National survey regarding the timing of endoscopic procedures during the COVID-19 pandemic.

BACKGROUND: During the COVID-19 pandemic, several questions have arisen about which endoscopic procedures (EPs) must be performed and which ones can be postponed. The aim of this study was to conduct a nationwide survey regarding the appropriate timing of EPs during the COVID-19 pandemic. METHODS: This prospective study was performed through a nationwide electronic survey. The survey consisted of 15 questions divided into three sections. The first evaluated the agreement for EPs classified as "time sensitive" and "not time sensitive". Two other sections assessed "high-priority" and "low-priority" scenarios. Agreement was considered when > 75% of respondents answered a question in the same direction. RESULTS: The response rate was 27.2% (214/784). Among the respondents, agreement for the need to perform EP in < 72 h was only reached for variceal bleeding (93.4%). Dysphagia with alarm symptoms was the scenario in which the highest percentage of physicians (95.9%) agreed that an EP needed to be performed within a month. Less than 30% of endoscopists would perform an EP within the first 72 h for patients with mild cholangitis, non-variceal upper gastrointestinal bleeding without hemodynamic instability, or severe anaemia without overt bleeding. In time-sensitive clinical scenarios suggestive of benign disease, none of the scenarios reached agreement in any sense. Among the time-sensitive clinical scenarios suggestive of malignancy, > 90% of the surveyed respondents considered that EP could not be postponed for > 8 weeks. CONCLUSIONS: There was no consensus among endoscopists about the timing of EPs in patients with pathologies considered time sensitive or in those with high-priority pathologies. Agreement was only reached in five (17%) of the evaluated clinical scenarios.

Patients With Unexplained Dilated Pancreatic Duct Have High Risk of Biliopancreatic Malignancy Detected by EUS.

INTRODUCTION: Patients with unexplained dilated common bile duct (CBD) and/or dilated main pancreatic duct (MPD) on noninvasive abdominal imaging tests are often referred for endoscopic ultrasound (EUS) in order to rule out biliopancreatic cancer. The aim of the study was to evaluate the diagnostic yield of EUS in this patient group. METHODS: A prospective study was conducted. Patients with unexplained dilated CBD and/or MPD on abdominal imaging, who underwent EUS, were enrolled. RESULTS: Fifty-four patients underwent EUS (CBD dilation n=38, MPD dilation n=5 or both n=11). In 31/54 patients (57.4%), EUS revealed pathologic findings. Sixteen patients (29.6%) had EUS evidence of biliopancreatic cancer and 15 patients (27.7%) had benign pathology. Ten (62.5%) of the patients with biliopancreatic cancer had MPD dilation. MPD dilation was significantly associated with malignancy (P=0.017). CONCLUSION: Patients with unexplained dilated MPD on noninvasive image have a high risk of biliopancreatic malignancy detected by EUS.

EUS-guided biliary drainage in patients with distal malignant biliary obstruction requires fewer interventions and has a lower cost compared to ERCP biliary drainage.

INTRODUCTION: Endoscopic retrograde cholangiopancreatography (ERCP) biliary drainage is considered the reference standard in patients with biliary obstruction, but it is not free of complications. EUS-guided biliary drainage (EUS-BD) is considered an alternative in patients with failed ERCP; however, data are scarce as to whether EUS-BD could be considered a first option. OBJECTIVE: The aim of our study was to compare the need for reintervention and cost between ERCP biliary drainage vs. EUS-BD. MATERIAL AND METHODS: We conducted a retrospective and comparative study of patients with distal malignant biliary obstruction with biliary drainage with ERCP + plastic stent (ERCP-PS) vs. ERCP + metal stent (ERCP-MS) vs. EUS-BD. RESULTS: 124 patients were included, divided into three groups: ERCP-PS, 60 (48.3%) patients; ERCP-MS, 40 (32.2%) patients; and EUS-BD, 24 (19.3%) patients. The need for reinterventions (67 vs. 37 vs. 4%, respectively), the number of procedures [3 (1-10) vs. 2 (1-7) vs. 1 (1-2)], and the costs (4550 ± 3130 vs. 5555 ± 3210 vs. 2375 ± 1020 USD) were lower in the EUS-BD group. No differences in terms of complications were detected. CONCLUSION: EUS-BD requires fewer reinterventions and has a lower cost compared to drainage by ERCP with metal or plastic stents.

A low-residue diet before colonoscopy tends to improve tolerability by patients with no differences in preparation quality: a randomized trial.

