Efficacy and safety of endoscopic ultrasound-guided drainage of pancreatic pseudocysts using double-pigtail plastic stents: A single tertiary center experience.

OBJECTIVES: Pancreatic pseudocysts (PPC) are fluid collections with a well-defined wall that persist for more than 4 weeks inside or around the pancreas as a result of pancreatic inflammation and/or a ductal lesion. PPC have been successfully treated with endoscopic ultrasound (EUS)-guided drainage using different stents. This study aimed to evaluate the safety and efficacy of EUS-guided drainage of PPC using double-pigtail plastic stents in a tertiary hospital. METHODS: Patients with PPC referred for EUS-guided drainage between May 2015 and December 2019 were included in this case series. The primary endpoint was to evaluate the efficacy (clinical success) and safety (adverse events and mortality) of EUS-guided drainage of PPC. Secondary endpoints included technical success and pseudocyst recurrence. RESULTS: Eleven patients (mean age, 44.5±18.98 years) were included in this study. The etiologies for PPC were acute biliary pancreatitis, chronic alcoholic pancreatitis, and blunt abdominal trauma. The mean pseudocyst size was 9.4±2.69 cm. The clinical success rate was 91% (10/11). Adverse events occurred in three of 11 patients (27%). There were no cases of mortality. The technical success rate was 100%. Pseudocyst recurrence was identified in one of 11 patients (9%) at 12 weeks after successful clinical drainage and complete pseudocyst resolution. CONCLUSION: EUS-guided transmural drainage of PPC using double-pigtail plastic stents is safe and effective with high technical and clinical success rates.

Efficacy and safety of endoscopic ultrasound-guided drainage of pancreatic pseudocysts using double-pigtail plastic stents: A single tertiary center experience

OBJECTIVES: Pancreatic pseudocysts (PPC) are fluid collections with a well-defined wall that persist for more than 4 weeks inside or around the pancreas as a result of pancreatic inflammation and/or a ductal lesion. PPC have been successfully treated with endoscopic ultrasound (EUS)-guided drainage using different stents. This study aimed to evaluate the safety and efficacy of EUS-guided drainage of PPC using double-pigtail plastic stents in a tertiary hospital. METHODS: Patients with PPC referred for EUS-guided drainage between May 2015 and December 2019 were included in this case series. The primary endpoint was to evaluate the efficacy (clinical success) and safety (adverse events and mortality) of EUS-guided drainage of PPC. Secondary endpoints included technical success and pseudocyst recurrence. RESULTS: Eleven patients (mean age, 44.5±18.98 years) were included in this study. The etiologies for PPC were acute biliary pancreatitis, chronic alcoholic pancreatitis, and blunt abdominal trauma. The mean pseudocyst size was 9.4±2.69 cm. The clinical success rate was 91% (10/11). Adverse events occurred in three of 11 patients (27%). There were no cases of mortality. The technical success rate was 100%. Pseudocyst recurrence was identified in one of 11 patients (9%) at 12 weeks after successful clinical drainage and complete pseudocyst resolution. CONCLUSION: EUS-guided transmural drainage of PPC using double-pigtail plastic stents is safe and effective with high technical and clinical success rates.

PROPOSAL OF A CLINICAL CARE PATHWAY FOR THE MANAGEMENT OF ACUTE UPPER GASTROINTESTINAL BLEEDING

Background - Upper gastrointestinal bleeding implies significant clinical and economic repercussions. The correct establishment of the latest therapies for the upper gastrointestinal bleeding is associated with reduced in-hospital mortality. The use of clinical pathways for the upper gastrointestinal bleeding is associated with shorter hospital stay and lower hospital costs. Objective - The primary objective is the development of a clinical care pathway for the management of patients with upper gastrointestinal bleeding, to be used in tertiary hospital. Methods - It was conducted an extensive literature review on the management of upper gastrointestinal bleeding, contained in the primary and secondary information sources. Results - The result is a clinical care pathway for the upper gastrointestinal bleeding in patients with evidence of recent bleeding, diagnosed by melena or hematemesis in the last 12 hours, who are admitted in the emergency rooms and intensive care units of tertiary hospitals. In this compact and understandable pathway, it is well demonstrated the management since the admission, with definition of the inclusion and exclusion criteria, passing through the initial clinical treatment, posterior guidance for endoscopic therapy, and referral to rescue therapies in cases of persistent or rebleeding. It was also included the care that must be taken before hospital discharge for all patients who recover from an episode of bleeding. Conclusion - The introduction of a clinical care pathway for patients with upper gastrointestinal bleeding may contribute to standardization of medical practices, decrease in waiting time for medications and services, length of hospital stay and costs.

