Factors Affecting the Learning Curve in the Endoscopic Ultrasound-Guided Sampling of Solid Pancreatic Lesions: A Prospective Study.

Background/Aims: Endosonography is associated with a long learning curve. We aimed to assess variables that may influence the diagnostic outcomes in endoscopic ultrasound-guided fine-needle aspiration/biopsy (EUS-FNA/B) of solid pancreatic tumors regarding the level of endoscopists' experience. Methods: Consecutive patients undergoing EUS-guided puncture of solid pancreatic tumors (eight endosonographers, including six trainees) were prospectively enrolled. An experienced endosonographer was defined as having performed at least 250 EUS examinations, including 75 FNA/Bs. The final diagnosis was determined by cytopathology, histopathology, or clinical follow-up. Results: In total, 283 EUS-FNA/Bs of solid pancreatic tumors (75.6% malignant) in 239 patients (median age 69 years, 57.6% males) were enrolled. Trainees performed 149/283 (52.7%) of the interventions. Accuracy and sensitivity for detecting malignancy were significantly higher in the expert group than in the trainee group (85.8% vs 73.2%, p=0.01 and 82.5% vs 68.4%, p=0.02). Solid lesions evaluated by an expert using FNB needles showed the best odds for a correct diagnosis (odds ratio, 3.07; 95% confidence interval, 1.15 to 8.23; p=0.02). More experienced endoscopists achieved better accuracy in sampling via the transduodenal approach (86.7% vs 68.5%, p<0.001), in the sampling of malignant lesions (82.5 vs 68.4, p=0.02), and in the sampling of lesions located in the pancreatic head (86.1 vs 69.1, p=0.02). In cases involving these factors, we observed a moderate improvement in the diagnostic accuracy after 40 attempts. Conclusions: Transduodenal approach, pancreatic head lesions, and malignancy were recognized as the most important clinical factors affecting the learning curve in EUS-FNA/B of solid pancreatic lesions.

Impact of endoscopist experience, patient age and comorbidities on dose of sedation and sedation-related complications by endoscopic ultrasound.

AIM: The aim of the study is to investigate the influence of endosonographer experience and patient-related factors on the dose of sedation and sedation-related complications during endoscopic ultrasound (EUS). METHODS: Our retrospective analysis included EUS investigations performed between 2015 and 2018 at our institution. Sedation-related complications were defined as cardiorespiratory instability with oxygen saturation drop below 90% or prolonged low blood pressure or bradycardia. RESULTS: In total, 537 EUS examinations were analyzed (37.3% interventional). The median dose of propofol and midazolam were: 140 (30-570) and 3(1-7) mg, respectively. Sedation-related complications were documented in 1.8% of cases. All patients had transient, nonfatal respiratory insufficiency. Totally, 60% of the patients who developed complications were >75 years and 70% were male. The presence of cardiac and/or pulmonary comorbidities was associated with an OR = 8.77 [95% confidence interval (CI), 1.8-41.7] and American Society of Anesthesiologists class III with an OR = 7.64 (95% CI, 1.60-36.3) for the occurrence of sedation-related complications. Endosonographer experience did not influence the rate of sedation-related complications. In both diagnostic and interventional EUS, patients with comorbidities and older age received significantly less sedation. Experienced endosonographers used less sedation than trainees. CONCLUSION: Endosonographer experience, patient age and the presence of comorbidities had a significant influence on sedation dose. Sedation-related complications occurred only in 1.8% of cases.

Challenges in hepatitis C elimination despite highly effective antiviral agents in patients with and without intravenous drug use.

AIM: To assess the adherence to treatment, sustained virologic response (SVR) rate, and reinfection rate in hepatitis C patients with and without intravenous drug use. METHODS: This retrospective study included hepatitis C patients, evaluated and treated in our hepatology outpatient clinic between January 2014 and October 2019. The following information was extracted from the patient's file: the presence of positive viral load for hepatitis C virus (HCV), active and recent (in the last 6 months) use of i.v. drugs, HCV genotype, treatment regimen, SVR, HCV reinfection rate, coinfection with human immunodeficiency virus (HIV) and ongoing opioid substitution therapy (OST). RESULTS: We included 431 hepatitis C patients, 234 people who inject drugs (PWID) and 197 non-PWID. Most patients were treated with direct-acting antivirals (DAA) only. The rate of documented SVR by treated patients was significantly higher in the non-PWID cohort (91.5% vs. 61.5%, p < 0.0001), while noncompliance (did not show up to start treatment) rate or refusal of treatment was significantly higher in the PWID cohort (19.4% vs. 8.9%, p = 0.004). In the PWID cohort, younger age and recent (in the last 6 months) or ongoing i.v. drug use was associated with noncompliance: 31.1 ± 8.4 years vs. 35.8 ± 10.6 years (p = 0.02) and 33.3% vs. 12.8% (p = 0.0008), respectively. Ongoing OST was associated with better compliance: 61.1% vs. 46.1% (p = 0.04). CONCLUSION: To achieve elimination of hepatitis C better treatment strategies are needed, especially in PWIDs.

