Detection of peritoneal carcinomatosis by EUS fine-needle aspiration: impact on staging and resectability (with videos).

BACKGROUND: Peritoneal carcinomatosis (PC) greatly affects cancer staging and resectability. OBJECTIVE: To compare the PC detection rate by using EUS and noninvasive imaging and to determine the impact on staging and resectability. DESIGN: Retrospective study. SETTING: Single tertiary-care referral center. PATIENTS: A prospectively maintained EUS database was reviewed to identify patients who underwent EUS-guided FNA (EUS-FNA) of a peritoneal anomaly. Findings were compared with a strict criterion standard that incorporated cytohistologic, radiologic, and clinical data. INTERVENTION: EUS-FNA of a peritoneal anomaly. MAIN OUTCOME MEASUREMENTS: Safety and diagnostic yield. RESULTS: Of 106 patients, a criterion standard was available in 98 (39 female patients; median age, 65 years). The sensitivity, specificity, and accuracy of EUS-FNA versus CT/magnetic resonance imaging (MRI) was 91% versus 28%, 100% versus 85%, and 94% versus 47%, respectively. In newly diagnosed cancer patients, peritoneal FNA upstaged 17 patients (23.6%). Of 32 patients deemed resectable by pre-EUS CT/MRI, 15 (46.9%) were deemed unresectable based solely on peritoneal FNA. The odds of FNA changing the resectability status remained highly significant after adjustment for cancer type, time between CT/MRI and EUS-FNA, and the quality of CT/MRI. The malignant appearance of the peritoneal anomaly but not the presence of ascites on EUS predicted a positive FNA finding (odds ratio 2.56; 95% confidence interval, 1.23-5.4 and odds ratio 0.83; 95% confidence interval, 0.4-1.8, respectively). There were 3 adverse events among 4 patients. Two of the patients developed abdominal pain and one each hypertensive urgency and pancreatitis. LIMITATIONS: Retrospective design, single-center, bias toward EUS as a diagnostic test. CONCLUSION: Peritoneal EUS-FNA appears to safely detect radiographically occult PC and improve cancer staging and patient care.

Survival among pancreaticoduodenectomy patients treated for pancreatic head cancer <1 or 2 cm.

BACKGROUND: Size of primary tumor has implications for staging, imaging, and treatment of pancreatic head carcinomas. Limited data suggest that small tumor size is associated with better survival. The objective of this population study is to analyze characteristics and survival of patients with resected pancreatic head ductal carcinomas sized <1 and 2 cm. METHODS: Analysis of resected invasive pancreatic head ductal carcinomas captured within SEER Program from 1998 to 2008. RESULTS: A total of 7,135 cases were analyzed with nodal metastases in 31, 55, and 67 % for subcentimeter, 1.1-2 cm, and >2 cm tumors, respectively. Median survival was longest for node-negative tumors (38, 26, 19 months for tumors measuring ≤ 1, 1.1-2, and >2 cm, respectively; p < 0.001) versus node-positive tumors (18, 19, 14 months, p < 0.001). In multivariate analysis, large tumor size was associated with higher risk of death (hazard ratio (HR) = 1.179 for tumors 1.1-2 cm, p = 0.152; HR = 1.665 for tumors >2 cm, p < 0.001). CONCLUSIONS: Small pancreatic cancers have a poor prognosis and surprisingly high rate of nodal involvement; therefore, they cannot be considered early cancers. Size-based screening is unlikely to save lives with current treatment options.

Fully covered removable nitinol self-expandable metal stents (SEMS) in malignant strictures of the esophagus: a multicenter analysis.

