ENDOSONOGRAPHY-GUIDED RESCUE PROCEDURES AFTER FAILED ERCP IN A PATIENT WITH PANCREATIC DUCTAL ADENOCARCINOMA.

BACKGROUND: • The ERCP even when done by experienced professionals, fails in 10% of cases. BACKGROUND: • Until the development of the EUS-BD, PTBD had a role as a rescue therapy, despite a high rate of adverse events. BACKGROUND: • The EUS-BD is safe and has similar efficacy, when compared to PTBD and should be performed immediately after ERCP failure. BACKGROUND: • A doctor with skills in both methods (ERCP/EUS) is needed to determine the best EUS-guided therapeutic option.

Clinical usefulness of tissue acquisition of pancreatic cystic lesions using an endoscopic ultrasound-guided needle for histological analysis.

Background and study aims There are rare data on the usefulness of endosonography-guided tissue acquisition (EUS-TA) in patients with pancreatic cystic lesions (PCLs). This study aimed to determine the accuracy of EUS-TA with ProCore 20G (PC20) for differentiating between mucinous neoplasia (MN) and non-MNs (n-MN) and identifying malignant PCLs, as well as its adverse events (AEs) in patients with PCLs without a classificatory diagnosis by imaging exams. Patients and methods In this observational, retrospective, single-center study, all patients with PCL who underwent EUS-TA due to diagnostic doubts in imaging studies were consecutively recruited from June 2017 to December 2021. The outcomes were to determine the diagnostic accuracy of EUS-TA with PC20 for differentiating between MN and n-MN, identifying malignant PCLs, and the AEs. Results Herein, 145 patients underwent EUS-TA, with 83 women (57.2%) and a mean age of 62.2 years. The mean size was 2.3 cm, with 81 patients (77.9%) having a PCL < 3.0 cm. The final diagnosis was made by EUS-TA (n = 81), surgery (n = 58), and follow-up (n = 6). The sensitivity, specificity, positive and negative predictive values, and accuracy for differentiating between MNs and n-MNs and identifying malignant PCLs were 92.6%, 98.4%, 98.7%, 91.3%, and 95.2% (kappa=0.9), and 92%, 99.2%, 95.8%, 98.3%, and 97.9% (kappa = 0.93), respectively. The AE rate was 2.7%, with no deaths in this cohort. Conclusions EUS-TA with PC20 has high accuracy and technical success with a low AE rate for PCL diagnosis.

The Safety and Cost Analysis of Outpatient Laparoendoscopy in the Treatment of Cholecystocholedocholithiasis: A Retrospective Study.

INTRODUCTION: The advantages of single-stage treatment of cholecystocholedocholithiasis are well established, but the conditions for carrying out treatment on an outpatient basis require a review of concepts and practices of medical corporations. OBJECTIVE: To evaluate the practice of treating cholecystocholedocholithiasis by laparoendoscopy on an outpatient basis with cost analysis. METHOD: A retrospective study was conducted on patients with cholecystocholedocholithiasis treated by combined laparoscopic cholecystectomy and endoscopic choledocholithotomy from January 2015 to January 2019. After collecting data from physical and digital medical records, the patients were divided into two groups-AR (n = 42)-ambulatory regimen and HR (n = 28)-hospitalization regimen-which were compared in terms of demographic, clinical and treatment variables and their results, as well as in terms of costs. RESULTS: The mean age of the AR group was lower than that of the HR group and the physical status of the AR patients was better when assessed according to the American Society of Anesthesiologists (ASA) (p = 0.01). There was no difference between groups regarding the risk of choledocholithiasis (p = 0.99). For the AR group, the length of stay was shorter: 11.29 h × 65.21 h (p = 0.02), as was the incidence of postoperative complications assessed by applying the Clavien-Dindo classification: 3 (7.1%) × 11 (39.2%) (p < 0.01). The total mean costs were higher for the HR group (USD 2489.93) than the AR group (USD 1650.98) (p = 0.02). CONCLUSION: Outpatient treatment of cholecystocholedocholithiasis by laparoendoscopy is safe and viable for most cases, has a lower cost and can support the reorientation of training and practice of hepatobiliary surgeons.

