All patients with upper gastrointestinal bleeding due to a peptic ulcer and treated with the OTSC® clip (OVESCO) as a rescue therapy were included in the study. RESULTS: a total of eleven patients were included in the study, nine due to rebleeding and two due to persistent bleeding. Technical success was 81.9 % (9/11, confidence interval [CI] 95 %: 52-95 %). The per-protocol and intention-to-treat clinical success were 88.9 % (8/9, CI 95 %: 57-98 %) and 72.7 % (8/11, CI 95 %: 43-90 %), respectively. No device-related adverse effects were recorded. CONCLUSION: the OTSC® clip was an effective and safe rescue therapy for bleeding peptic ulcers.
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Hemostasis Endoscópica , Úlcera Péptica , Humanos , Hemostasis Endoscópica/efectos adversos , Hemostasis Endoscópica/métodos , Estudios Retrospectivos , Endoscopía Gastrointestinal/métodos , Resultado del Tratamiento , Hemorragia Gastrointestinal/etiología , Hemorragia Gastrointestinal/cirugía , Úlcera Péptica/complicaciones , Úlcera Péptica/terapia , Instrumentos QuirúrgicosRESUMEN
BACKGROUND: It is unclear whether the insertion of an axis-orienting double-pigtail plastic stent (DPS) through biliary lumen-apposing meal stent (LAMS) in EUS-guided choledochoduodenostomy (CDS) improves the stent patency. The aim of this study is to determine whether this technical variant offers a clinical benefit in EUS-guided biliary drainage (BD) for the management of distal malignant biliary obstruction. METHODS/DESIGN: This is a multicenter open-label, randomized controlled trial with two parallel groups. Eighty-four patients with malignant biliary obstruction will undergo EUS-BD (CDS type) using LAMS in 7 tertiary hospitals in Spain and will be randomized to the LAMS and LAMS plus DPS groups. The primary endpoint is the rate of recurrent biliary obstruction, as a stent dysfunction parameter, detected during follow-up. Secondary endpoints: technical and clinical success (reduction in bilirubin > 50% within 14 days of stent placement), safety, and others (number of reinterventions, time to biliary obstruction, prognostic factors, survival rate). DISCUSSION: The BAMPI trial has been designed to determine whether the addition of a coaxial axis-orienting DPS through LAMS is superior to LAMS alone to prevent stent dysfunction. TRIAL REGISTRATION: ClinicalTrials.gov NCT04595058 . Registered on October 14, 2020.
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Colestasis , Endosonografía , Colestasis/diagnóstico por imagen , Colestasis/etiología , Colestasis/cirugía , Drenaje/métodos , Endosonografía/métodos , Humanos , Estudios Multicéntricos como Asunto , Ensayos Clínicos Controlados Aleatorios como Asunto , Stents , Ultrasonografía Intervencional/métodosRESUMEN
BACKGROUND & AIMS: Management of delayed (within 30 days) postpolypectomy bleeding (DPPB) has not been standardized. Patients often undergo colonoscopies that do not provide any benefit. We aimed to identify factors associated with therapeutic intervention and active bleeding after DPPB. METHODS: We performed a retrospective study of 548 patients with bleeding within 30 days after an index polypectomy (DPPB; 71.9% underwent colonoscopy, 2.6% underwent primary angiographic embolization, and 25.5% were managed without intervention) at 6 tertiary centers in Spain, from January 2010 through September 2018. We collected demographic and medical data from patients. The primary outcomes were the need for therapeutic intervention and the presence of active bleeding during colonoscopy. RESULTS: A need for therapeutic intervention was associated independently with the use of antithrombotic agents, hemoglobin decrease greater than 2 g/dL, hemodynamic instability, and comorbidities (P < .05). The bleeding point during colonoscopy was identified in 344 patients; 74 of these patients (21.5%) had active bleeding. Active use of anticoagulants (odds ratio [OR], 2.6; 95% CI, 1.5-4.5), left-sided polyps (OR, 1.95; 95% CI, 1-3.8), prior use of electrocautery (OR, 2.6; 95% CI, 1.1-6.1), and pedunculated polyp morphology (OR, 1.8, 95% CI, 1-3.2) significantly increased the risk of encountering active bleeding. We developed a visual nomogram to estimate the risk of active bleeding. Overall, 43% of the cohort did not require any hemostatic therapy. Rebleeding (<6%) and transfusion requirements were low in those managed without intervention. CONCLUSIONS: In a study of patients with DPPB, we found that almost half do not warrant any therapeutic intervention. Colonoscopy often is overused for patients with DPPB. We identified independent risk factors for active bleeding that might be used to identify patients most likely to benefit from colonoscopy.