BACKGROUND: Fully covered esophageal self-expandable metallic stents (SEMS) often are used for palliation of malignant dysphagia. However, experience and data on these stents are still limited. The purpose of this multicenter study was to evaluate the efficacy and safety of fully covered nitinol SEMS in patients with malignant dysphagia. METHODS: 37 patients underwent placement of a SEMS during a 3 year period. Five patients underwent SEMS placement as a bridge to surgery: one for tracheoesophageal fistula in the setting of squamous cell carcinoma of the esophagus, one for perforation in setting of esophageal adenocarcinoma, 27 for unresectable esophageal cancer (16 adenocarcinoma, 11 squamous cell carcinoma), two for lung cancer, and one for breast-cancer-related esophageal strictures. RESULTS: SEMS placement was successful in all 37 patients. Immediate complications after stent deployment included chest pain (n = 6), severe heartburn (n = 1), and upper gastrointestinal bleeding requiring SEMS revision (n = 1). Dysphagia scores improved significantly from 3.2 ± 0.4 before stent placement to 1.4 ± 1.0 at 1 month (P < 0.0001), 1.1 ± 1.2 (P < 0.0001) at 3 months, and 1.3 ± 1.4 (P = 0.0018) at 6 months. The stent was removed in 11 patients (30%) for the following indications: resolution of stricture (n = 3), stent malfunction (n = 5), and stent migration (n = 3). After stent removal, three patients were restented, three underwent dilation, and two underwent PEG placement. Mean survival for the 37 patients after stent placement was 146.3 ± 143.6 (range, 13-680) days. CONCLUSIONS: Our study suggests that fully covered SEMS placement improve dysphagia scores in patients with malignant strictures, particularly in the unresectable population. Further technical improvements in design to minimize long-term malfunction and migration are required.

Success and complications associated with placement of fully covered removable self-expandable metal stents for benign esophageal diseases (with videos).

BACKGROUND: Fully covered esophageal self-expandable metal stents (FCSEMSs) are thought to induce less mucosal hyperplasia and are potentially removable. They may constitute an attractive alternative for the treatment of benign esophageal diseases. OBJECTIVE: To evaluate the efficacy and safety of FCSEMSs in the treatment of benign esophageal diseases. DESIGN: Patients referred for management of benign esophageal disease underwent placement of an FCSEMS and were entered into a prospective database and analyzed retrospectively for clinical response, efficacy, and morbidity. SETTING: Two tertiary care centers with long-standing experience in the management of benign esophageal strictures. PATIENTS: Between January 2006 and September 2007, 35 patients (mean age 61 years, range 20-85 years) underwent FCSEMS placement for benign esophageal diseases at 2 tertiary academic medical centers. There were 19 patients with benign esophageal strictures and 16 patients with leaks/perforations. INTERVENTION: Temporary placement of FCSEMS until stricture resolution. MAIN OUTCOME MEASUREMENTS: Clinical response, efficacy, and morbidity. RESULTS: Indications for stent placement were esophageal leak/fistulae (n = 12), refractory benign strictures (n = 10), anastomotic strictures (n = 7), perforations (n = 4), and radiation-induced strictures (n = 2). Immediate complications were chest pain (2 patients), stent migration (2 patients), dysphagia (1 patient), respiratory compromise (1 patient), and arrhythmia (1 patient). Long-term complications included recurrent dysphagia (6 patients), aspiration pneumonia (2 patients), globus sensation (2 patients), abdominal pain (2 patients), and fever (1 patient). Stent migration was observed in 12 patients (34%). After placement, dysphagia scores at 1 month improved significantly from 3.1 ± 1.0 to 1.2 ± 1.3 (P < .0001). A total of 11 of 35 patients (31%) were treated successfully. Specifically, 21% of patients with refractory strictures and 44% of patients with leaks/fistulae had successful long-term outcomes without any need for reinterventions. All stents were retrieved successfully, except for 1 stent, which fractured and was retrieved in 2 pieces without any complications. CONCLUSION: Use of FCSEMSs for benign esophageal conditions was associated with frequent stent migration and long-term improvement in only one third of patients. Further investigation is required before recommending FCSEMS placement to treat benign diseases of the esophagus and to further characterize the subgroup that might benefit from these interventions.

Endoscopic stenting versus surgical colostomy for the management of malignant colonic obstruction: comparison of hospital costs and clinical outcomes.

