Plastic pigtail vs lumen-apposing metal stents for drainage of walled-off necrosis (PROMETHEUS study): an open-label, multicenter randomized trial.

BACKGROUND: Lumen-apposing metal stents (LAMS) have displaced double-pigtail plastic stents (DPS) as the standard treatment for walled-off necrosis (WON),ß but evidence for exclusively using LAMS is limited. We aimed to assess whether the theoretical benefit of LAMS was superior to DPS. METHODS: This multicenter, open-label, randomized trial was carried out in 9 tertiary hospitals. Between June 2017, and Oct 2020, we screened 99 patients with symptomatic WON, of whom 64 were enrolled and randomly assigned to the DPS group (n = 31) or the LAMS group (n = 33). The primary outcome was short-term (4-weeks) clinical success determined by the reduction of collection. Secondary endpoints included long-term clinical success, hospitalization, procedure duration, recurrence, safety, and costs. Analyses were by intention-to-treat. CLINICALTRIALS: gov, NCT03100578. RESULTS: A similar clinical success rate in the short term (RR, 1.41; 95% CI 0.88-2.25; p = 0.218) and in the long term (RR, 1.2; 95% CI 0.92-1.58; p = 0.291) was observed between both groups. Procedure duration was significantly shorter in the LAMS group (35 vs. 45-min, p = 0.003). The hospital admission after the index procedure (median difference, - 10 [95% CI - 17.5, - 1]; p = 0.077) and global hospitalization (median difference - 4 [95% CI - 33, 25.51]; p = 0.82) were similar between both groups. Reported stent-related adverse events were similar for the two groups (36 vs.45% in LAMS vs. DPS), except for de novo fever, which was significantly 26% lower in LAMS (RR, 0.26 [0.08-0.83], p = 0.015). CONCLUSIONS: The clinical superiority of LAMS over DPS for WON therapy was not proved, with similar clinical success, hospital stay and similar safety profile between both groups, yet a significant reduction in procedure time was observed. TRIAL REGISTRATION NUMBER: ClinicalTrials.gov, NCT03100578.

Self-expandable metal stents versus endoscopic balloon dilation for the treatment of strictures in Crohn's disease (ProtDilat study): an open-label, multicentre, randomised trial.

BACKGROUND: Endoscopic balloon dilation (EBD) is the established endoscopic treatment for short strictures in Crohn's disease. Fully covered self-expandable metal stents (FCSEMS) have been used for endoscopic treatment of patients for whom EBD was unsuccessful. We aimed to determine the efficacy and safety of the two endoscopic treatments in patients with Crohn's disease with stenosis and compare the mean cost of both treatments. METHODS: This multicentre, open-label, randomised trial was done in 19 tertiary and secondary hospitals in Spain. Patients with Crohn's disease with obstructive symptoms and predominantly fibrotic strictures of less than 10 cm in length were eligible for inclusion. We excluded patients with stenosis treated with SEMS or EBD in the previous year and stenosis not accessible to a colonoscope. Patients were randomly assigned (1:1) to receive either EBD (EBD group) or FCSEMS (FCSEMS group) using a digital en-block randomisation system (block size of four). In the EBD group, dilation was done with a CRE Boston Scientific (Marlborough, MA, USA) pneumatic balloon with the diameter set at the discretion of the endoscopist; a maximum of two sessions of dilation were allowed with a minimum interval of 15-30 days between them. In the FCSEMS group, a 20 mm diameter Taewoong (Gimpo-si, South Korea) fully covered metal stent was placed; stent length was set at the discretion of the endoscopist. The primary outcome was to assess the efficacy of the endoscopic treatment, defined by the proportion of patients free of a new therapeutic intervention (EBD, FCSEMS, or surgery) due to symptomatic recurrence at 1 year of follow-up. Patients were analysed according to the intention-to-treat principle. Adverse events were recorded for all the patients; events were considered associated to be with the procedure when a causal association was possible, probable, or definite. This trial is registered with ClinicalTrials.gov, NCT02395354. FINDINGS: From Aug 28, 2013, to Oct 9, 2017, we assessed the eligibility of 99 patients, of whom 19 (19%) patients were excluded. Thus, 80 (81%) patients were randomly assigned to treatment: 39 (49%) patients to the FCSEMS group and 41 (51%) patients to the EBD group. 33 (80%) of 41 patients in the EBD group and 20 (51%) of 39 patients in the FCSEMS group were free of a new therapeutic intervention at 1 year (odds ratio [OR] 3·9 [95% CI 1·4-10·6]; p=0·0061). Two (3%) of 80 patients had severe adverse events (one [2%] patient in the EBD group and one [3%] patient in the FCSEMS group); both patients had perforations. INTERPRETATION: EBD is more effective than FCSEMS for Crohn's disease strictures, with a good safety profile for both treatments. FUNDING: Spanish National Institute of Health, Foundation of Spanish Society of Digestive Endoscopy, Catalan Society of Gastroenterology, and Taweoong.