PERFORMANCE OF AGA, FUKUOKA AND EUROPEAN GUIDELINES IN INCIDENTALOMAS OF THE PANCREAS SUBMITTED TO ENDOSCOPIC ULTRASOUND WITH FINE NEEDLE PUNCH / DESEMPENHO DAS DIRETRIZES AGA, FUKUOKA E EUROPEIA NOS INCIDENTALOMAS MUCINOSOS DO PÂNCREAS SUBMETIDOS À ULTRASSONOGRAFIA ENDOSCÓPICA COM PUNÇÃO POR AGULHA FINA

Introduction: Pancreatic cystic lesions are common and are not exclusively benign. There are 3 guidelines that help recommend surgery if there is a risk factor, sign of malignancy or follow the patient with imaging tests. Objective: To review and compare the performance of these guidelines in asymptomatic patients with mucinous neoplasms. Method: The literature review was carried out by collecting information published on virtual platforms in Portuguese and English. The material for reading and analysis was selected from the SciELO, Google Scholar, Pubmed and Scopus platforms. Initially, a search was carried out using the keywords "mucinous cystic neoplasm. pancreatic intraductal neoplasms. endoscopic ultrasound. fine needle aspiration" with AND or OR search, considering the title and/or abstract. Afterwards, considering only those that were most related to the topic, the full texts were read. Results: 37 articles were included. Conclusion: The European Guideline-DE-2018 proved to be more accurate for use in patients with asymptomatic mucinous neoplasia after the diagnosis obtained by EUS-PAF.

Introdução: As lesões císticas pancreáticas são comuns e não são exclusivamente benignas. Existem 3 diretrizes que ajudam a indicar cirurgia no caso de haver algum fator de risco, sinal de malignidade ou acompanhar o paciente com exames de imagem. Objetivo: Revisar e comparar o desempenho dessas diretrizes em neoplasias mucinosas identificados de forma incidental. Método: A revisão da literatura foi feita colhendo informações publicadas em plataformas virtuais em português e inglês. O material para leitura e análise foi selecionado das plataformas SciELO, Google Scholar, Pubmed e Scopus. Inicialmente foi realizada busca por descritores "neoplasia cística mucinosa. neoplasias intraductais pancreáticas. ultrassonografia endoscópica. aspiração por agulha fina" com busca AND ou OR, considerando o título e/ou resumo. Após, considerando-se somente os que tinham maior relação ao tema, foi realizada a leitura da íntegra dos textos. Resultados: Foram incluídos 37 artigos. Conclusão: A Diretriz Europeia- DE-2018 mostrou-se mais precisa para ser utilizada em pacientes com neoplasia mucinosa assintomática após o diagnóstico obtido pela USE-PAF.

Multicenter Study on the Performance of Imaging Tests Compared to Endosonography-Guided Fine-Needle Aspiration in the Diagnosis of Solid Pseudopapillary Neoplasms of the Pancreas.