BACKGROUND: Although stent placement is increasingly performed, colostomy still is considered the gold standard for emergent relief of malignant colonic obstruction (MCO). This study aimed to compare hospital costs and clinical outcomes between patients undergoing colostomy and those undergoing stenting for the management of MCO. METHODS: A retrospective claims analysis of the Medicare Provider Analysis and Review (MedPAR) data set was conducted to identify inpatient hospitalizations for colostomy or stent placement for the treatment of colon cancer (2007-2008). The outcomes evaluated using MedPAR compared the total length of hospital stay (LOS) and the costs associated with both techniques. Because MedPAR is a claims data set that does not provide outcomes at a patient level, a single-institution retrospective case-control study was conducted in which each stent placement patient was matched with two colostomy patients during the same period. Outcome measures (institutional data) were used to compare rates of treatment success, postprocedure LOS, and reinterventions between the two cohorts. RESULTS: The MedPAR data evaluated 778 stent placements and 5,868 colostomy hospitalizations. There were no differences in gender, age distribution, or comorbidity between the two groups. Compared with colostomy, the median LOS (8 vs. 12 days; p<0.0001) and the median cost ($15,071 vs. $24,695; p<0.001) per claim were significantly less for stent placement. Stent placement was more commonly performed at urban versus rural hospitals (84% vs. 16%; p<0.0001), teaching versus nonteaching hospitals (56% vs. 44%; p=0.0058) and larger versus smaller institutions (mean bed capacity, 331 vs. 227; p<0.0001). The institution data included 12 patients who underwent stent placement and 24 who underwent colostomy. Although both methods were technically successful, the median postprocedure LOS (2.17 vs. 10.58 days; p=0.0004) and the rate of readmissions for complications (0% vs. 25%; p=0.01) were significantly lower for stent placement. CONCLUSION: Although the technical and clinical outcomes for colostomy and stent placement appear comparable, stent placement is less costly and associated with shorter LOS and fewer complications. Dissemination of stent placement beyond large teaching hospitals located in urban areas as a treatment for MCO is important given its implications for patient care and resource use.

Nitinol biliary stent versus surgery for palliation of distal malignant biliary obstruction.

BACKGROUND: Curative resection of pancreatic and biliary malignancies is rare. Most tumors are inoperable at presentation, and palliation of jaundice often is the goal. Biliary decompression can be achieved by surgical diversion or endoscopic biliary stents. This study aimed to compare clinical outcomes between surgical bypass and endoscopic uncovered nitinol stents in the palliation of patients with malignant distal common bile duct obstruction. METHODS: A multicenter, retrospective, cohort study investigated 86 patients with inoperable malignant distal common bile duct strictures at tertiary referral centers in Medellín, Colombia. These patients had undergone surgery (group 1) or placement of an uncovered 30-Fr self-expandable nitinol stent produced locally in Medellín, Colombia (group 2). The main outcome measurements included cumulative biliary patency, hospital stay, and patient survival. RESULTS: The study enrolled 86 patients (mean age, 66 years; range, 43-78 years) including 40 patients in group 1 and 46 patients in group 2. Both groups were similar in terms of age, gender, liver metastasis, and diagnosis. Technical success was achieved for 38 patients in group 1 (95%) and 43 patients in group 2 (93%). Functional biliary decompression was obtained in for 35 of the surgical patients (88%) and 42 of the stented patients (91%). Group 2 had lower rates for procedure-related mortality (2 vs. 7.5%; p = 0.01), a lower frequency of early complications (8.7 vs. 45%; p = 0.02), and a shorter hospital stay (median, 6 vs. 12 days; p = 0.01). Recurrent jaundice occurred for three patients in group 1 (7.5%) and eight patients in group 2 (17.3%) (p = 0.198). Late gastric outlet obstruction occurred for 12.5% of the patients in group 1 and 13% of the patients in group 2 (p = 0.73). Despite the early benefits of stenting, no significant difference in the median overall survival between the two groups was found (group 1, 163 days; group 2, 178 days; p = 0.11). The limitations of this study included the small number of patients and the retrospective design. CONCLUSIONS: Endoscopic stenting and surgery are effective palliation. The former is associated with fewer early complications and the latter with fewer late complications. Patients who do not qualify for curative resection may be better managed by stent placement. Surgery should be reserved for patients more likely to survive longer.

Novel removable internally fully covered self-expanding metal esophageal stent: feasibility, technique of removal, and tissue response in humans.