CHOLANGIOPANCREATOSCOPY. WORKING PROTOCOL. SEED Recommendations.

Direct endoscopic visualization of biliary and pancreatic ducts represents one step further in the journey of digestive endoscopy. It allows the identification of lesions that were previously attainable through indirect means. Directed biopsy taking has permitted a better characterization of the lesions. The use of power sources through the cholangiopancreatoscope means that it is now possible to fragment and remove refractory lithiases using traditional endoscopic systems. This document aims to define the advisable workflow when using a single-use, flexible cholangiopancreatoscope with the commercial name of SpyGlass®. Penning a set of guidelines to provide instructions on the technique, as well as tips and tricks related with the operation of these endoscopes will be a useful resource.

Tratamiento de pancreatitis recidivante por páncreas divisum y ansa pancreática mediante técnica de Rendez-Vous guiada por ecoendoscopia / The endoscopic ultrasound-assisted Rendez-Vous technique for treatment of recurrent pancreatitis due to pancreas divisum and ansa pancreatica

El tratamiento endoscópico de malformaciones ductales pancreáticas causantes de pancreatitis aguda de repetición, como el páncreas divisum o el ansa pancreática, se basa fundamentalmente en la esfinterotomía de la papila minor. En estos casos, no obstante, la complejidad técnica de la colangiopancreatografía endoscópica retrógrada (CPRE) convencional es mayor, pudiendo resultar fallida. Presentamos el caso de un páncreas divisum completo combinado con ansa pancreática, sintomático, en el que, tras fracasar el acceso endoscópico convencional a la papila minor, se logra la canulación y esfinterotomía de esta mediante técnica de Rendez-Vous guiada ecoendoscópicamente (AU)

Endoscopic treatment of pancreatic ductal malformations causing recurrent acute pancreatitis, such as pancreas divisum or ansa pancreatica, is mainly based on the sphincterotomy of the minor papilla. However, the technical complexity of conventional endoscopic retrograde cholangiopancreatography (ERCP) is increased in patients presenting anatomical variants like these and it may be unsuccessful. We report the case of a pancreas divisum combined with ansa pancreatica and describe the cannulation and sphincterotomy of the minor papilla using an ultrasound-assisted Rendez-Vous technique (AU)

The endoscopic ultrasound-assisted Rendez-Vous technique for treatment of recurrent pancreatitis due to pancreas divisum and ansa pancreatica.

Endoscopic treatment of pancreatic ductal malformations causing recurrent acute pancreatitis, such as pancreas divisum or ansa pancreatica, is mainly based on the sphincterotomy of the minor papilla. However, the technical complexity of conventional endoscopic retrograde cholangiopancreatography (ERCP) is increased in patients presenting anatomical variants like these and it may be unsuccessful. We report the case of a pancreas divisum combined with ansa pancreatica and describe the cannulation and sphincterotomy of the minor papilla using an ultrasound-assisted Rendez-Vous technique.

Gut eradication of VIM-1 producing ST9 Klebsiella oxytoca after fecal microbiota transplantation for diarrhea caused by a Clostridium difficile hypervirulent R027 strain.

We report the fecal carriage eradication of a VIM-1-producing ST9 Klebsiella oxytoca strain in a pluripathological 84-year-old woman after fecal microbiota transplantation to control relapsing R027 hypervirulent Clostridium difficile infections. The donor was her son, in which the absence of fecal carbapenemase-producing bacteria was corroborated.

La cupruria estimulada en el diagnóstico de la enfermedad de Wilson / Stimulated urinary copper excretion in the diagnosis of Wilson's disease

No disponible

Gastric polyps: analysis of endoscopic and histological features in our center.