Introduction: Imaging diagnosis of pancreatic solid-pseudopapillary neoplasms (SPNs) is difficult. Preoperative diagnosis by endosonography-guided fine-needle aspiration (EUS-FNA) is possible and has been reported in the literature in pancreatic tumors. However, its usefulness is still controversial. The aim of this study was to determine the accuracy of the EUS-FNA in the diagnosis of patients with SPN and describe the findings in computerized tomography (CT), magnetic resonance cholangiopancreatography imaging (MRI/MRCP), and EUS therefore comparing the imaging methods alone to the findings of microhistology (McH) obtained by EUS-FNA. Materials and Methods: We retrospectively reviewed the medical records of patients undergoing EUS-FNA with suspected SPN in imaging studies in 5 Brazilian high-volume hospitals (two university hospitals and three private hospitals). The demographic data; findings in CT, MRI/MRCP, and EUS; and McH results obtained by EUS-FNA were noted prospectively. The final diagnosis was obtained after the anatomopathological examination of the surgical specimen in all patients (gold standard), and we compared the results of CT, MRI/MRCP, EUS, and the McH with the gold standard. Results: Fifty-four patients were included in the study, of which 49 (90.7%) were women with an average age of 33.4 (range 11-78) years. The most common symptom presented was abdominal pain, present in 35.2% patients. SPN was detected incidentally in 32 (59%) patients. The average size of the tumors was 3.8 cm (SD: 2.26). The most common finding at EUS was a solid, solid/cystic, and cystic lesion in 52.9%, 41.1%, and 7.8% patients, respectively. The final diagnosis was 51 patients with SPN and 3 with nonfunctioning pancreatic neuroendocrine tumors (NF-NET). The correct diagnosis was made by CT, MRI/MRCP, EUS isolated, and EUS-FNA in 21.9%, 28.88%, 64.71%, and 88.24%, respectively. EUS-FNA associated with CT and MRI increased diagnostic performance from 22.72% to 94.11% and from 29.16% to 94.11%, respectively. Conclusions: SPN are rare, incidentally identified in most cases, and affect young women. Differential diagnosis between SPN, NF-NET, and other types of tumors with imaging tests can be difficult. EUS-FNA increases preoperative diagnosis in case of diagnostic doubt and should be used whenever necessary to rule out NF-NET or other type of solid/cystic nodular lesion of the pancreas.

Introdução: O diagnóstico por imagem da neoplasia pseudopapilar sólida do pâncreas (NPS) é difícil. O diagnóstico pré-operatório obtido pela endosonografia com punção aspirativa por agulha fina (USE-PAF) é possível e tem sido relatado na literatura em tumores do pâncreas. No entanto, sua indicação é controversa e merece discussão. O objetivo do estudo foi determinar a acurácia da USE-PAF no diagnóstico de pacientes com NPS, descrever os achados da tomografia computadorizada (TC), colangiopancreatografia por ressonância magnética (RM/ CPRM) e USE, comparando os métodos de imagem isolados aos achados da microhistologia (McH) obtida pela USE-PAF. Material e Métodos: Revisamos retrospectivamente os prontuários de pacientes submetidos à USE-PAF com suspeita de NPS em exames de imagem de 5 hospitais brasileiros de alto volume (dois universitários e três privados). Foram anotados prospectivamente os dados demográficos, os achados da TC, RM/CPRM e USE e o resultado da McH obtida pela USE-PAF. O diagnóstico final foi obtido após o anatomopatológico da peça operatória em todos os pacientes (padrão-ouro). Comparamos os resultados da TC, RM/CPRM, EUS isoladas e da McH obtida pela USE-PAF com o padrão-ouro. Resultados: Cinquenta e quatro pacientes foram incluídos no estudo, 49 (90.7%) eram mulheres com média de idade de 33.4 (11­78) anos. O sintoma mais frequente foi dor abdominal, presente em 35.2%. A NPS foi detectada acidentalmente em 32 (59%) pacientes. O tamanho médio da lesão foi de 3.8 cm (SD: 2.26). O achado mais comum à USE foi lesão sólida, sólida/ cística e cística em 52.9%, 41.1% e 7.8%, respectivamente. O diagnóstico final foi NPS (51) e tumor neuroendócrino pancreático não funcionante [NF-NET] (3). O diagnóstico correto feito pela TC, RM, USE e USE-PAF foi feito em 21.9%, 28.9%, 64.7% e 88.2%, respectivamente. A USEPAF associada a TC e a RM aumentou o desempenho diagnóstico de 21.9% para 94.1% e de 28.8% para 94.1%, respectivamente. Conclusões: NPS são raras, identificadas de forma acidental na maioria dos casos e afetam principalmente mulheres jovens. O diagnóstico diferencial entre NPS, NF-NET e outros tipos de lesões com exames de imagem isolados pode ser difícil. A USE-PAF aumenta a chance do diagnóstico pré-operatório em caso de dúvida diagnóstica e deve ser usado sempre que necessário para descartar NF-NET ou outro tipo de lesão nodular sólida ou sólido/cística do pâncreas.