Contexto - A hemorragia digestiva alta implica em significativas repercussões clínicas e econômicas. O estabelecimento correto das mais recentes terapêuticas para a hemorragia digestiva alta está associado à redução na mortalidade intra-hospitalar. O uso de algoritmos para atendimento da hemorragia digestiva alta está associado com menor tempo de internação e menores custos hospitalares. Objetivos - O objetivo primário é a criação de um protocolo de atendimento da hemorragia digestiva alta, para ser utilizado em hospital terciário. Métodos - Realizada extensa revisão da literatura sobre as condutas na hemorragia digestiva alta, contidas nas bases de dados primária e secundária. Resultados - O resultado é um modelo de atendimento para os pacientes com hemorragia digestiva alta e com evidência de sangramento recente, dado por melena ou hematêmese nas ultimas 24h, que são atendidos nas salas de emergência e unidades de terapia intensiva de hospitais terciários. Neste protocolo de atendimento, desenhado de forma compacta e compreensível, fica bem evidenciado o manejo dos pacientes desde a admissão, com definição dos critérios de inclusão e exclusão, passando considerações acerca do atendimento clínico inicial, posterior direcionamento para a terapêutica endoscópica, e encaminhamento às terapias de resgate em casos de sangramento persistente ou recorrente. Destacam-se também os cuidados que devem ser tomados antes da alta hospitalar para todos os pacientes que se recuperam de um episódio de sangramento. Conclusão - A introdução de um protocolo para atendimento e tratamento de pacientes com hemorragia digestiva alta pode contribuir para uniformização de condutas médicas, diminuição no tempo de espera por medicações e serviços, no tempo de internação e nos custos hospitalares.

PROPOSAL OF A CLINICAL CARE PATHWAY FOR THE MANAGEMENT OF ACUTE UPPER GASTROINTESTINAL BLEEDING.

BACKGROUND: Upper gastrointestinal bleeding implies significant clinical and economic repercussions. The correct establishment of the latest therapies for the upper gastrointestinal bleeding is associated with reduced in-hospital mortality. The use of clinical pathways for the upper gastrointestinal bleeding is associated with shorter hospital stay and lower hospital costs. OBJECTIVE: The primary objective is the development of a clinical care pathway for the management of patients with upper gastrointestinal bleeding, to be used in tertiary hospital. METHODS: It was conducted an extensive literature review on the management of upper gastrointestinal bleeding, contained in the primary and secondary information sources. RESULTS: The result is a clinical care pathway for the upper gastrointestinal bleeding in patients with evidence of recent bleeding, diagnosed by melena or hematemesis in the last 12 hours, who are admitted in the emergency rooms and intensive care units of tertiary hospitals. In this compact and understandable pathway, it is well demonstrated the management since the admission, with definition of the inclusion and exclusion criteria, passing through the initial clinical treatment, posterior guidance for endoscopic therapy, and referral to rescue therapies in cases of persistent or rebleeding. It was also included the care that must be taken before hospital discharge for all patients who recover from an episode of bleeding. CONCLUSION: The introduction of a clinical care pathway for patients with upper gastrointestinal bleeding may contribute to standardization of medical practices, decrease in waiting time for medications and services, length of hospital stay and costs.

Sedation during upper GI endoscopy in cirrhotic outpatients: a randomized, controlled trial comparing propofol and fentanyl with midazolam and fentanyl.

BACKGROUND: Patients with liver cirrhosis frequently undergo diagnostic or therapeutic upper GI endoscopy (UGIE), and the liver disease might impair the metabolism of drugs usually administered for sedation. OBJECTIVE AND SETTING: To compare sedation with a combination of propofol plus fentanyl and midazolam plus fentanyl in cirrhotic outpatients undergoing UGIE. DESIGN: A prospective, randomized, controlled trial was conducted between February 2008 and February 2009. MAIN OUTCOMES MEASUREMENTS: Efficacy (proportion of complete procedures using the initial proposed sedation scheme), safety (occurrence of sedation-related complications), and recovery time were measured. RESULTS: Two hundred ten cirrhotic patients referred for UGIE were randomized to 2 groups: midazolam group (0.05 mg/kg plus fentanyl 50 µg intravenously) or propofol group (0.25 mg/kg plus fentanyl 50 µg intravenously). There were no differences between groups regarding age, sex, weight, etiology of cirrhosis, and Child-Pugh or American Society of Anesthesiologists classification. Sedation with propofol was more efficacious (100% vs 88.2%; P < .001) and had a shorter recovery time than sedation with midazolam (16.23 ± 6.84 minutes and 27.40 ± 17.19 minutes, respectively; P < .001). Complication rates were similar in both groups (14% vs 7.3%; P = .172). LIMITATIONS: Single-blind study; sample size. CONCLUSION: Both sedation schemes were safe in this setting. Sedation with propofol plus fentanyl was more efficacious with a shorter recovery time compared with midazolam plus fentanyl. Therefore, the former scheme is an alternative when sedating cirrhotic patients undergoing UGIE.