OBJECTIVES: Internally fully covered self-expandable metal stents (FCSEMSs) have recently become available offering the possibility of removal. However, to our knowledge, the feasibility, techniques for endoscopic removal, and tissue reaction to FCSEMS have not been reported in humans. Our aims are (1) to report reasons for and success of FCSEMS removal in consecutive patients, (2) to describe methods of esophageal stent retrieval, and (3) to describe stent reactions induced by FCSEMS in humans. METHODS: Removable FCSEMSs (ALIMAXX-E, Alveolus Inc., Charlotte, NC) were placed in consecutive patients requiring palliation of dysphagia symptoms with locally advanced esophageal or gastro-esophageal junction cancers, refractory benign esophageal strictures, postoperative mediastinal leaks, or tracheoesophageal fistulas. Dysphagia scores were assessed at 1, 3, and 6 months. Esophagogram and endoscopy follow-up were performed routinely at 1 month or to assess new symptoms. RESULTS: A total of 36 stents were placed in 31 patients over 16 months (mean age 62.8 years, 61% white, 58% male). Indications included the following: malignant strictures (n=17), refractory benign strictures (n=7), tracheoesophageal fistulas (n=8), postoperative mediastinal leaks (n=2), and iatrogenic perforations (n=2). Dysphagia scores improved (decreased) significantly at 1 (mean difference 2.09; 95% confidence interval (CI) 1.65-2.52, P=0.0001), 3 (mean difference 2.1; 95% CI 1.57-2.62, P=0.0001), and 6 months (mean difference of 2; 95% CI 1.28-2.73, P<0.0001). Clinical success rates for various indications were: malignant strictures 88%, refractory benign strictures 29%, tracheoesophageal fistula 88%, postoperative mediastinal leaks 100%, and iatrogenic perforations 50%. Sixty one percent (n=22) of the stents were removed (removal was successful in 100% of cases attempted). Twenty three percent (n=5 stents in four patients) were removed due to chest pain or abdominal pain. The stents satisfied their purposes in all of these four patients. The remainder were removed on schedule or had satisfied their purpose and/or migrated. Fifty percent of removed stents had ulcers (median size=2 cm) at the distal edge of the stent, whereas 23% had ulcers at the proximal edge of the stent. Pseudo-polyps formed at either the proximal or distal edge of the stent in four patients. Tissue reaction was severe in only two patients. Stents were embedded in four cases but were easily lifted from tissue. Our preferred method of retrieval was the double-channel therapeutic endoscope with two rat-tooth forceps or rat-tooth forceps with a snare. CONCLUSIONS: FCSEMSs palliate dysphagia from both benign and malignant conditions and seal postoperative tracheoesophageal fistulas and mediastinal leaks. Tissue reaction to the stents was common but remained clinically insignificant in the majority of patients. Close follow-up of patients with FCSEMS is required and repeat endoscopy with stent retrieval might be necessary with the development of new symptoms or complications from the stent.

Cervical esophageal perforations at the time of endoscopic ultrasound: a prospective evaluation of frequency, outcomes, and patient management.

OBJECTIVES: With the exception of one retrospective survey, there are currently no prospectively published data about the frequency of cervical esophageal perforation at the time of endoscopic ultrasound (CEP-EUS). We prospectively investigated the frequency of CEP-EUS and the outcomes and management of patients sustaining CEP-EUS. METHODS: All patients that underwent upper EUS by a single experienced endosonographer over a 7-year period were enrolled. All indications and immediate complications encountered, the baseline demographics, indication of the procedures, surgical interventions, length of hospital stay, and the final outcomes of the patients were prospectively recorded. RESULTS: A total of 5,225 EUS procedures were performed. Lower gastrointestinal tract EUS procedures (n=331) were excluded from the analysis, and thus 4,894 upper EUSs constitute this study. The mean age of the patients was 59.7 years (s.d. 14.3 years); 54% patients were men and 79% were white. Indications for EUS included pancreaticobiliary (58%), esophageal (14%), mediastinal (14%), gastric (9%), celiac blocks (1%), and other (4%). Of 4,894 patients, 3 (0.06%, exact 95% confidence interval: 0.01-0.18) suffered CEP-EUS. The curvilinear echoendoscope was used in all three patients. All patients were octogenarians and women. All perforations were suspected at the time of intubation. Esophagogram confirmed contained perforation in all patients. All patients were immediately admitted and underwent surgical repair with a neck incision and recovered completely. The length of hospital stay was 6, 11, and 23 days respectively. All patients resumed swallowing without complications. One patient died from progressive pancreatic cancer 6 months after Whipple's procedure. The two other patients remained alive and well 12 and 22 months after the procedure. CONCLUSIONS: CEP-EUS is rare but a potentially devastating event for the patient and the treating physician. Although rare, the incidence is 2- to 3-fold higher than what has been reported in the survey literature. Early recognition and treatment is crucial for prompt intervention and complete recovery from CEP-EUS. These data can be used by endosonographers to counsel their patients about frequency, management, and outcomes of CEP-EUS.

Laparoscopy-assisted ERCP: experience of a high-volume bariatric surgery center (with video).