THE IMPACT OF THE COVID-19 PANDEMIC ON ENDOSCOPIC ULTRASOUND PROCEDURES IN A HIGH-VOLUME ENDOSCOPY UNIT IN BRAZIL.

•In pancreatic neoplasms the EUS plays a key role in the management. •During the pandemic period, lockdown measures prevented patients with comorbidities from performing EUS. •The D-EUS decreased during COVID-19, while I-EUS increased and EUS-TA was the most commonly I-EUS procedure performed, with no increase in adverse events. •Despite the moderate impact of the pandemic period in endoscopic services around the world, EUS-TA of solid and cystic tumors of the pancreas was the main indication. Background - Reports of the impact of the 2020 COVID-19 pandemic period/2020 on endoscopic ultrasound (EUS) are scarce. Objective - We analyzed the impact of the pandemic period/2020 on the demographics, indications, and number of diagnostic EUS (D-EUS) and interventional EUS (I-EUS) procedures performed in a high-volume endoscopy unit compared with the previous non-pandemic period/2019. Methods - We retrospectively reviewed the medical records of all patients undergoing D-EUS or I-EUS from March 1, 2019, to February 29, 2020 (non-pandemic period/2019) and from March 1, 2020, to February 28, 2021 (pandemic period/2020). Data compared between the study periods included sex, age, comorbidities, EUS findings and diagnosis, need for interventional procedures during EUS, and adverse events (AEs). Results were significant at P<0.05. Results - EUS procedures decreased from 475 in the non-pandemic period/2019 to 289 in the pandemic period/2020, accounting for a 39% reduction. In non-pandemic period/2019, 388 (81.7%) D-EUS and 88 (18.5%) I-EUS were performed, against 206 (71.3%) D-EUS and 83 (28.7%) I-EUS in pandemic period/2020 (P=0.001). Only 5/289 (1.7%) patients had COVID-19. Fewer patients with comorbidities underwent EUS during pandemic period/2020 due to lockdown measures (P<0.001). D-EUS decreased, whereas I-EUS increased (P<0.001). EUS-guided tissue acquisition (EUS-TA) was the most common I-EUS, performed in 83/289 (28.7%) patients in pandemic period/2020, against 88/475 (18.5%) in non-pandemic period/2019 (P=0.001). AEs did not differ significantly between the study periods. Conclusion - Pandemic Period/2020 had a moderate impact on reducing EUS procedures due to the risks involved. Although I-EUS increased, EUS-related AEs did not. Solid and cystic pancreatic tumors remained a major indication for EUS-TA even during the pandemic period/2020.

Impacto da pandemia de COVID-19 nos procedimentos de ultrassonografia endoscópica em uma unidade de endoscopia de alto volume no Brasil / The impact of the covid-19 pandemic on endoscopic ultrasound procedures in a high-volume endoscopy unit in brazil