The prevalence of cirrhotic cardiomyopathy according to different diagnostic criteria.

BACKGROUND AND AIMS: Recently published criteria by 2019 Cirrhotic Cardiomyopathy Consortium set a lower threshold for reduced ejection fraction to diagnose systolic dysfunction in cirrhotic patients, and stress testing was replaced by echocardiography strain imaging. The criteria to diagnose diastolic dysfunction are in general concordant with the 2016 ASE/EACVI guidelines and differ considerably from the 2005 Montreal recommendations. We aimed to assess the prevalence of cirrhotic cardiomyopathy according to different diagnostic criteria. METHODS: Cirrhotic patients without another structural heart disease, arterial hypertension, portal vein thrombosis, HCC outside Milan criteria and presence of TIPS were enrolled. Speckle-tracking echocardiography was performed by EACVI certified investigators. RESULTS: A total of 122 patients with cirrhosis fulfilled the inclusion criteria. Overall prevalence of cirrhotic cardiomyopathy was similar for 2005 Montreal and 2019 CCC: 67.2% vs 55.7% (P = .09); and significantly higher compared to 2009 ASE/EACVI criteria: 67.2% vs 35.2% (P < .0001) and 55.7% vs 35.2% (P = .002) respectively. Significantly more patients had diastolic dysfunction according to the 2005 Montreal compared to the 2009 ASE/EACVI and 2019 CCC criteria: 64.8% vs 32.8% (P < .0001) and 64.8% vs 7.4% (P < .0001). Systolic dysfunction was more frequently diagnosed according to 2019 CCC criteria compared to 2005 Montreal (53.3% vs 16.4%,P < .0001) or ASE/EACVI criteria (53.3% vs 4.9%,P < .0001). CONCLUSION: Cirrhotic cardiomyopathy was present in around 60% of cirrhotic patients when applying the hepatological criteria. A considerably higher prevalence of systolic dysfunction according to the 2019 CCC criteria was observed. Long-term follow-up studies are needed to establish the validity of these criteria to predict clinically relevant outcomes.

The bleeding risk after endoscopic ultrasound-guided puncture of pancreatic masses.

BACKGROUND: Although EUS-fine-needle aspiration (FNA) is considered to be safe, there are limited studies on adverse events of fine-needle biopsy (FNB). AIM: To compare the bleeding rate of EUS-FNA and EUS-FNB of solid and cystic pancreatic masses. METHODS: Our retrospective study included EUS-FNA/FNB of solid and cystic pancreatic masses performed between 02/2017-03/2019 in Klinikum Klagenfurt and 11/2018-03/2019 in University Hospital St. Pölten, Austria. Minor bleeding was defined as an event with a duration of more than 1 min, no need for intervention, large coagulum on the puncture site, or decrease in hemoglobin ≥1.5 g/dL (but <2 g/dL). Major bleeding was defined as a reduction in hemoglobin level ≥2 g/dL, need for red cell transfusions, or interventional hemostasis. RESULTS: About 202 patients were biopsied in that period (141 solid, 61cystic pancreatic masses). FNA needle was used in 54.6% of cases with solid pancreatic masses and 73.7% of cysts. Bleeding with hemodynamic instability was not observed in our cohort. In pancreatic cysts, minor bleeding was observed in 8.2% of cases and was associated with the use of FNB needles and lower platelet count. In solid tumors, one major bleeding (0.7%) from a duodenal vessel occurred and was immediately treated with hemoclip. In this group, minor bleeding was observed in 15.6% of cases. Overall, the bleeding rate correlates with the use of FNB needles. CONCLUSION: Use of EUS-FNB needles increases the rate of minor bleeding for both solid and cystic pancreatic tumors, while major bleeding is a rare occurrence, irrespective of the needle type.

Endoscopic ultrasound (EUS) in pancreatic masses with inconclusive radiologic workup - a case series and short review of the literature.

Endoscopic ultrasound (EUS) is a very sensitive examination to detect pancreatic masses and can provide useful information in cases where conventional radiologic workup remains inconclusive. We present three cases in which EUS was decisive in establishing the correct diagnosis. Case 1: A 74-year-old female was hospitalized because of acute pancreatitis. Medical history, CT and MRI gave no clue to etiology, but EUS diagnosed a small pancreatic tumor. Case 2: A female patient was admitted because of abdominal pain and weight loss. While MRI suspected a pancreatic tumor, EUS showed typical features of autoimmune pancreatitis. Case 3: A 50-year-old patient was hospitalized with cachexia, ascites and pulmonary embolism. At first, a pancreatic tumor was suspected, but EUS showed a cystic lesion with a solid component (pancreatic pseudocyst).