BACKGROUND: Laparoscopy-assisted ERCP (LAERCP) allows the diagnosis and treatment of biliopancreatic conditions in patients with Roux-en-Y anatomy (RY). However, experience with this technique is limited. OBJECTIVES: To report on the experience with LAERCP in consecutive patients from a high-volume bariatric surgery center and to evaluate success rates of ERCP with the laparoscopy-assisted approach. DESIGN: Retrospective case series. SETTING: High-volume bariatric surgery center. PATIENTS: Consecutive patients undergoing LAERCP between 2003 and 2009. INTERVENTION: LAERCP. OUTCOMES: Immediate/delayed complications, biliary/pancreatic duct cannulation, endoscopic/laparoscopic interventions, postprocedure hospital stay, procedure duration. RESULTS: Ten patients underwent LAERCP: 9 after Roux-en-Y gastric bypass (RYGB) and 1 after antrectomy with RY (9 female, 1 male; 9 white, 1 black). Indications for the procedure were choledocholithiasis (n=4), biliary stricture (n=3), and sphincter of Oddi dysfunction (n=3). Endoscopic access was obtained to the gastric remnant (n=9) or biliopancreatic limb (n=1). Biliary cannulation was successfully achieved in 9 of 10 patients, biliary sphincterotomy was performed in all, pancreatography in 3 of 3, and sphincter of Oddi manometry in 2. In 1 patient, a 3F pancreatic duct stent was placed prophylactically. Mild post-ERCP pancreatitis developed in 2 patients, and 1 patient had a pneumothorax intraoperatively that was treated successfully. The mean duration of the procedure was 89 minutes (range 41-245), and the median postprocedure hospital stay was 2 days (mean 2.59, standard deviation 2.46). LIMITATIONS: Single-center, retrospective design. CONCLUSION: LAERCP is safe and successful for the diagnosis and therapy of biliopancreatic conditions in patients with RY. It additionally allows the diagnosis and treatment of internal hernias, a known complication of RYGB.

A randomized trial comparing endoscopic stenting to a sham procedure for chronic pancreatitis.

BACKGROUND: A number of studies support the use of endoscopically placed pancreatic duct (PD) stents to decrease pain in chronic pancreatitis (CP). Nevertheless, flaws in study design have prevented experts from reaching a consensus. PURPOSE: (1) Evaluate the efficacy of PD stenting to ameliorate abdominal pain in patients with CP and ductal strictures; (2) evaluate the placebo response rate from sham endoscopic therapy; (3) compare pain medication usage, healthcare utilization, psychological distress, and quality of life before and after endoscopic stenting; (4) prospectively evaluate the durability of the response. METHODS: Patients with typical abdominal pain, imaging confirmation of CP and endoscopic retrograde cholangiopancreatography (ERCP) confirmation of PD stricture will complete questionnaires to assess quality of life, psychological distress, pain intensity/unpleasantness, pain medication usage, and healthcare utilization. Enrolled patients will be randomized to ERCP with sphincterotomy and PD stenting versus sham procedure. Pain level and medication usage will be assessed weekly with telephone interviews. At 6-8 weeks, patients treated with stents will undergo stent removal; those randomized to the sham procedure without significant improvement (<50% reduction in pain score) will cross over to the treatment group; and those randomized to sham procedure who experienced improvement (>50% reduction) will be followed clinically. Patients will be followed in clinic or by phone biannually (up to 3 years). The primary endpoint is improvement in abdominal pain. The secondary endpoints are reduction in narcotic use, healthcare utilization, and work days missed; return to employment; improvement in quality of life and weight gain. RESULTS: Proposed study. LIMITATIONS: Strict inclusion criteria may limit enrollment. CONCLUSION: The proposed study represents the first trial of endoscopic stenting for symptomatic CP and ductal strictures with a credible sham procedure, assessment of multiple dimensions of pain, and psychosocial factors.

Usefulness of endoscopic ultrasound for perianal fistula in Crohn's disease. / Papel da ultrassonografia endoscópica na avaliação da fístula perianal na doença de Crohn.

OBJECTIVE: to determine the role of endoscopic ultrasonography (EU) in comparison with nuclear magnetic resonance imaging (MRI) and examination under anesthesia (EUA) in the management of patients with perianal fistulizing Crohn's disease. METHODS: we conducted a cross-sectional, observational study with patients with perianal Crohn's disease evaluated at a tertiary center in Curitiba, Paraná, Brazil, from February 2016 to March 2017. All patients underwent EU, MRI and EUA. We evaluated the degree of agreement between the three methods by obtaining the Kappa coefficient. A Kappa value of 0.7 or greater indicated good agreement. We used the Friedman's non-parametric test to compare the number of fistulous paths detected in each modality. We set the level of statistical significance at p<0.05. RESULTS: we included 20 patients. There was agreement between the three exams in 11 patients. The level of Kappa agreement between the three exams was 0.53 (moderate - p<0.001). There was no statistically significant difference in relation to the number of fistulous trajectories detected in the three exams (p=0.641). EU failed to identify a fistulous pathway in three patients; MRI failed in three; and EUA failed in two. CONCLUSION: EU was comparable to MRI and EUA for the evaluation of perianal fistulizing Crohn's disease, and can be considered a valid exam for preoperative investigation of such patients.