Endoscopic treatment of esophageal varices in advanced liver disease patients: band ligation versus cyanoacrylate injection.

BACKGROUND: The results of variceal band ligation (VBL) in patients with advanced liver disease are unknown. Cyanoacrylate injection (CI) might have a better outcome than VBL in the treatment of esophageal varices (EV) in these patients. AIM: To compare VBL and CI in the treatment of EV in patients with advanced liver disease. PATIENTS AND METHODS: Thirty-eight patients with medium or large EV and Child-Pugh index of at least eight were randomized into two groups: VBL (n=20) and CI (n=18). The patients were followed-up for at least 6 months after the end of treatment. Main outcomes were eradication, bleeding, mortality, complication, and recurrence rates. RESULTS: Variceal eradication rates were similar in the VBL and CI groups (90 vs. 72%, P=0.39). Mean number of sessions until eradication was 3.17 and 3, respectively. Bleeding episodes until eradication were equally observed in both groups (P=0.17). Mortality (55 vs. 56%, P=0.52) and major complication rates (5 and 17%, P=0.32) were similar. Chest pain with dysphagia was more frequent in the CI group (55.6 vs. 10%, P=0.004). A higher risk of variceal recurrence was observed in the CI group (33 vs. 57%, P=0.04). CONCLUSION: No significant differences between the VBL and CI groups were observed in the treatment of EV in patients with advanced liver disease regarding mortality, variceal eradication, and major complications rates. However, minor complications and variceal recurrence were significantly more common in the CI group. In addition, there was a clear trend toward more bleeding episodes in patients included in the CI group.

[Prospective comparative study of ERCP brush cytology and EUS-FNA for the differential diagnosis of biliary strictures]. / Estudo prospectivo e comparativo do escovado obtido pela CPER à ecoendoscopia associada à punção aspirativa com agulha fina (EE-PAAF) no diagnóstico diferencial das estenoses biliares.

OBJECTIVE: To evaluate and to compare the diagnostic yield of ERCP brush cytology (ERCP) and EUS-FNA in patients with biliary strictures and evaluates the agreement between general pathologists (GP) and expert GI pathologists (GIP) in the final diagnosis of biliary strictures. METHODS: Patients with biliary strictures documented by ERCP were included. Brush cytology was performed and during EUS, only visible mass lesions or localized bile duct wall thickening were aspirated. The gold standard method for diagnosis was surgical histology and/or follow-up. Tissue sampling results were: malignant, suspicious, atypical, insufficiently or benign. Specimens were interpreted by GP and GIP, blinded for prior tests results. RESULTS: 46 patients were included. Final diagnosis was malignancy in 37 (26 pancreatic--11 biliary) and benign in 9 (8 chronic pancreatitis--1 common bile duct inflammatory stricture). Sensitivity and accuracy for ERCP brush cytology were 43.2% and 52.2% for GP and 51.4% and 58.7% for GIP. Sensitivity and accuracy for EUS-FNA were 52.8% and 58.5%, respectively for GP and 69.4% e 73.2% for GIP. In comparison, the combination of brush cytology and EUS-FNA demonstrated higher sensitivity and accuracy for both GP (64.9% and 69.6%, respectively) and GIP (83.8% and 84.8%, respectively) and improved agreement with final diagnosis for both (mostly for GIP). CONCLUSION: Both, ERCP brush cytology and EUS-FNA has a similar yield for the diagnosis of biliary strictures. However, the combination of these methods results in an improved diagnostic accuracy. In addition, GIP might be expected to interpret specimens with greater accuracy than GP.

Estudo prospectivo e comparativo do escovado obtido pela CPER à ecoendoscopia associada à punção aspirativa com agulha fina (EE-PAAF) no diagnóstico diferencial das estenoses biliares / Prospective comparative study of ERCP brush cytology and EUS-FNA for the diferential diagnosis of biliary strictures