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Pólipos del Colon , Estudios de Cohortes , Pólipos del Colon/cirugía , Colonoscopía , Hemorragia Gastrointestinal , Humanos , Hemorragia Posoperatoria , Estudios RetrospectivosRESUMEN
Pancreatic fluid collections frequently occur in the context of moderate and severe acute pancreatitis, and may also appear as a complication of chronic pancreatitis, pancreatic surgery or trauma. It is essential to adhere to the Atlanta classification nomenclature that subclassifies them into four categories (acute peripancreatic fluid collections, acute necrotic collections, pseudocysts, and walled-off necrosis) since it has an impact on prognosis and management. Pseudocysts and walled-off pancreatic necrosis are encapsulated pancreatic fluid collections characterized by a surrounding inflammatory wall, which typically develops three to four weeks after the onset of acute pancreatitis. Most pancreatic fluid collections resolve spontaneously and do not require intervention. However, when they become symptomatic or complicated drainage is indicated, and endoscopic ultrasound-guided drainage has become first-line treatment of encapsulated collections. Drainage of pseudocysts is relatively straightforward due to their liquid content. However, in walled-off necrosis the presence of solid necrotic debris can make treatment more challenging and therefore multidisciplinary management in experienced centers is recommended, being a step-up approach the current standard of care. In this review, we aim to address the management of pancreatic fluid collections with an especial focus on endoscopic drainage.
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Seudoquiste Pancreático , Pancreatitis Aguda Necrotizante , Enfermedad Aguda , Drenaje , Humanos , Seudoquiste Pancreático/diagnóstico por imagen , Seudoquiste Pancreático/terapiaRESUMEN
Background and study aims Endoscopic ultrasound (EUS)-guided drainage has become first-line treatment for pancreatic fluid collections (PFC). The aim of this study was to compare the effectiveness and safety of biliary fully-covered self-expandable metal stents (BFCSEMS) and lumen-apposing metal stents with electrocautery (EC-LAMS). Patients and methods From April 2008 to March 2017, consecutive patients with symptomatic PFC drained under EUS-guidance with metal stents were included. Patients drained with EC-LAMS were considered the study group and those drained with BFCSEMS the control group.âTwo primary endpoints were evaluated: effectiveness (defined as reduction ofâ≥â50â% of PFC size in cross-sectional imaging and improvement of symptoms 6 months after the transmural drainage) and safety. Results Thirty patients were drained with EC-LAMS and 60 patients with BFCSEMS.âPatients and PFC baseline characteristics in both groups were similar. Use of a coaxial double pigtail plastic stent and a nasocystic lavage catheter was significantly less frequent in patients drained with EC-LAMS (33â% vs. 100â%, and 13â% vs. 58â%, respectively; P â<â0.0001). Technical success was 100â% in both groups. Procedure time wasâ<â30 minutes in all patients drained with EC-LAMS and over 30 minutes in all patients drained with BFCSEMS ( P â=â0.0001). Clinical success was higher with a tendency to significance in patients drained with EC-LAMS (96â% vs. 82â%, P â=â0.055) and the adverse event rate was lower (4â% vs. 18â%, P â=â0.04). No case of procedure-related mortality was recorded. Conclusions EC-LAMS and BFCSEMS are both effective for EUS-guided drainage of PFC. However, EC-LAMS requires less time to be performed and appears to be safer.
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INTRODUCTION: In Europe, gastric adenocarcinoma (GADC) is commonly regarded as a disease of the elderly. This study aims to assess the proportion, characteristics, and survival of patients diagnosed with GADC under the age of 60. MATERIALS AND METHODS: This is a retrospective, multicentric, and analytical study conducted at four tertiary Spanish hospitals. All patients diagnosed with GADC between 2008 and 2015 were included. Demographic, clinical, endoscopic, histologic, and survival data were retrieved. A multivariate analysis was performed to compare GADC in young (age≤60 years) and elderly patients. RESULTS: A total of 1374 patients with GADC were included. The mean age was 74 years (SD:11.1); 62.2% were males. There were 177 patients under the age of 60 (12.9%, 95% CI: 11.2-14.8%). GADC was frequently encountered as a metastatic disease in both young and elderly patients (Stage IV: 45.7% and 41%, respectively). In the multivariate analysis, alcohol abuse, ASA functional status I-II, diffuse subtype, neoadjuvant, and palliative therapy were independently associated (P<0.05) with age ≤60 years. No differences were found in 2-year survival (GADC ≤60: 39% vs. 35%, P=0.45). Curative-intent surgery, TNM stage I-II, body mass index<30kg/m2, and better functional status at diagnosis were independent predictors of survival in GADC under the age of 60. CONCLUSIONS: One out of eight cases of GADC were diagnosed under the age of 60. Metastatic disease was frequent at diagnosis and overall survival was poor regardless of age. Factors associated with localized disease correlated with improved survival in younger patients. Our results underline the need for early diagnosis strategies in our country.