OBJETIVO: determinar o papel da ultrassonografia endoscópica (UE) em relação à ressonância magnética nuclear (RMN) e ao exame sob anestesia (ESA) no manejo de pacientes com doença de Crohn fistulizante perianal. MÉTODOS: estudo observacional transversal com pacientes com doença de Crohn perianal, avaliados em um centro terciário de Curitiba, Paraná, Brasil, de fevereiro de 2016 a março de 2017. Todos os pacientes foram submetidos à UE, RMN e ESA. O grau de concordância entre os três métodos foi avaliado através da obtenção do coeficiente de Kappa. Um valor de Kappa de 0,7 ou maior indicou boa concordância. O teste não paramétrico de Friedman foi utilizado para comparar o número de trajetos fistulosos detectados em cada modalidade. Considerou-se o nível de significância estatística como p<0,05. RESULTADOS: vinte pacientes foram incluídos. Houve concordância entre os três exames em 11 pacientes. O nível de concordância de Kappa entre os três exames foi 0,53 (moderado) (p<0,001). Não houve diferença estatisticamente significativa em relação ao número de trajetos fistulosos detectados nos três exames (p=0,641). Houve falha na identificação de um trajeto fistuloso em três pacientes com a UE, em três pacientes com a RMN e em dois pacientes com o ESA. CONCLUSÃO: a UE foi comparável à RMN e ao ESA para avaliação da doença de Crohn fistulizante perianal, e pode ser considerada um exame válido para investigação pré-operatória desses pacientes.

EUS versus surgical cyst-gastrostomy for management of pancreatic pseudocysts.

BACKGROUND: Although EUS-guided cyst-gastrostomy is increasingly being performed, there are no studies that compare the clinical outcomes and cost-effectiveness with surgical cyst-gastrostomy. OBJECTIVES: To compare the clinical outcomes of EUS-guided cyst-gastrostomy with surgical cyst-gastrostomy for the management of patients with uncomplicated pancreatic pseudocysts and to perform a cost analysis of each treatment modality. DESIGN: A retrospective case-controlled study. SETTING: A tertiary-referral center. PATIENTS: Consecutive patients with uncomplicated pancreatic pseudocysts managed by surgical and EUS-guided cyst-gastrostomy. METHODS: An independent observer blinded to all clinic outcomes matched each patient who underwent a surgical cyst-gastrostomy with 2 patients who underwent an EUS-guided cyst-gastrostomy for age, etiology of pancreatitis, and the size of the pseudocyst. MAIN OUTCOME MEASUREMENTS: Rates of treatment success, complications, and reinterventions; length of postprocedure hospital stay; and cost associated with each treatment modality. RESULTS: Ten patients (6 men; mean age 42.3 years, range 22-65 years) who underwent surgical cyst-gastrostomy were matched with 20 patients who underwent an EUS-guided cyst-gastrostomy. There were no significant differences in demographics, major comorbidities, and clinical characteristics between both cohorts. Although there were no significant differences in rates of treatment success (100% vs 95%, P = .36), procedural complications (none in either cohort), or reinterventions (10% vs 0%, P = .13) between surgery versus an EUS-guided cyst-gastrostomy, the mean length of a postprocedure hospital stay for an EUS-guided cyst-gastrostomy was significantly shorter than for surgical cyst-gastrostomy (2.65 vs 6.5 days, P = .008). The average direct cost per case for EUS-guided cyst-gastrostomy was significantly less when compared with surgical cyst-gastrostomy ($9077 vs $14,815, P = .01), which corresponded to a cost savings of $5738 per patient. LIMITATIONS: Retrospective, nonrandomized design; patients with pancreatic abscess or necrosis were not evaluated; a limited sample size and a short duration of follow-up. CONCLUSIONS: EUS-guided cyst-gastrostomy should be considered as a first-line treatment approach for patients with uncomplicated pancreatic pseudocysts, because the procedure is cost saving and is associated with a shorter length of a postprocedure hospital stay when compared with surgical cyst-gastrostomy. There was no significant difference in clinical outcomes between both treatment modalities.