ABSTRACT Background: Reports of the impact of the 2020 COVID-19 pandemic period/2020 on endoscopic ultrasound (EUS) are scarce. Objective: We analyzed the impact of the pandemic period/2020 on the demographics, indications, and number of diagnostic EUS (D-EUS) and interventional EUS (I-EUS) procedures performed in a high-volume endoscopy unit compared with the previous non-pandemic period/2019. Methods: We retrospectively reviewed the medical records of all patients undergoing D-EUS or I-EUS from March 1, 2019, to February 29, 2020 (non-pandemic period/2019) and from March 1, 2020, to February 28, 2021 (pandemic period/2020). Data compared between the study periods included sex, age, comorbidities, EUS findings and diagnosis, need for interventional procedures during EUS, and adverse events (AEs). Results were significant at P<0.05. Results: EUS procedures decreased from 475 in the non-pandemic period/2019 to 289 in the pandemic period/2020, accounting for a 39% reduction. In non-pandemic period/2019, 388 (81.7%) D-EUS and 88 (18.5%) I-EUS were performed, against 206 (71.3%) D-EUS and 83 (28.7%) I-EUS in pandemic period/2020 (P=0.001). Only 5/289 (1.7%) patients had COVID-19. Fewer patients with comorbidities underwent EUS during pandemic period/2020 due to lockdown measures (P<0.001). D-EUS decreased, whereas I-EUS increased (P<0.001). EUS-guided tissue acquisition (EUS-TA) was the most common I-EUS, performed in 83/289 (28.7%) patients in pandemic period/2020, against 88/475 (18.5%) in non-pandemic period/2019 (P=0.001). AEs did not differ significantly between the study periods. Conclusion: Pandemic Period/2020 had a moderate impact on reducing EUS procedures due to the risks involved. Although I-EUS increased, EUS-related AEs did not. Solid and cystic pancreatic tumors remained a major indication for EUS-TA even during the pandemic period/2020.

RESUMO Contexto: Os dados sobre o impacto da pandemia de COVID-19 2020 na ultrassonografia endoscópica (EUS) são escassos. Objetivo: Analisamos o impacto do período pandêmico/2020 na demografia, indicações e número das EUS diagnósticas (D-EUS) e intervencionistas EUS (I-EUS) realizados em uma unidade de endoscopia de alto volume e os comparamos com o período imediatamente anterior não-pandêmico/2019. Métodos: Revisamos retrospectivamente os prontuários de todos os pacientes submetidos a D-EUS ou I-EUS de 1 de março de 2019 a 29 de fevereiro de 2020 (período não-pandêmico/2019) e de 1º de março de 2020 a 28 de fevereiro de 2021 (período da pandemia/2020). Comparamos os dados entre os períodos do estudo incluímos o sexo, idade, comorbidades, achados e diagnóstico da EUS, necessidade de procedimentos intervencionistas durante a EUS e a ocorrência de eventos adversos (EAs). Os resultados foram significativos com P<0,05. Resultados: O número de ecoendoscopias diminuíram de 475 no período não-pandêmico/2019 para 289 no período pandêmico/2020, representando uma redução de 39%. No período não-pandêmico/2019 e pandêmico/2020 foram realizados 388 (81,7%) D-EUS e 88 (18,5%) I-EUS, contra 206 (71,3%) D-EUS e 83 (28,7%) I-EUS, respectivamente (P=0,001). Apenas 5/289 (1,7%) pacientes tinham COVID-19. Menos pacientes com comorbidades realizaram EUS durante o período pandêmico/2020 devido as medidas de bloqueio (P<0,001). D-EUS diminuiu, enquanto I-EUS aumentou (P<0,001). A EUS associada a aquisição tecidual (EUS-AT) foi a I-EUS mais comum, realizada em 83/289 (28,7%) pacientes no período pandêmico/2020, versus 88/475 (18,5%) no período não-pandêmico/2019 (P=0,001). Os EAs não diferiram significativamente entre os períodos do estudo. Conclusão: O período da pandemia/2020 teve impacto moderado na redução da EUS devido aos riscos envolvidos. Embora o I-EUS tenha aumentado, os EAs relacionados ao EUS não aumentaram. Os tumores pancreáticos sólidos e císticos permaneceram como uma das principais indicações para EUS-AT mesmo durante o período pandêmico/2020.