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Adenocarcinoma , Neoplasias Gástricas , Adenocarcinoma/diagnóstico , Adenocarcinoma/mortalidad , Adenocarcinoma/terapia , Factores de Edad , Anciano , Anciano de 80 o más Años , Femenino , Humanos , Masculino , Persona de Mediana Edad , Estudios Retrospectivos , España/epidemiología , Neoplasias Gástricas/diagnóstico , Neoplasias Gástricas/mortalidad , Neoplasias Gástricas/terapia , Análisis de Supervivencia , Tasa de SupervivenciaRESUMEN
Intraductal papillary neoplasm of the bile duct (IPNB) is a rare entity characterized by papillary growth within the bile duct lumen1, currently regarded as a biliary counterpart of intraductal papillary mucinous neoplasm of the pancreas. The most common clinical findings are abdominal pain, jaundice or cholangitis, although some patients are asyntomatic. The diagnosis requires careful assessment of imaging findings and cito-histological evaluation, with endoscopic ultrasound guided fine needle aspiration (EUS-FNA) playing a very important role. IPNB is a premalignant lesion which can evolve into invasive cholangiocarcinom. A radical treatment strategy should be planned accordingly.
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Adenocarcinoma Mucinoso/diagnóstico por imagen , Carcinoma Papilar/diagnóstico por imagen , Neoplasias del Conducto Colédoco/diagnóstico por imagen , Neoplasias de la Vesícula Biliar/diagnóstico por imagen , Anciano de 80 o más Años , Constricción Patológica/diagnóstico por imagen , Endosonografía , Femenino , Conducto Hepático Común/diagnóstico por imagen , Humanos , Imagen por Resonancia MagnéticaRESUMEN
BACKGROUND: Population aging and comorbidity are leading to an increase in patients unfit for cholecystectomy. AIMS: To evaluate whether endoscopic biliary sphincterotomy after a first episode of acute gallstone pancreatitis reduces the risk of pancreatitis recurrence and gallstone-related events in non-surgical candidates. METHODS: Retrospective study of patients admitted for a first episode of acute gallstone pancreatitis rejected for cholecystectomy between 2013-2018. The role of endoscopic sphincterotomy was evaluated by adjusting for age, severity of pancreatitis, and presence of choledocholithiasis. RESULTS: We included 247 patients (mean age 80⯱â¯12â¯years; Charlson index: 5; severity of pancreatitis: 72% mild). Sphincterotomy was performed in 23.9%. Recurrence of pancreatitis occurred in 17.4% patients (median follow-up: 426â¯days). The one-year cumulative incidence of a new episode of pancreatitis was 1.8% (95% confidence interval [CI]: 0.2-12%) and 23% (95% CI: 17-31%) in patients with and without sphincterotomy, respectively (pâ¯=â¯0.006). In multivariate analysis, sphincterotomy showed a protective role for recurrence of pancreatitis (adjusted hazard ratio [HR]: 0.29, 95% CI: 0.08-0.92, pâ¯=â¯0.037) and for any gallstone-related event (HR 0.46, 95% CI: 0.21-0.98, pâ¯=â¯0.043). CONCLUSIONS: Endoscopic biliary sphincterotomy reduced the risk of gallstone pancreatitis recurrence and other biliary-related disorders in patients with a first episode of pancreatitis non-candidates for cholecystectomy.