Papel da ultrassonografia endoscópica na avaliação da fístula perianal na doença de Crohn / Usefulness of endoscopic ultrasound for perianal fistula in Crohn's disease

RESUMO Objetivo: determinar o papel da ultrassonografia endoscópica (UE) em relação à ressonância magnética nuclear (RMN) e ao exame sob anestesia (ESA) no manejo de pacientes com doença de Crohn fistulizante perianal. Métodos: estudo observacional transversal com pacientes com doença de Crohn perianal, avaliados em um centro terciário de Curitiba, Paraná, Brasil, de fevereiro de 2016 a março de 2017. Todos os pacientes foram submetidos à UE, RMN e ESA. O grau de concordância entre os três métodos foi avaliado através da obtenção do coeficiente de Kappa. Um valor de Kappa de 0,7 ou maior indicou boa concordância. O teste não paramétrico de Friedman foi utilizado para comparar o número de trajetos fistulosos detectados em cada modalidade. Considerou-se o nível de significância estatística como p<0,05. Resultados: vinte pacientes foram incluídos. Houve concordância entre os três exames em 11 pacientes. O nível de concordância de Kappa entre os três exames foi 0,53 (moderado) (p<0,001). Não houve diferença estatisticamente significativa em relação ao número de trajetos fistulosos detectados nos três exames (p=0,641). Houve falha na identificação de um trajeto fistuloso em três pacientes com a UE, em três pacientes com a RMN e em dois pacientes com o ESA. Conclusão: a UE foi comparável à RMN e ao ESA para avaliação da doença de Crohn fistulizante perianal, e pode ser considerada um exame válido para investigação pré-operatória desses pacientes.

ABSTRACT Objective: to determine the role of endoscopic ultrasonography (EU) in comparison with nuclear magnetic resonance imaging (MRI) and examination under anesthesia (EUA) in the management of patients with perianal fistulizing Crohn's disease. Methods: we conducted a cross-sectional, observational study with patients with perianal Crohn's disease evaluated at a tertiary center in Curitiba, Paraná, Brazil, from February 2016 to March 2017. All patients underwent EU, MRI and EUA. We evaluated the degree of agreement between the three methods by obtaining the Kappa coefficient. A Kappa value of 0.7 or greater indicated good agreement. We used the Friedman's non-parametric test to compare the number of fistulous paths detected in each modality. We set the level of statistical significance at p<0.05. Results: we included 20 patients. There was agreement between the three exams in 11 patients. The level of Kappa agreement between the three exams was 0.53 (moderate - p<0.001). There was no statistically significant difference in relation to the number of fistulous trajectories detected in the three exams (p=0.641). EU failed to identify a fistulous pathway in three patients; MRI failed in three; and EUA failed in two. Conclusion: EU was comparable to MRI and EUA for the evaluation of perianal fistulizing Crohn's disease, and can be considered a valid exam for preoperative investigation of such patients.

Endoscopic retrograde cholangiopancreatography in patients with Roux-en-Y anatomy.

INTRODUCTION: Roux-en-Y gastric bypass is increasingly performed in the United States. In addition, liver transplantation and other complex hepatobiliary surgeries are increasingly performed with creation of a Roux-en-Y hepaticojejunostomy. Consequently, endoscopists more frequently need to carry out endoscopic procedures in patients with Roux-en-Y anatomy. MATERIALS AND METHODS: The present article discusses the techniques and instruments available to therapeutic endoscopists who are faced with the challenge of performing endoscopic retrograde cholangiopancreatography (ERCP) in patients with long- or short-limb Roux-en-Y anatomy. CONCLUSION: Endoscopists can successfully perform ERCP in patients with Roux-en-Y anatomy by making use of appropriate techniques and instruments.

Endoscopic retrograde cholangiopancreatography in patients with Roux-en-Y anatomy.

Bariatric surgery has been increasingly performed in response to the obesity pandemic. During the last decade, Roux-en-Y gastric bypass (RYGB) has become the preferred surgical approach. It is also commonly performed after pylorus preserving pancreaticoduodenectomy and other biliary tract surgeries. This article discusses the different options available for endoscopists who are faced with the need to perform endoscopic retrograde cholangiopancreatography in patients after Roux-en-Y reconstruction, with special emphasis on those after RYGB.