CHRONIC ANEMIA CAUSED BY GIANT AND SOLITARY PEUTZ-JEGHERS HAMARTOMATOUS POLYP TREATED BY ENDOSCOPIC RESECTION.

•Giant and solitary polyps evolve with anemia. •EUS is an important tool for stage and manage this disease. •Endoscopic treatment is the best treatment choice. •Supplementary video available on this case report.

Endoscopic Ultrasound-Guided Gallbladder Drainage Versus Percutaneous Drainage in Patients With Acute Cholecystitis Undergoing Elective Cholecystectomy.

INTRODUCTION: Cholecystectomy (CCY) is the gold standard treatment of acute cholecystitis (AC). Nonsurgical management of AC includes percutaneous transhepatic gallbladder drainage (PT-GBD) and endoscopic ultrasound-guided gallbladder drainage (EUS-GBD). This study aims to compare outcomes of patients who undergo CCY after having received EUS-GBD vs PT-GBD. METHODS: A multicenter international study was conducted in patients with AC who underwent EUS-GBD or PT-GBD, followed by an attempted CCY, between January 2018 and October 2021. Demographics, clinical characteristics, procedural details, postprocedure outcomes, and surgical details and outcomes were compared. RESULTS: One hundred thirty-nine patients were included: EUS-GBD in 46 patients (27% male, mean age 74 years) and PT-GBD in 93 patients (50% male, mean age 72 years). Surgical technical success was not significantly different between the 2 groups. In the EUS-GBD group, there was decreased operative time (84.2 vs 165.4 minutes, P < 0.00001), time to symptom resolution (4.2 vs 6.3 days, P = 0.005), and length of stay (5.4 vs 12.3 days, P = 0.001) compared with the PT-GBD group. There was no difference in the rate of conversion from laparoscopic to open CCY: 5 of 46 (11%) in the EUS-GBD arm and 18 of 93 (19%) in the PT-GBD group ( P value 0.2324). DISCUSSION: Patients who received EUS-GBD had a significantly shorter interval between gallbladder drainage and CCY, shorter surgical procedure times, and shorter length of stay for the CCY compared with those who received PT-GBD. EUS-GBD should be considered an acceptable modality for gallbladder drainage and should not preclude patients from eventual CCY.

NECROTIZING PANCREATITIS WITH A RECURRING PANCREATIC PSEUDOCYST TREATED BY ENDOSCOPIC DUODENUM-GASTROPANCREATIC ANASTOMOSIS.

•ANP might evolve to MPD rupture which favors PP recurrence. •In cases of MPD rupture the pancreatic tail must be drained to the stomach. •Endoscopic duodenum-gastropancreatic anastomosis is a treatment option.

A gastric neuroendocrine tumor after prolonged use of proton pump inhibitors.

We describe a case of a gastric neuroendocrine tumor (NET) in a patient with a history of long- term proton pump inhibitor (PPI) use. A 29- year- old man using PPI for the last 10 years due to gastroesophageal reflux disease developed progressive bouts of heartburn. Upper gastrointestinal endoscopy localized an elevated lesion with central depression in the greater curvature of gastric body. Lesion biopsies revealed a well- differentiated neuroendocrine tumor. Despite PPIs have a well- established safety profile, concerns have been raised about a potential relationship between PPI- induced hypergastrinemia and the development of neuroendocrine tumors.

IMPACT OF DIAGNOSTIC AND INTERVENTIONAL ENDOSCOPIC ULTRASONOGRAPHY IN CHILDREN.