OBJETIVO: Avaliar o desempenho diagnóstico da citologia obtida pela CPER, aquele obtido pela EE-PAAF e a concordância entre patologistas gerais (PG) e especialistas (PE) em pacientes com estenose biliar. MÉTODOS: Incluímos pacientes com estenose biliar identificados pela CPER. A EE-PAAF foi realizada apenas em áreas com efeito de massa ou da parede espessada do ducto biliar. O padrão-ouro foi a cirurgia, histologia e/ou o seguimento. As amostras teciduais foram consideradas: malignas, suspeitas, atípicas, insuficientes ou benignas. Os espécimes obtidos por cada método foi interpretado (cego) por um PG e outro PE. RESULTADO: 46 pacientes foram incluídos (37 malignos e 9 benignos). O diagnóstico final foi de tumor pancreático (26), biliar (11), pancreatite crônica (8) e estenose inflamatória do ducto biliar (1). Sensibilidade e acurácia da CPER foram 43,2 por cento e 52,2 por cento para o PG e 51,4 por cento e 58,7 por cento para o PE. Sensibilidade e acurácia da EE-PAAF foi 52,8 por cento e 58,5 por cento para o PG e 69,4 por cento e 73,2 por cento para o PE. A combinação entre a CPER e EE-PAAF demonstrou maior sensibilidade e acurácia para ambos PG (64,9 por cento e 69,6 por cento) e PE (83,8 por cento e 84,8 por cento), respectivamente. CONCLUSÃO: A citologia obtida pelo escovado da via biliar durante a CPER e as amostras teciduais colhidas pela EE-PAAF tem rendimento semelhante para o diagnóstico das estenoses biliares. No entanto, a combinação dos métodos resulta em uma maior acurácia. Além disso, espera-se que a interpretação das amostras ocorra com maior precisão pelo PE se comparado ao PG.

OBJECTIVE: To evaluate and to compare the diagnostic yield of ERCP brush cytology (ERCP) and EUS-FNA in patients with biliary strictures and evaluates the agreement between general pathologists (GP) and expert GI pathologists (GIP) in the final diagnosis of biliary strictures. METHODS: Patients with biliary strictures documented by ERCP were included. Brush cytology was performed and during EUS, only visible mass lesions or localized bile duct wall thickening were aspirated. The gold standard method for diagnosis was surgical histology and/or follow-up. Tissue sampling results were: malignant, suspicious, atypical, insufficiently or benign. Specimens were interpreted by GP and GIP, blinded for prior tests results. RESULTS: 46 patients were included. Final diagnosis was malignancy in 37 (26 pancreatic - 11 biliary) and benign in 9 (8 chronic pancreatitis - 1 common bile duct inflammatory stricture). Sensitivity and accuracy for ERCP brush cytology were 43.2 percent and 52.2 percent for GP and 51.4 percent and 58.7 percent for GIP. Sensitivity and accuracy for EUS-FNA were 52.8 percent and 58.5 percent, respectively for GP and 69.4 percent e 73.2 percent for GIP. In comparison, the combination of brush cytology and EUS-FNA demonstrated higher sensitivity and accuracy for both GP (64.9 percent and 69.6 percent, respectively) and GIP (83.8 percent and 84.8 percent, respectively) and improved agreement with final diagnosis for both (mostly for GIP). CONCLUSION: Both, ERCP brush cytology and EUS-FNA has a similar yield for the diagnosis of biliary strictures. However, the combination of these methods results in an improved diagnostic accuracy. In addition, GIP might be expected to interpret specimens with greater accuracy than GP.

Endoscopic follow-up of cyanoacrylate obliteration of gastric varices.

Bleeding from gastric varices is a life-threatening condition. We report our experience with cyanoacrylate injection. Twenty three patients with portal hypertension and gastric varices underwent intra-variceal injection of a cyanoacrylate/lipiodol solution (1:1). Study endpoint was variceal obliteration. Mean follow-up was 25.3 months. Variceal obliteration was achieved in 87% of patients. Recurrence occurred in one patient (4.3%) and rebleeding in another case (4.3%). Mild abdominal pain was described in 13% of patients. Overall mortality was 21.7% and rebleeding related mortality rate was 4.3%. Our results confirm that cyanoacrylate injection is effective and safe to eradicate gastric varices.

Endoscopic follow-up of cyanoacrylate obliteration of gastric varices / Seguimento endoscópico da erradicação de varizes gástricas com cianoacrilato

Bleeding from gastric varices is a life-threatening condition. We report our experience with cyanoacrylate injection. Twenty three patients with portal hypertension and gastric varices underwent intra-variceal injection of a cyanoacrylate/lipiodol solution (1:1). Study endpoint was variceal obliteration. Mean follow-up was 25.3 months. Variceal obliteration was achieved in 87 percent of patients. Recurrence occurred in one patient (4.3 percent) and rebleeding in another case (4.3 percent). Mild abdominal pain was described in 13 percent of patients. Overall mortality was 21.7 percent and rebleeding related mortality rate was 4.3 percent. Our results confirm that cyanoacrylate injection is effective and safe to eradicate gastric varices.