BACKGROUND AND OBJECTIVE: the prevalence of gastric polyps in esophagogastroduodenoscopies (EGDs) ranges between 0.33 and 6.35%. The relative frequency of histological subspecies varies widely among published series. The objective is to describe the endoscopic and histological characteristics of the polypoid lesions, and to study possible associations. MATERIAL AND METHODS: we retrospectively revised the EGDs done in our center in 2009. Demographic, endoscopic and histological data were gathered. We proceeded to a descriptive analysis and studied possible associations. RESULTS: gastric polypoid lesions were found in 269 of the 6,307 (4.2%) reviewed EGDs, 61% were found in women. Mean age was 64.93 years (SD: ±15.23). A single polyp was found in 186 patients (69.1%), over 10 lesions appeared in 31 (11.5%). An estimated size of ≤ 3 mm was found in 108 lesions (37.2%) and greater than 10 mm in 52 cases (17.9%). Most lesions were sessile (90.8%). The location of 34.8% was the gastric antrum, 39.3% were found in the gastric body and 25.9% were in the fundus. Chronic gastritis was confirmed in 53.5% of the patients and 46.5% had received protom pump inhibitors (PPIs). Histopathological diagnosis was: hyperplastic polyps 50.9%, fundic gland polyps 7.4%, adenomas 3%, adenocarcinomas 1.9% and normal mucosa 29.7%. We found no significant association between the histopathological type of lesions and the use of proton pump inhibitor. CONCLUSIONS: we found polypoid lesions in 4.2% of the EGDs. The most frequent histopathological findings were hyperplastic polyps (50.9%), followed by fundic gland polyps (7.4%), adenomas (3%), and adenocarcinomas (1.9%).

Pólipos gástricos: análisis de características endoscópicas e histológicas en nuestro medio / Gastric polyps: analysis of endoscopic and histological features in our center

Antecedentes y objetivo: la prevalencia de pólipos gástricos en la endoscopia digestiva alta (EDA) oscila entre el 0,33 y el 6,35%. La frecuencia de los subtipos histológicos varía ampliamente entre las series publicadas. El objetivo de nuestro estudio es describir las características endoscópicas e histológicas de los pólipos hallados en las EDA y valorar posibles asociaciones. Material y métodos: revisamos retrospectivamente las EDA realizadas en nuestro centro en 2009. Se recogieron variables demográficas, endoscópicas e histológicas. Se realizó un análisis descriptivo y se estudiaron posibles asociaciones. Resultados: se analizaron 6.307 EDA identificándose lesiones polipoideas en 269 (4,2%), el 61% en mujeres. La edad media fue de 64,93 años (DE: ±15.23). En 186 pacientes (69,1%) se objetivó un solo pólipo y en 31 (11,5%), más de 10. Se estimó un tamaño <= 3 mm en 108 lesiones (37,2%), y mayor de 10 mm en 52 casos (17,9%). La mayoría de los pólipos eran sésiles (90,8%). El 34,8% se ubicaban en antro, el 39,3% en cuerpo y el 25,9% en fundus. El 53,5% de los pacientes presentaba gastritis crónica y el 46,5% había recibido inhibidores de la bomba de protones (IBP). Los hallazgos histológicos principales fueron: pólipos hiperplásicos 50,9%, pólipos de glándulas fúndicas 7,4%, adenomatosos 3% y adenocarcinomas 1,9%. En el 29,7% la biopsia mostró una mucosa normal. No se objetivó asociación entre el tipo histológico y el consumo de IBP. Conclusiones: encontramos lesiones polipoideas en el 4,2% de las EDA. La histología relevante más frecuente fueron pólipos hiperplásicos (50,9%), de glándulas fúndicas (7,4%), adenomas (3%) y adenocarcinomas (1,9%)(AU)