BACKGROUND: The pre-colonoscopy diet traditionally involves 24 h of a clear liquid diet (CLD) in combination with a lavage solution; however, this preparation is poorly tolerated. AIM: To compare the impact on the quality of bowel cleansing and tolerability of a CLD versus a low-residue diet (LRD). METHODS: We performed a randomized trial. Subjects were randomized to CLD or LRD the day before of elective colonoscopy. All subjects received a 4-L preparation of single-dose PEG beginning 16 h prior to colonoscopy. The Boston bowel preparation scale was used to evaluate bowel cleansing; an adequate-quality preparation was defined as a score ≥ 2 per segment. RESULTS: A total of 205 subjects were included with a mean age (SD) of 55.6 (12.6) years; 133 (64.9%) of them were female. A total of 105 subjects were randomized to receive CLD and 100 to LRD. No significant differences in bowel preparation quality were observed between groups according to the section of colon: right colon (70% vs. 73%, p = 0.08), transverse colon (82% vs. 79%, p = 0.062), or left colon (80% vs. 78.7%, p = 0.28). There was a tendency toward less-frequent nausea (p = 0.08) and vomiting (p = 0.07) in patients with LRD. No differences between groups regarding ADR (12% vs. 10%) were noted. CONCLUSIONS: An LRD before colonoscopy resulted in a tendency toward improved tolerability by patients, with no differences in the quality of bowel preparation.

Repeat endoscopic ultrasound fine needle aspiration after a first negative procedure is useful in pancreatic lesions.

BACKGROUND AND OBJECTIVES: There is no consensus about the ideal method for diagnosis in patients who have already undergone endoscopic ultrasound fine needle aspiration (EUS-FNA), and the inconclusive material is often obtained. The aim was to evaluate the diagnostic yield of the second EUS-FNA of pancreatic lesions. MATERIALS AND METHODS: A retrospective analysis of prospectively collected data of patients with EUS-FNA of pancreatic lesions is performed. All patients who underwent more than one EUS-FNA for the evaluation of suspected pancreatic cancer over a 7-year period were included in the analysis. RESULTS: A total of 296 EUS-FNAs of the pancreas were performed in 257 patients. The diagnostic yield with the first EUS-FNA was 78.6% (202/257). Thirty-nine (13.3%) FNAs were repeated in 34 patients; 17 (50%) patients were women. The mean ± standard deviation (SD) age was 58.8 ± 16.1 years. The location of the lesions in the pancreatic gland, from which the second biopsies were taken, was head of the pancreas, n = 28 (82.4%), body of the pancreas, n = 3 (8.8%), and tail, n = 3 (8.8%). The mean ± SD of the size of the lesion was 36.3 ± 14.6 mm. The second EUS-FNA was more likely to be positive for diagnosis in patients with an "atypical" histological result in the first EUS-FNA (odds ratio [OR]: 4.04; 95% confidence interval [CI]: 0.9-18.3), in contrast to patients with a first EUS-FNA reported as "normal" (OR: 0.21; 95% CI: 0.06-0.71). Overall, the diagnostic yield of the second EUS-FNA was 58.8% (20/34) with an increase to 86.3% overall (222/257). CONCLUSION: Repeat EUS-FNA in pancreatic lesions is necessary in patients with a negative first EUS-FNA because it improves the diagnostic yield.

High rate of post-ERCP pancreatitis in patients undergoing endoscopic treatment of benign biliary stricture.

INTRODUCTION AND AIM: Endoscopic treatment is the best option for patients with postsurgical stricture of main biliary duct. There is scarce information about the incidence of post-endoscopic retrograde cholangiopancreatography (ERCP) complications in this condition. The aim was to evaluate the incidence of complications and the associated risk factors in patients undergoing ERCP for postcholecystectomy biliary stricture. MATERIALS AND METHODS: Prospective analysis of patients with postsurgical stenosis of main biliary duct was carried out. Rate of post-ERCP complications was determined and the associated risk factors were analyzed. RESULTS: A total of 25 patients were included. The success rate of endoscopic treatment was 92% (n=23). Two patients had recurrence of stricture with median follow-up of 23 months (range, 0.3 to 65.4 mo). Five patients (20%) developed acute pancreatitis after ERCP. No risk factors were detected in multivariate analysis. CONCLUSION: Incidence of post-ERCP pancreatitis is high in patients with biliary stricture associated with surgical procedures.

Efficacy and tolerability of low-volume (2 L) versus single- (4 L) versus split-dose (2 L + 2 L) polyethylene glycol bowel preparation for colonoscopy: randomized clinical trial.