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Cálculos Biliares/cirugía , Pancreatitis/cirugía , Esfinterotomía Endoscópica/métodos , Anciano , Anciano de 80 o más Años , Colangiopancreatografia Retrógrada Endoscópica , Colecistectomía Laparoscópica , Coledocolitiasis/etiología , Coledocolitiasis/cirugía , Femenino , Cálculos Biliares/etiología , Humanos , Incidencia , Masculino , Pancreatitis/epidemiología , Pancreatitis/etiología , Modelos de Riesgos Proporcionales , Recurrencia , Estudios Retrospectivos , Factores de Riesgo , España/epidemiología , Centros de Atención Terciaria , Factores de Tiempo , Resultado del TratamientoAsunto(s)
Drenaje/efectos adversos , Endosonografía/efectos adversos , Hemorragia Gastrointestinal/etiología , Ultrasonografía Intervencional/efectos adversos , Anciano de 80 o más Años , Carcinoma Hepatocelular/complicaciones , Colecistitis Aguda/complicaciones , Colecistitis Aguda/cirugía , Colecistostomía , Colelitiasis/complicaciones , Colelitiasis/cirugía , Drenaje/métodos , Úlcera Duodenal/complicaciones , Embolización Terapéutica , Hemorragia Gastrointestinal/terapia , Técnicas Hemostáticas , Humanos , Neoplasias Hepáticas/complicaciones , Masculino , Cuidados Paliativos , Úlcera Péptica Hemorrágica/etiología , Úlcera Péptica Hemorrágica/terapia , Soluciones Esclerosantes/uso terapéutico , Escleroterapia , Choque/etiología , Choque Séptico/etiología , Stents , Ultrasonografía Intervencional/métodosRESUMEN
INTRODUCTION: endoscopic ultrasound (EUS) is a highly useful technique for the diagnosis and management of different gastrointestinal (GI) tract conditions. OBJECTIVE: to prospectively assess the clinical usefulness of a novel forward-viewing echoendoscope (FV-CLA). METHODS: this was a cross-sectional observational study. All patients that underwent EUS over a two-month period were considered for the study. All mediastinal, perigastric and periduodenal stations were consistently assessed with a rating from 0 to 10 points with regard to the ease to obtain ultrasonographic sections and the quality of ultrasound images. The identified lesions were punctured when clinically indicated. RESULTS: a total of 45 patients were included. EUS was completed in 100% of patients, with two minor complications recorded. Echoendoscope maneuverability was graded as "A" (9-10 points), overall plane visibility was graded as "B" (7-8 points) and only stations 4L and 5 visualization were graded as "D" (< 7 points). Visualization of the pancreas and the rest of the EUS stations were rated as excellent or very good. The feasibility to perform EUS-FNA, even from the second portion of the duodenum, was graded excellent or very good. CONCLUSION: the FV-CLA allows a complete, high-quality examination of the upper GI tract, including EUS-FNA punctures. Some mediastinal stations are hardly accessible with this new device. A formal validation of the FV-CLA for EUS-guided therapy would be of interest.
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Endoscopios , Endosonografía/instrumentación , Enfermedades Gastrointestinales/diagnóstico por imagen , Adulto , Anciano , Anciano de 80 o más Años , Estudios Transversales , Femenino , Humanos , Masculino , Persona de Mediana Edad , Estudios ProspectivosRESUMEN
INTRODUCTION: Endoscopic papillary large balloon dilatation (EPLBD) is an alternative for the treatment of common bile duct (CBD) stones. Existing evidence of factors associated with its outcomes is contradictory. OBJECTIVE: To identify predictors (including the experience of an endoscopist) of success and adverse events in EPLBD. METHODS: We reviewed the first 200 EPLBD with endoscopic sphincterotomy (EST) performed at our center. Demographic, clinical, and anatomic variables were studied, as well as the performance characteristics, correlating them with individual and group experience. RESULTS: Global success was obtained in 87% of cases, and adverse events occurred in 16% of cases. Success was associated with stone size, CBD diameter, and the need to perform mechanical lithotripsy (ML). Despite that adverse events were not univariately associated with any factor, severe adverse events were more likely to occur in stones > 13.5 mm. Multivariate analysis which disclosed success was higher when ML was not required and stones were < 13.5 mm. It also showed that no factor was associated with adverse events or their severity. No differences were found on success or adverse events that could be directly related to experience. CONCLUSIONS: Success of EPLBD-EST is higher in stones < 13.5 mm and when ML is not required. Experience does not appear to play a major role.