BACKGROUND: Endoscopic ultrasonography is used in the diagnosis and treatment of digestive diseases in adults. In children, its use is limited due to a lack of available expertise. OBJECTIVE: This study aimed to evaluate the clinical impact of endoscopic ultrasonography on diagnostic and therapeutic strategy changes in pediatric patients. METHODS: Over ten years, this study retrospectively and consecutively analyzed children aged ≤18 years who underwent endoscopic ultrasonography because of inconclusive imaging or laboratory tests. The indications, results, occurrence of adverse events, and clinical impact of the procedures were analyzed. The clinical impact was classified as major (when the findings led to changes in diagnosis and management), minor (change in diagnosis but not in management), or none (no change in diagnosis or management). RESULTS: Overall, 107 children [77 (72%) of whom were female; mean age: 11.7 ± 4 years] underwent upper [102 (95.3%)] and lower [5 (4.7%)] endoscopic ultrasonography; 64 (58%) patients underwent diagnostic endoscopic ultrasonography, and 43 (42%) underwent interventional endoscopic ultrasonography. Endoscopic ultrasonography was used to investigate pancreaticobiliary, gastric, rectal, esophageal, duodenal, and mediastinal diseases in 81 (76%), 14 (13%), 5 (4.6%), 3 (2.8%), 2 (1.8%), and 2 (1.8%) patients, respectively. The clinical impact was significant in 81% of the children. Major and no clinical impact on pancreaticobiliary, gastrointestinal diseases, and mediastinal masses occurred in 50 (62%) and 13 (16%), 13 (54%) and 9 (37%), and 2 (100%) and 0 (0%) of the patients, respectively. CONCLUSION: This study evaluated the impact of diagnostic and interventional endoscopic ultrasonography in pediatric patients. When clinically and appropriately indicated, these procedures are safe and effective diagnostic or therapeutic interventions in pediatric patients with gastrointestinal or pancreaticobiliary disorders.

Impacto da ecoendoscopia diagnóstica e terapêutica nas crianças / Impact of diagnostic and interventional endoscopic ultrasonography in children

ABSTRACT Background: Endoscopic ultrasonography is used in the diagnosis and treatment of digestive diseases in adults. In children, its use is limited due to a lack of available expertise. Objective: This study aimed to evaluate the clinical impact of endoscopic ultrasonography on diagnostic and therapeutic strategy changes in pediatric patients. Methods: Over ten years, this study retrospectively and consecutively analyzed children aged ≤18 years who underwent endoscopic ultrasonography because of inconclusive imaging or laboratory tests. The indications, results, occurrence of adverse events, and clinical impact of the procedures were analyzed. The clinical impact was classified as major (when the findings led to changes in diagnosis and management), minor (change in diagnosis but not in management), or none (no change in diagnosis or management). Results: Overall, 107 children [77 (72%) of whom were female; mean age: 11.7 ± 4 years] underwent upper [102 (95.3%)] and lower [5 (4.7%)] endoscopic ultrasonography; 64 (58%) patients underwent diagnostic endoscopic ultrasonography, and 43 (42%) underwent interventional endoscopic ultrasonography. Endoscopic ultrasonography was used to investigate pancreaticobiliary, gastric, rectal, esophageal, duodenal, and mediastinal diseases in 81 (76%), 14 (13%), 5 (4.6%), 3 (2.8%), 2 (1.8%), and 2 (1.8%) patients, respectively. The clinical impact was significant in 81% of the children. Major and no clinical impact on pancreaticobiliary, gastrointestinal diseases, and mediastinal masses occurred in 50 (62%) and 13 (16%), 13 (54%) and 9 (37%), and 2 (100%) and 0 (0%) of the patients, respectively. Conclusion: This study evaluated the impact of diagnostic and interventional endoscopic ultrasonography in pediatric patients. When clinically and appropriately indicated, these procedures are safe and effective diagnostic or therapeutic interventions in pediatric patients with gastrointestinal or pancreaticobiliary disorders.