BACKGROUND AND AIM: To compare the efficacy and tolerability of a low-volume (2-L) polyethylene glycol (PEG) regimen for colonoscopy compared to single (4-L) or split-dose (2-L + 2-L) regimens. METHODS: In-hospital patients who were candidates for colonoscopy were randomly assigned to: group 1 single-dose (PEG 4 L the day before the study, n = 60); group 2: split-dose (2 L the day before and 2 L on the day of the procedure, n = 61); and group 3: low-volume 2-L PEG solution (the day of the procedure, n = 59). A blinded evaluation of the quality of colonic preparation was assessed by the Boston bowel preparation scale. RESULTS: Satisfactory bowel preparation of the right colon was more frequently reported for group 3 than for group 1 (70% vs 53%, P = 0.045), in the transverse colon it was 82% versus 69% (P = 0.032), and on the left side of the colon it was 80% versus 67.7% (P = 0.028). Compared to group 2, satisfactory bowel preparation in group 3 was similar in the transverse colon and left colon. Nausea, vomiting, and abdominal discomfort were less frequent in patients of group 3. Patients in group 3 had fewer sleep disorders and fewer hours of sleep loss compared to patients in the other groups. CONCLUSIONS: Preparation with 2 L caused less abdominal discomfort and fewer sleep disorders. The split dose had a better quality of preparation in the right colon. Both preparations were clearly better than the 4-L preparation.

Inflammatory myofibroblastic tumour of the liver. Case report.

Inflammatory myofibroblastic tumour (IMT), also called inflammatory pseudotumour, is an uncommon neoplastic benign lesion histopathologically characterized by fibroblast and myofibroblast proliferation, with inflammatory cell infiltration. Systemic inflammatory response can appear although specific pathogens are rarely found. We present a case of a woman in whom liver abscess was initially suspected The absence of microorganisms in the tissue obtained by needle aspiration biopsy and the lack of antibiotic therapy response indicated hepatic resection that lead to diagnosis of IMT of the liver, which has to be differentiated from abscess and abscessed tumours. The aim of this case report is to analyze the clinical presentation, course, diagnostic methods, therapies, and existing evidence of the possible pathogenic mechanisms leading to this neoplasm.

Rapid diagnosis of spontaneous bacterial peritonitis using leukocyte esterase reagent strips in emergency department: uri-quick clini-10SG® vs. Multistix 10SG®.

BACKGROUND AND AIM: Bacterial peritonitis (SBP) is the most frequent infection in patients with cirrhosis causing significant mortality. Delay in SBP diagnosis is a serious problem. The aim of this study was to evaluate the diagnostic yield of Uri-Quick Clini-10SG® vs. Multistix 10SG® reagent strips in an Emergency Department. MATERIAL AND METHODS: A prospective study of consecutive patients with ascites and paracentesis attending to Emergency Department from March 2005 to February 2007 was made. SBP was defined by ≥ 250 neutrophiles /mm³. The ascites obtained at bedside was immediately tested in a dry test tube with both the Uri-Quick Clini 10SG® and MultistixSG10®. The Uri-Quick Clini 10SG® and Multistix SG10®. Strips were considered positive at grade ≥ 3 (≥ 125 leukocytes/mL). RESULTS: A total of 223 ascitic fluid samples were obtained. There were 49 episodes of SBP. Median age was 54 (range 18-87 year) years; 62.3% were female. The sensitivity, specificity, PPV, NPV, and 95% CI for Uri-Quick Clini 10SG® were 79.6 (64-87), 98.2 (94-99), 90.5 (78-96) and 93.9 (89-96), respectively. For MultistixSG10® the values were 77.5 (64-88), 97.7 (93-98), 90 (77.9-96.2), and 94 (89.4-96.6), respectively. CONCLUSION: The use of reagent strip is useful for SBP diagnosis in an emergency setting. The high PPV allow start antibiotic treatment. In areas without the resources to perform conventional ascites fluid analyses, these strips could be presently used.

Vascular invasion in pancreatic cancer: predictive values for endoscopic ultrasound and computed tomography imaging.

OBJECTIVES: To evaluate the accuracy of endoscopic ultrasound (EUS) to determine vascular invasion in patients with pancreatic cancer. METHODS: Data were obtained prospectively from patients with a pancreatic lesion who underwent EUS, computed tomographic (CT) imaging, and surgery from March 2005 to March 2010. RESULTS: Fifty patients were included with a mean ± SD age 61 ± 11.5 years; 27 (54%) were women. The sensitivity, specificity, positive predictive value, and negative predictive value for EUS were the following: 61.1 (95% CI, 38.6-79.7), 90.3 (95% CI, 75.1-96.7), 78.6 (95% CI, 52.4-92.4), and 80 (95% CI, 64.1-90), respectively. The area under the curve for EUS and that for CT were 0.80 (95% CI, 0.68-0.92) and 0.74 (95% CI, 0.61-0.86), respectively. The positive predictive value for arterial invasion was 100% (95% CI, 61-100) for EUS and 60% (95% CI, 31.3-83.2) for CT. There were no complications associated with the EUS or the CT. CONCLUSION: Endoscopic US is a very good option to detect vascular invasion in patients with pancreatic cancer and is especially sensitive for arterial invasion. When it is available, we recommend that it be performed in addition to CT staging.