Laparoscopy-assisted transjejunal ERCP in a patient with Roux-en-Y reconstruction following partial gastrectomy.

In this article, we report a patient with a history of partial gastrectomy and Roux-en-Y reconstruction who presented with abdominal pain due to sphincter of Oddi dysfunction. After failed endoscopic retrograde cholangiopancreatography (ERCP) through the anatomic route, the procedure was successfully performed with laparoscopy assistance through an enterotomy into the biliopancreatic limb. An internal hernia was diagnosed incidentally and treated appropriately. Laparoscopy-assisted ERCP is a viable option in patients with Roux-en-Y anatomy, even when the gastric remnant and duodenum are not available.

Esquistossomose hepato-esplênica em crianças: avaliação morfológica e funcional após esplenectomia e auto-implante esplênico / Hepatosplenic schistosomiasis in children: morphologic and functional evaluation after splenectomy and autologous splenic implantation

A esquistossomose mansônica hepato-esplênica com varizes sangrantes do esôfago é infrequente em crianças, entretanto, determina morbidade atingindo a produtividade desses futuros adultos. Uma das opções para o tratamento cirúrgico é a esplenectomia associada à ligadura da veia gástrica esquerda e esclerose endoscópica das varizes, nos casos de recidiva hemorrágica. Auto-implante esplênico tem sido adicionado em crianças. Há evidências de que a esplenose pós-esplenectomia por trauma mantém, de forma parcial, as funções imunológica e de filtração esplênicas. Todavia, estudos semelhantes não foram realizados em pacientes esquistossomóticos. Foram analisados 23 pacientes, de 9 a 18 anos, com esquistossomose hepato-esplênica submetidos à esplenectomia, ligadura de veia gástrica esquerda e auto-implante esplênico no omento maior. Avaliou-se a função de filtração através da pesquisa de corpúsculos de Howell-Jolly em esfregaços de sangue periférico, cuja presença indica ausência ou insuficiência de função de filtração esplênica. Foi realizada análise morfológica da esplenose através de exame cintilográfico, usando enxofre coloidal, marcado com Tecnécio 99m. Observou-se captação dos implantes esplênicos em todos os pacientes, entretanto, em dois (8,7 por cento), o número de nódulos esplênicos observados foi inferior a cinco, sendo considerado insuficiente. Em correspondência, esses dois pacientes foram os únicos que apresentaram positividade para corpúsculos de Howell-Jolly. Os dados confirmam o auto-implante esplênico no omento maior como método eficaz de produção de esplenose e manutenção da função de filtração esplênica em mais de 90 por cento dos pacientes

Esquistossomose hepato-esplênica em crianças: corpúsculo de Howell-Jolly após esplenectomia e esplenose / Hepatosplenic schistosomiais mansoni in children: Howell-Jolly bodies after splenectomy and splenosis

A esquistossomose mansônica hepato-esplênica com varizes esofágicas é infrequente em crianças, entretanto, determina morbidade atingindo a produtividade desses futuros adultos. Há evidências de que a esplenose pós-esplenectomia, por trauma, mantém, de forma parcial, as funçSes imunológica e hemocaterética esplênicas. Estudos semelhantes, entretanto, nÝo foram realizados em esquistossomóticos submetidos a esplenectomia. Foram analisados, para avaliaçÝo da funçÝo de esplenose, 15 pacientes, de 7 a 18 anos, com esquistossomose hepato-esplênica submetidos a esplenectomia, ligadura de veia gástrica esquerda e auto-implante esplênico (Grupo A). A esplenose foi comprovada por cintilografia ou por Dopplerfluxometria. Também foram analisados cinco pacientes similares antes da cirurgia (grupo B) e três crianças, nÝo esquistossomóticas submetidas a esplenectomia sem auto-implante esplênico (grupo C). Os esfregaços de sangue periférico foram examinados para pesquisa de corpúsculos de Howell-Jolly, que indicam ausência ou insuficiência de funçÝo hemocaterética esplênica. Dos pacientes do grupo A, um (7por cento) apresentou corpúsculosde Howell-Jolly. Os demais nÝo apresentaram estes corpúsculos (93por cento). Nenhum paciente do grupo B os apresentou, enquanto que todos os esfregaços dos pacientes do Grupo C apresentaram estes corpúsculos. Os dados confirmam o auto-implante esplênico como método edicaz na manutençÝo da funçÝo hemocaterética esplênica