Sangramento por varizes gástricas é grave. Relato de experiência com injeção de cianoacrilato. Vinte e três pacientes com hipertensão portal e varizes gástricas foram tratados com injeção intravasal de solução de cianoacrilato/lipiodol (1:1). O objetivo do estudo foi alcançar obliteração da variz. O tempo médio de acompanhamento foi 25,3 meses. Obliteração foi atingida em 87 por cento dos pacientes. Recidiva foi observada em um (4,3 por cento) e ressangramento em outro caso (4.3 por cento). Dor abdominal ocorreu em 13 por cento dos pacientes. A mortalidade global foi de 21,7 por cento e 4,3 por cento relacionada ao ressangramento. Estes resultados confirmam a injeção de cianoacrilato como efetiva e segura na erradicação das varizes gástricas.

Endoscopic ultrasound guided fine-needle aspiration core biopsy: comparison between an automatic biopsy device and two conventional needle systems.

BACKGROUND: endoscopic ultrasound guided fine-needle aspiration (EUS-FNA) allows cytologic and/or histologic diagnosis of lesions within or adjacent to the gastrointestinal tract. However, the amount of tissue obtained with a regular 22 gauge needle is not always satisfactory. With the development of a needle XNA-10J-KB (Shot-Gun) that resembles the automatic liver biopsy needle, it is expected that significant samples be obtained more frequently (core biopsy), optimizing histological analysis. OBJECTIVE: to compare samples obtained with EUS-FNA using 3 different needle systems: GIP, NA-10J-1 and Shot-Gun. METHODS: 19 patients underwent EUS-FNA for diagnosis (5) or tumor staging (14). Mean age was 58.9 years (range 27-82), being 50% men. All patients were submitted to EUS-FNA with the 3 needle models. The Shot-Gun model was "shot" when its tip was near the target inside the lesion, followed by aspiration. Samples were submitted for cytologic and histologic examination. RESULTS: mean lesion size was 3.0 cm (range 0.8-5.5 cm). Final diagnoses were made after surgery or intra-operative biopsy: 13 pancreatic tumors (12 adenocarcinomas and 1 neuroendocrine tumor), 4 chronic pancreatitis, 1 acute pancreatitis, and 1 cholangiocarcinoma. Specimens adequate for cytologic diagnosis were obtained in 13/19 (68. 4%) patients using GIP model, in 14/19 (73.7%) with NA10J-1 model, and in 17/19 (89.5%) with ShotGun, model (p=0.039). Histologic analysis was possible in 10/19 (52.6%) patients using the GIP model, in 14/19 (73.7%) with NA10J-1, and in 17/19 (89.5%) with Shot-Gun, model (p=0.005). Adequate samples for cytologic or histologic assessment in 16/19 (84.2%) patients using the GIP model, in 17/19 (89.5%) with NA10J-1, and in 18/19 (94.7%) with Shot-Gun, model (p=0.223). In two cases biopsies were negative due to very hard tumors. CONCLUSION: the Shot-Gun needle obtained better samples for histological diagnosis than NA10J-1 needle and GIP.

Endoscopic resolution of pseudocyst infection and necrosis as a complication of endoscopic pseudocyst drainage. A case report.

CONTEXT: Endoscopic therapy has recently gained importance as an option for the treatment of pancreatic necrosis. We report a case of transgastric endoscopic resolution of pseudocyst infection and necrosis as a complication of endoscopic pseudocyst drainage. CASE REPORT: The patient underwent several sessions of endoscopic removal of debris and necrotic material, intercalated with daily lavage and aspiration through a nasocystic tube. CONCLUSIONS: At the present time, fourteen months after pancreatic pseudocyst secondary infection, the patient remains asymptomatic with no radiographic signs of pseudocyst recurrence. Transmural endoscopic therapy followed by continuous drainage and necrosectomy is a reasonable option for treating the pancreatic pseudocyst secondary infection.

Endoscopic ultrasound guided fine-needle aspiration core biopsy: comparison between an automatic biopsy device and two conventional needle systems / Biopsia tecidual con aguja fina guiada por ultrasonido endoscópico: comparación entre un dispositivo automático de la biopsia y dos sistemas de agujas convencionales