Background and objective: the prevalence of gastric polyps in esophagogastroduodenoscopies (EGDs) ranges between 0.33 and 6.35%. The relative frequency of histological subspecies varies widely among published series. The objective is to describe the endoscopic and histological characteristics of the polypoid lesions, and to study possible associations. Material and methods: we retrospectively revised the EGDs done in our center in 2009. Demographic, endoscopic and histological data were gathered. We proceeded to a descriptive analysis and studied possible associations. Results: gastric polypoid lesions were found in 269 of the 6,307 (4.2%) reviewed EGDs, 61% were found in women. Mean age was 64.93 years (SD: ±15.23). A single polyp was found in 186 patients (69.1%), over 10 lesions appeared in 31 (11.5%). An estimated size of <= 3 mm was found in 108 lesions (37.2%) and greater than 10 mm in 52 cases (17.9%). Most lesions were sessile (90.8%). The location of 34.8% was the gastric antrum, 39.3% were found in the gastric body and 25.9% were in the fundus. Chronic gastritis was confirmed in 53.5% of the patients and 46.5% had received protom pump inhibitors (PPIs). Histopathological diagnosis was: hyperplastic polyps 50.9%, fundic gland polyps 7.4%, adenomas 3%, adenocarcinomas 1.9% and normal mucosa 29.7%. We found no significant association between the histopathological type of lesions and the use of proton pump inhibitor. Conclusions: we found polypoid lesions in 4.2% of the EGDs. The most frequent histopathological findings were hyperplastic polyps (50.9%), followed by fundic gland polyps (7.4%), adenomas (3%), and adenocarcinomas (1.9%)(AU)

Usefulness of penicillamine-stimulated urinary copper excretion in the diagnosis of adult Wilson's disease.

OBJECTIVE: Diagnosis of Wilson's disease (WD) is reliant on liver biopsy (LB) and measurement of hepatic copper. The aim of this study was to determine the usefulness of penicillamine-stimulated urinary copper excretion (PS-UCE), a non-invasive diagnostic test, for the diagnosis of WD in adults. MATERIAL AND METHODS: In this prospective study of patients with suspected WD, total serum copper, ceruloplasmin, basal 24-h UCE and PS-UCE levels were measured. LB with copper determination was performed in those patients with persistent hypertransaminasemia and low ceruloplasmin or basal UCE > 40 microg/24 h. Diagnosis was established if the ceruloplasmin level was found to be < 20 mg/dl and hepatic copper > 250 microg/g. Results. A total of 115 patients were studied; LB was performed in 43, and WD was diagnosed in 6 (13.9%). Significant differences between WD and non-WD patients were found for basal UCE (WD: median 134.3 microg/24 h versus non-WD: median 19.0 microg/24 h (p < 0.05)) and PS-UCE (WD: median 1284.0 microg/24 h versus non-WD: median 776.0 microg/24 h; p < 0.01). In the ROC (receiver-operated curve) analysis, PS-UCE was the best discriminant between WD and non-WD (area under the curve (AUC) = 0.911, best cut-off point 1057 microg/24 h, 100% sensitivity, 82.3% specificity). CONCLUSIONS: PS-UCE is probably a useful non-invasive test in the diagnosis of WD, improving the selection of patients for diagnostic liver biopsy. Patients with PS-UCE under 1057 microg/24 h only rarely will suffer from WD and are unlikely to benefit from LB.

Improved graft function in liver-transplanted patients after partial splenic embolization: reversal of splenic artery steal syndrome?

AIM: To describe the functional effect of partial splenic embolization (PSE) in liver-transplanted (LT) patients with hypersplenism and hepatitis C virus (HCV) recurrence. PATIENTS AND METHODS: From May 2002 to May 2005, five LT patients with persistent hypersplenism, viral recurrence and graft dysfunction underwent PSE prior to pegylated interferon/ribavirin (peg-IFN/RBV). RESULTS: The mean splenic size was 19.5 cm (16-21) and there was evidence of an enlarged splenic artery (10.7+/-1 mm). PSE produced a median splenic infarction of 90% and a significant reduction in the splenic artery diameter to 5.8+/-0.4 mm (p=0.04). PSE significantly improved hematologic parameters, bilirubin levels, prothrombin activity, international normalized ratio and the Model for End-stage Liver Disease (MELD) score despite high HCV-RNA (6.2 log10 IU/mL). It was demonstrated histologic amelioration of ischemic changes in all subjects. PSE allowed the safe use of full-dose peg-IFN plus RBV in all subjects. CONCLUSIONS: In HCV LT patients with chronic graft dysfunction and cholestasis the improvement in the liver function following PSE might be due to the reversal of an undiagnosed splenic artery steal syndrome related to chronic hypersplenism masked by HCV recurrence.