[Clinical characteristics associated to resectability in patients with tumors of the ampulla of Vater in a third-level hospital in Mexico: an 18-year experience]. / Caracteristicas clínicas asociadas a resecabilidad en pacientes con tumores del ámpula de Vater en un hospital de tercer nivel en Mexico: experiencia de 18 años.

BACKGROUND: Ampulla of Vater's tumors (AVT) are rare and account for 0.2% of neoplasia in necropsies. The stage, comorbidities and surgical experience are crucial for prognosis. The aim of this work is to report the clinical characteristics, treatment and complication of a group of patients with AVT. MATERIAL AND METHODS: Patients with AVT were included in a retrospective manner. Descriptive statistics was used and data were shown as means and SD. RESULTS: One hundred and six patients were included with a mean age of 58.5 +/- 14 years and 58% were women. Jaundice was the most common clinical data and it was present in 90% of cases. Two-thirds of patients underwent a Whipple surgical procedure. Complications of surgery were present in 35% of cases and abdominal sepsis and pancreatic fistulae were the most common (32% and 29%, respectively). Adenocarcinoma was the most common histological type and 39% of cases were in stage IV at diagnosis. Age higher or equal to 65 years was associated with less surgical possibilities. Melena at presentation was associated with a higher probability of surgical resection. CONCLUSION: The probability of surgical resection is lower in patients older than 65 years and higher in those with melena at the diagnosis.

[Surgical treatment of familial adenomatous polyposis with an open technique. Experience of a third level Latin American center]. / Tratamiento quirúrgico de la poliposis adenomatosa familiar con técnica abierta. Experiencia de un centro latinoamericano de tercer nivel.

INTRODUCTION: The ileal pouch-anal anastomosis (IPAA) and ileorectal anastomosis (IRA) are the preferred surgical methods in patients with familial adenomatous polyposis (FAP). OBJECTIVE: To describe the results obtained from the surgical treatment in patients with FAP related to morbidity, mortality, rectal cancer and overall survival. METHODS: We studied a retrospective cohort including all patients operated on with IPAA or IRA for FAP during the period of 1969 to 2000 at the Instituto Nacional de Ciencias Medicas y Nutricion Salvador Zubiran. RESULTS: Twenty-six patients were included. IRA was performed in 9 patients and IPAA in 17. Surgical morbidity was observed in 5 patients (19.2%). Mean postoperative follow-up was 68.8 +/- 58.8 months (median 52.5 months, range 0-240 months). Functional results were similar in both groups. The five year survival in patients with IPAA and IRA was 100% and 55.6%, respectively (P = 0.035). CONCLUSIONS: In our institution, postoperative morbidity and mortality in patients with FAP are similar to those published in the literature. IPAA seems to offer better results related to survival with similar functional results and postoperative complications.

Bacterial meningitis in cirrhotic patients: case series and description of the prognostic role of acute renal failure.

AIM: To analyze the mortality risk factors in cirrhotic patients with bacterial meningitis (BM). BACKGROUND: Cirrhotic patients are susceptible to infections. Despite its high mortality rate, BM has not been extensively studied in this group of patients. STUDY: BM patients diagnosed with cirrhosis, between 1987 and 2008, were studied. BM was defined as the presence of signs or symptoms of meningitis and a cerebrospinal fluid (CSF) leukocyte count >100/mm3 or the presence of bacteria in CSF. RESULTS: We identified 4955 infections among 7591 cirrhotic patients; 12 (0.2%) had BM. The mean age at diagnosis was 60±16 years. Abnormal mental status (83%), fever (67%), and neck stiffness (67%) were the most frequent clinical presentations. The sensitivity of CSF culture was 75% (Streptococcus pneumoniae, 2; Staphylococcus aureus, 2; Listeria monocytogenes, 1; Group B Streptococcus, 1; Streptococcus agalactiae, 1; Streptococcus bovis, 1; and Escherichia coli, 1), and its correlation with blood culture was 78%. Five patients died. On admission, the serum creatinine level was 1.63±0.93 mg/dL. A serum creatinine level ≥1.3 mg/dL was associated with increased mortality (P=0.028). The model for end-stage liver disease score, gastrointestinal bleeding, bilirubin level >3.5 mg/dL, hepatic encephalopathy, diabetes mellitus, and results of cytology and biochemistry tests of CSF were not associated with mortality. CONCLUSIONS: BM in cirrhotic patients is associated with a high mortality rate. The clinical and microbiologic features of BM in cirrhotic patients differ from those in the general population. A serum creatinine level ≥1.3 mg/dL on admission is associated with a higher risk of mortality.