BACKGROUND: endoscopic ultrasound guided fine-needle aspiration (EUS-FNA) allows cytologic and/or histologic diagnosis of lesions within or adjacent to the gastrointestinal tract. However, the amount of tissue obtained with a regular 22 gauge needle is not always satisfactory. With the development of a needle XNA-10J-KB (Shot-Gun) that resembles the automatic liver biopsy needle, it is expected that significant samples be obtained more frequently (core biopsy), optimizing histological analysis. OBJECTIVE: to compare samples obtained with EUS-FNA using 3 different needle systems: GIP, NA-10J-1 and Shot-Gun. METHODS: 19 patients underwent EUS-FNA for diagnosis (5) or tumor staging (14). Mean age was 58.9 years (range 27-82), being 50% men. All patients were submitted to EUS-FNA with the 3 needle models. The Shot-Gun model was "shot" when its tip was near the target inside the lesion, followed by aspiration. Samples were submitted for cytologic and histologic examination. RESULTS: mean lesion size was 3.0 cm (range 0.8-5.5 cm). Final diagnoses were made after surgery or intra-operative biopsy: 13 pancreatic tumors (12 adenocarcinomas and 1 neuroendocrine tumor), 4 chronic pancreatitis, 1 acute pancreatitis, and 1 cholangiocarcinoma. Specimens adequate for cytologic diagnosis were obtained in 13/19 (68. 4%) patients using GIP model, in 14/19 (73.7%) with NA10J-1 model, and in 17/19 (89.5%) with ShotGun, model (p=0.039). Histologic analysis was possible in 10/19 (52.6%) patients using the GIP model, in 14/19 (73.7%) with NA10J-1, and in 17/19 (89.5%) with Shot-Gun, model (p=0.005). Adequate samples for cytologic or histologic assessment in 16/19 (84.2%) patients using the GIP model, in 17/19 (89.5%) with NA10J-1, and in 18/19 (94.7%) with Shot-Gun, model (p=0.223). In two cases biopsies were negative due to very hard tumors. CONCLUSION: the Shot-Gun needle obtained better samples for histological diagnosis than NA10J-1 needle and GIP.

Introducción: la ecografía endoscópica asociada a la punción guiada con aguja fina (EUS-FNA) permite el examen citológico y/o diagnóstico histológico de las lesiones dentro o junto al tracto gastrointestinal. Sin embargo, la cantidad de tejido obtenido con una aguja de calibre 22 G no es siempre satisfactoria. Con el desarrollo de una aguja XNA-10J-KB (Shot-Gun®) que seasemeja a la biopsia hepática automática como una aguja especial, se espera que se obtengan muestras importantes con más frecuencia permitindo optimizar el mejor análisis histopatológico. Objetivo: comparar lasmuestras obtenidas con EUS-FNA con 3 diferentes sistemas de aguja: GIP ®, NA-10J-1 ® y Shot-Gun ®. Métodos: 19 pacientes fueron sometidos a EUS-FNApara el diagnóstico (5) para el análisis de las etapas del tumor (14). La edad media fue de 58,9 años (rango 27-82), siendo el 50% hombres. Todos los pacientes fueron sometidos a EUS-FNA con los 3 modelos de aguja. Del Shot-Gun ® fue "disparada" su punta cuandoestaba cerca de la meta en el interior de la lesión, seguida de aspiración. Las muestras se sometieron a examencitológico e histológico. Resultados: el promedio de tamaño de la lesión fue de 3,0 cm (rango 0,8-5,5 cm). Los diagnósticos definitivos fueron hechos después de la cirugía o la biopsia intra-operatoria: 13 tumores de páncreas (12 adenocarcinomas y 1 tumor neuroendócrino), 4 de pancreatitis crónica, 1 de pancreatitis aguda, y 1 de colangiocarcinoma. Las muestras adecuadas para el diagnóstico citológico se obtuvieron en 13/19 (68,4%) pacientes que utilizan GIP ®, en 14/19 (73,7%) con NA10J-1 ®, y en 17/19 (89,5%) con Shot-Gun® (p = 0,039). El análisis histológico fue posible en 10/19 (52,6%) pacientes que utilizan elGIP®, en 14/19 (73,7%) con NA10J-1 ®, y en 17/19 (89,5%) con Shot-Gun® (p = 0,005). Suficientes muestras para citológico o histológico de evaluación en16/19 (84,2%) pacientes que utilizan el modelo GIP ®, en 17/19 (89,5%) con NA10J-1 ®...

Comparison between endoscopic brush cytology performed before and after biliary stricture dilation for cancer detection.

BACKGROUND: Confirmation of malignancy within biliary strictures is endoscopically challenging. Dilation of strictures has been reported to enhance cytological diagnosis. AIM: To compare brush cytology results before and after biliary stricture dilation. PATIENTS AND METHODS: Patients with extra-hepatic biliary stricture at endoscopic retrograde cholangiopancreatography were included in the study. Brushing was performed before and immediately after dilation using a 10 Fr dilating catheter. Cytology samples were classified as: negative for malignancy, presence of atypical cells, insufficient material, suspicious for malignancy or positive for malignancy. Final diagnosis was established by surgery, biopsy or follow-up. RESULTS: Biliary brush cytology was performed in 50 patients, with an overall sensitivity of 40% and 27.5%, before and after dilation, respectively. The combination of results increased cancer detection rate to 45%. There were 5/50 (10%) minor complications and one death related to the procedure. CONCLUSIONS: Brush cytology performed before biliary stricture dilation has a similar cancer detection rate to that following dilation, although the combination of results enhances sensitivity.