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INTRODUCTION: Recurrent Clostridium difficile infection (CDI) is common and often difficult to manage. Faecal microbiota transplant (FMT) is an effective therapeutic tool in these cases, although its applicability and effectiveness in Spain is currently unknown. AIM: To analyse the technical aspects, safety and effectiveness of the first consolidated FMT programme in Spain. METHODS: Retrospective descriptive study of all patients with recurrent CDI treated with FMT performed by colonoscopy in a tertiary centre after the implementation of a multidisciplinary protocol between March 2015 and September 2016. RESULTS: A total of 13 FMT were performed in 12 patients (11/12; 91.7% women) with a median age of 84.6 years (range: 38.2-98.2). Recurrence of CDI was the indication for FMT in all cases. Patients had suffered a median of 3 previous episodes of CDI (range: 2-6) and all had failed treatment with fidaxomicin. All procedures were performed by colonoscopy. Effectiveness with one session of FMT was 91.7% (11/12; 95% CI: 64.6 to 98.5%). In the non-responder patient, a second FMT was performed 17 days after the first procedure, with disappearance of symptoms. No side effects related to the endoscopic procedure or the FMT were recorded after a median follow-up of 6.5 months (range: 1-16 months). Two patients died during follow-up due to causes unrelated to FMT. CONCLUSION: FMT by colonoscopy is an effective and safe therapeutic alternative in recurrent CDI. It is a simple procedure that should be implemented in more centres in Spain.
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Infecciones por Clostridium/terapia , Colonoscopía , Trasplante de Microbiota Fecal/métodos , Adulto , Anciano , Anciano de 80 o más Años , Trasplante de Microbiota Fecal/efectos adversos , Femenino , Humanos , Persona de Mediana Edad , Evaluación de Programas y Proyectos de Salud , Recurrencia , Estudios Retrospectivos , Resultado del TratamientoAsunto(s)
Hemorragia Gastrointestinal/etiología , Pancreatitis Aguda Necrotizante/complicaciones , Dolor Abdominal/etiología , Adulto , Anticoagulantes/efectos adversos , Anticoagulantes/uso terapéutico , Enfermedades del Ciego/etiología , Angiografía por Tomografía Computarizada , Embolización Terapéutica , Hemorragia Gastrointestinal/diagnóstico por imagen , Hematoma/diagnóstico por imagen , Hematoma/etiología , Heparina de Bajo-Peso-Molecular/uso terapéutico , Humanos , Perforación Intestinal/etiología , Masculino , Isquemia Mesentérica/diagnóstico por imagen , Isquemia Mesentérica/tratamiento farmacológico , Isquemia Mesentérica/etiología , Rotura Espontánea , Síndrome de Respuesta Inflamatoria Sistémica/complicacionesAsunto(s)
Biopsia con Aguja/métodos , Carcinoma de Células de Merkel/secundario , Endosonografía , Biopsia Guiada por Imagen , Neoplasias Pancreáticas/secundario , Anciano , Protocolos de Quimioterapia Combinada Antineoplásica/uso terapéutico , Carboplatino/administración & dosificación , Carcinoma de Células de Merkel/diagnóstico por imagen , Carcinoma de Células de Merkel/patología , Carcinoma de Células de Merkel/terapia , Terapia Combinada , Etopósido/administración & dosificación , Humanos , Metástasis Linfática , Masculino , Recurrencia Local de Neoplasia/radioterapia , Recurrencia Local de Neoplasia/cirugía , Cuidados Paliativos , Neoplasias Pancreáticas/diagnóstico por imagen , Neoplasias Pancreáticas/tratamiento farmacológico , Neoplasias Pancreáticas/patología , Radioterapia Adyuvante , Neoplasias Cutáneas/radioterapia , Neoplasias Cutáneas/cirugía , Ultrasonografía IntervencionalRESUMEN
Autoimmune pancreatitis is a benign fibroinflammatory disease of the pancreas of probable autoimmune origin, which includes 2 different phenotypes: type 1 (lymphoplasmacytic sclerosing pancreatitis) and type 2 (idiopathic duct-centric pancreatitis). Its clinical presentation as obstructive jaundice in patients with a pancreatic mass is common and therefore it must be included in the differential diagnosis of pancreatic neoplasia. Many diagnostic criteria have been described throughout history. The most famous are the HISORT criteria of the Mayo Clinic and the international consensus criteria of 2011. One of the main features of autoimmune pancreatitis is its dramatic response to steroid therapy, without the need for surgical treatment. Knowledge of this disease can dramatically change the management of patients with obstructive jaundice, who would otherwise be subjected to a pancreaticoduodenectomy.