RESUMO Contexto: A ecoendoscopia (EUS) faz parte da prática clínica diária no diagnóstico e tratamento de doenças digestivas em adultos, no entanto, seu uso em crianças é limitado. Objetivo: O objetivo do trabalho foi avaliar o impacto clínico da ecoendoscopia diagnóstica (EUS-D) e ecoendoscopia intervencionista (EUS-I) na população pediátrica. Métodos: Por um período de 10 anos, analisamos retrospectivamente os prontuários de 107 crianças (≤18 anos) submetidas à ecoendoscopia alta [102 (95.3%)] e ecoendoscopia baixa [5 (4.7%)] que tiveram teste de imagem ou laboratorial inconclusivos. O impacto clínico foi classificado como forte (quando mudou o diagnóstico e a terapêutica), fraco (modificou o diagnóstico, mas não o manejo) e ausente (não houve mudança nem do diagnóstico e nem no manejo). Resultados: 107 meninas (72%) e 30 meninos (28%), média de idade 11.7±4 anos (5-18), foram submetidas à ecoendoscopia. 64 (58%) à EUS-D e 43 (42%) à EUS-I [EUS-FNA em 33 (77%) e 10 (33%) a drenagens (pseudocisto (5), walled off necrosis (2), perirectal abscesso (1)) e neurólise do plexo celíaco (2). O sucesso técnico, clínico e a taxa de efeitos adversos para a EUS-I foram de 100%, 90% e 0%, respectivamente. A via biliopancreática foi estudada em 81 (76%), estômago 14 (13%), reto 5 (4.6%), esôfago 3 (2.8%), duodeno 2 (1.8%) e mediastino 2 (1.8%) casos. O impacto clínico total foi de 81%. O impacto clínico foi forte e fraco para a via biliopancreática (81), gastrointestinal (24) e mediastinal (2) em 62% e 16%, 54% e 37% e 100% e 0%, respectivamente. A sensibilidade, especificidade e acurácia da EUS-FNA com microhistologia foi de 76.2%, 100% e 84.8%, respectivamente. Conclusão: Os autores concluem que a EUS-D e a EUS-I são efetivas e seguras quando indicadas corretamente para as doenças digestivas em crianças. A EUS-FNA tem elevada acurácia e pode esclarecer a maioria dos casos duvidosos, determinando o diagnóstico preciso das enfermidades digestivas. O impacto clínico foi grande em relação ao diagnóstico e a mudança do tipo de tratamento na maioria das crianças.

Digital single-operator cholangioscopy interobserver study using a new classification: the Mendoza Classification (with video).

BACKGROUND AND AIMS: Digital single-operator cholangioscopy (DSOC) allows direct visualization of the biliary tree for evaluation of biliary strictures. Our objective was to assess the interobserver agreement (IOA) of DSOC interpretation for indeterminate biliary strictures using newly refined criteria. METHODS: Fourteen endoscopists were asked to review an atlas of reference clips and images of 5 criteria derived from expert consensus. They then proceeded to score 50 deidentified DSOC video clips based on the visualization of tortuous and dilated vessels, irregular nodulations, raised intraductal lesions, irregular surface with or without ulcerations, and friability. The endoscopists then diagnosed the clips as neoplastic or non-neoplastic. Intraclass correlation (ICC) analysis was done to evaluate inter-rater agreement for both criteria sets and final diagnosis. RESULTS: Clips of 41 malignant lesions and 9 benign lesions were scored. Three of 5 revised criteria had almost perfect agreement. ICC was almost perfect for presence of tortuous and dilated vessels (.86), raised intraductal lesions (.90), and presence of friability (.83); substantial agreement for presence of irregular nodulations (.71); and moderate agreement for presence of irregular surface with or without ulcerations (.44). The diagnostic ICC was almost perfect for neoplastic (.90) and non-neoplastic (.90) diagnoses. The overall diagnostic accuracy using the revised criteria was 77%, ranging from 64% to 88%. CONCLUSIONS: The IOA and accuracy rate of DSOC using the new Mendoza criteria shows a significant increase of 16% and 20% compared with previous criteria. The reference atlas helps with formal training and may improve diagnostic accuracy. (Clinical trial registration number: NCT02166099.).