Comparison between endoscopic brush cytology performed before and after biliary stricture dilation for cancer detection

RACIONAL: A citologia por escovado apresenta baixa sensibilidade na detecção de câncer em estenoses biliares, mas manipulação endoscópica prévia poderia aumentar a esfoliação de células tumorais. OBJETIVO: Comparar os resultados dos escovados obtidos antes e depois da dilatação de estenoses biliares. PACIENTES E MÉTODOS: Pacientes com estenose biliar extra-hepática diagnosticada durante colangiopancreatografia endoscópica retrógada foram submetidos a citologia por escovado. Em seguida, a estenose foi dilatada com cateter de 10 French e o escovado foi repetido. A citologia foi classificada como: negativa para malignidade, presença de células atípicas, material insuficiente, suspeita para malignidade ou positiva para malignidade. O diagnóstico final foi determinado por cirurgia, biopsia ou acompanhamento clínico. RESULTADOS: O escovado biliar foi obtido em 50 pacientes, com sensibilidade de 40% e 27,5%, respectivamente, antes e depois da dilatação. A combinação dos resultados aumentou a positividade para 45%. Houve 5/50 (10%) complicações menores e um óbito relacionado ao procedimento. CONCLUSÕES: A positividade do escovado biliar realizado antes de dilatar a estenose para detecção de neoplasia maligna é semelhante àquela obtida depois da dilatação, embora a combinação dos resultados aumente a sensibilidade.

Treatment of esophageal varices: a randomized controlled trial comparing endoscopic sclerotherapy and EUS-guided sclerotherapy of esophageal collateral veins.

BACKGROUND: Endoscopic sclerotherapy (ES) and band ligation are standard treatments for esophageal varices. Unfortunately, recurrence is common and seems to be related to esophageal collateral vessels, easily identified by EUS. Eradication of these vessels might lead to a more durable therapeutic effect. OBJECTIVE: To compare ES with EUS-guided sclerotherapy of collateral vessels (EUS-ES). DESIGN: Randomized controlled trial. SETTING: Endoscopy Unit, Division of Gastroenterology. Universidade Federal de São Paulo, São Paulo, Brazil. PATIENTS AND INTERVENTIONS: Fifty cirrhotic patients with esophageal varices were randomized into 2 groups: ES (n = 25) and EUS-ES (n = 25). EUS-ES was targeted at collateral veins. Patients were followed-up for at least 6 months after eradication. MAIN OUTCOME MEASUREMENTS: Efficacy in eradication, complications, and recurrence of varices. RESULTS: Varices were eradicated in 48 patients who adhered to the study protocol. The mean (SD) number of sessions until eradication was 4.3 (1.5) for the ES group and 4.1 (1.2) for the EUS-ES group. In ES group, 4 patients had mild bleeding. In EUS-ES group, 4 patients had pain. The mean (SD) length of the follow-up period was 22.6 (6.9) months for the ES group and 24.9 (8.1) months for the EUS-ES group. Recurrence was seen in 4 patients after ES and in 2 after EUS-ES (P = .32). The presence of collateral vessels was associated with recurrence (P = .003). CONCLUSION: EUS-ES is as safe and effective as ES in variceal eradication. Recurrence tends to be less frequent and occurs later. Persistence of esophageal collateral vessels after sclerotherapy is a risk factor for recurrence.

Fístula pancreaticoportal e tumor pamcreático / Pancreatic-portal fistula and pancreatic tumor

Apresenta-se o caso de paciente do sexo masculino, com 40 anos, no qual se identificou uma fístula pancreaticoportal, durante colangiopancreatografia retrógrada endoscópica (CPRE). Não houve possibilidade de tratamento cirúrgico; o paciente recebeu tratamento de suporte, morrendo dois meses após o CPRE. Relatos de fístula ligando o ducto pancreático principal (DPP) ao sistema portal, associada a pancreatite e pseudocisto, não são raros e o tratamento cirúrgico é a melhor opção, mas fístula causada por câncer de pâncreas é rara e não há conduta terapêutica estabelecida

Endoscopic ultrasonography and alcoholic patients: can one predict early pancreatic tissue abnormalities?

CONTEXT: The diagnosis of chronic pancreatitis in early stages remains challenging and agreement between various methods is poor. Alcohol consumption is the most important cause of chronic pancreatitis. OBJECTIVE: The aim of this study was to evaluate the endosonographic evidence of pancreatic disease in patients with alcohol abuse. SETTING: Consecutive patients referred for endoscopic ultrasonography for various indications between May 2001 and December 2003. PATIENTS: Two hundred twenty-eight patients were enrolled in the study. One hundred 89 patients were studied; 39 (17.1%) were excluded because the pancreas could not be completely assessed (n=23) or because a previous diagnosis of chronic pancreatitis and/or pancreatic neoplasm was suspected (n=16). DESIGN: Prospective study. The patients were divided into 2 groups: alcoholics (n=17) and non-alcoholics (n=172). MAIN OUTCOME MEASURE: The assessment of pancreatic disease according to parenchymal and ductal changes as previously described by Catalano and Sahai (scores 1 and 2, respectively). RESULTS: The male:female ratio was 7.5 and 0.9 in the alcoholic and the non-alcoholic groups, respectively (P=0.002). Mean ages were 53.0 and 47.8 years, respectively (P=0.156). Alcoholic patients had significantly (P<0.001) more endosonographic abnormalities than non-alcoholics for both scores. A ROC curve comparison between patients and controls showed that the best specificity and sensitivity combination was obtained for the number of EUS features greater than 1 and 2 for the scores 1 and 2, respectively. CONCLUSION: Alcoholic patients had significantly more endosonographic abnormalities reflecting possible early changes of chronic pancreatitis. By using reported scores, values up to 1 or 2 can be seen in patients with no risk for pancreatitis, suggesting that chronic pancreatitis should be considered only for scores equal to or greater than 2 or 3 for scores 1 and 2, respectively.

Videocolonoscopia convencional e cromoscopia com índigo carmim no diagnóstico de pólipos colônicos / Colonic polyps diagnosis by conventional video colonoscopes and chromoscopy with indigo carmine dye solution

Racional - Colonoscópios com magnificaçäo e cromoscopia com índigo carmim vêm sendo utilizados na diferenciaçäo de pólipos colônicos neoplásicos (adenomatosos e adenocarcinomas) dos näo-neoplásicos (hiperplásicos, inflamatórios, juvenis), in loco, antes da realizaçäo do estudo histológico. Por outro lado, ainda foi pouco estudado o uso de colonoscópios convencionais e cromoscopia na prediçäo da histologia destas lesöes. Objetivo - Avaliar o desempenho de videocolonoscópios convencionais com cromoscopia com índigo carmim no diagnóstico diferencial de pólipos colônicos. Métodos - Previamente à polipectomia de pólipos detectados durante exames diagnósticos de rotina, foi realizada cromoscopia com índigo carmim. Se fossem observados sulcos na superfície da lesäo a mesma era classificada como neoplásica. Na ausência deste aspecto, a mesma era classificada como näo-neoplásica. Estas observaçöes foram comparadas com as conclusöes do estudo histológico. Resultados - No período de estudo (18 meses), foram detectados 133 pólipos em 53 pacientes. A cromoendoscopia apresentou, em 126 lesöes, sensibilidade de 56,4 por cento, especificidade de 79,2 por cento, valor preditivo positivo de 81,5 por cento, valor preditivo negativo de 52,8 por cento e acurácia de 65,1 por cento no diagnóstico de lesöes neoplásicas. Conclusäo - Os dados desta série permitem concluir que a cromoscopia com índigo carmim durante a colonoscopia convencional näo é método confiável no diagnóstico diferencial in loco do tipo histológico dos pólipos colônicos

[Colonic polyps diagnosis by conventional video colonoscopes and chromoscopy with indigo carmine dye solution]. / Videocolonoscopia convencional e cromoscopia com índigo carmim no diagnóstico de pólipos colônicos.

BACKGROUND: Magnification colonoscopy and contrast chromoscopy with indigo carmine dye solution have been used to differentiate neoplastic polyps (adenomas and adenocarcinomas) from non-neoplastic (hyperplastic, inflammatory, juvenile) in an attempt to obviate endoscopic polypectomy. On the other hand, little published information exists concerning conventional video colonoscopes and chromoscopy for polyp histology prediction. Aim - To assess usefullness of conventional video colonoscopes and contrast chromoscopy with indigo carmine solution for differential diagnosis of colon polyps. METHODS: In a routine colonoscopy series, we performed chromoscopy with conventional video colonoscopes before endoscopic excision of detected polyps. If a sulcus pattern was observed on the surface of the lesion, it was classified as neoplastic. Polyps were classified as non-neoplastic if no sulcus was detected on its surface. These observations were then compared with histology. RESULTS: In the study period (18 months), we detected 133 polyps in 53 patients. We were able to compare results of histology and chromoscopy in 126 lesions. The sensitivity, specificity, diagnostic accuracy, negative predictive value, and positive predictive value were 56,4%, 79,2%, 65,1%, 52,8%, and 81,5%, respectively. CONCLUSION: On the base of the presented data, we concluded that conventional video colonoscopes and contrast chromoscopy with indigo carmine solution is not a good technique for differential diagnosis of colon polyps.