Preoperative endoscopic biliary drainage by metal versus plastic stents for resectable perihilar cholangiocarcinoma.

BACKGROUND AND AIMS: Adequate preoperative biliary drainage (PBD) is recommended in most patients with resectable perihilar cholangiocarcinoma (pCCA). Most expert centers use endoscopic plastic stents rather than self-expandable metal stents (SEMSs). In the palliative setting, however, use of SEMSs has shown longer patency and superior survival. The aim of this retrospective study was to compare stent dysfunction of SEMSs versus plastic stents for PBD in resectable pCCA patients. METHODS: In this multicenter international retrospective cohort study, patients with potentially resectable pCCAs who underwent initial endoscopic PBD from 2010 to 2020 were included. Stent failure was a composite end point of cholangitis or reintervention due to adverse events or insufficient PBD. Other adverse events, surgical outcomes, and survival were recorded. Propensity score matching (PSM) was performed on several baseline characteristics. RESULTS: A total of 474 patients had successful stent placement, of whom 61 received SEMSs and 413 plastic stents. PSM (1:1) resulted in 2 groups of 59 patients each. Stent failure occurred significantly less in the SEMSs group (31% vs 64%; P < .001). Besides less cholangitis after SEMSs placement (15% vs 31%; P = .012), other PBD-related adverse events did not differ. The number of patients undergoing surgical resection was not significantly different (46% vs 49%; P = .71). Complete intraoperative SEMSs removal was successful and without adverse events in all patients. CONCLUSIONS: Stent failure was lower in patients with SEMSs as PBD compared with plastic stents in patients with resectable pCCA. Removal during surgery was quite feasible. Surgical outcomes were similar.

Impact of EUS in liver transplantation workup for patients with unresectable perihilar cholangiocarcinoma.

BACKGROUND AND AIMS: For a highly selected group of patients with unresectable perihilar cholangiocarcinoma (pCCA), liver transplantation (LT) is a treatment option. The Dutch screening protocol comprises nonregional lymph node (LN) assessment by EUS, and whenever LN metastases are identified, further LT screening is precluded. The aim of this study is to investigate the yield of EUS in patients with pCCA who are potentially eligible for LT. METHODS: In this retrospective, nationwide cohort study, all consecutive patients with suspected unresectable pCCA who underwent EUS in the screening protocol for LT were included from 2011 to 2021. During EUS, sampling of a "suspicious" nonregional LN was performed based on the endoscopist's discretion. The primary outcome was the added value of EUS, defined as the number of patients who were precluded from further screening because of malignant LNs. RESULTS: A total of 75 patients were included in whom 84 EUS procedures were performed, with EUS-guided tissue acquisition confirming malignancy in LNs in 3 of 75 (4%) patients. In the 43 who underwent surgical staging according to the protocol, nonregional LNs with malignancy were identified in 6 (14%) patients. Positive regional LNs were found in 7 patients in post-LT-resected specimens. CONCLUSIONS: Our current EUS screening for the detection of malignant LNs in patients with pCCA eligible for LT shows a limited but clinically important yield. EUS with systematic screening of all LN stations, both regional and nonregional, and the sampling of suspicious lymph nodes according to defined and set criteria could potentially increase this yield.

Impact of long-term transmural plastic stents on recurrence after endoscopic treatment of walled-off pancreatic necrosis.

BACKGROUND: Endoscopic transmural drainage (ETD) using double-pigtail stents (DPSs) is a well-established treatment for walled-off pancreatic necrosis (WON). This study aimed to compare outcomes in patients undergoing ETD with DPSs left indwelling versus those where stents were removed or migrated. METHODS: This retrospective multicenter cohort study included patients with WON who underwent ETD using DPSs between July 2001 and December 2019. The primary outcome was recurrence of a pancreatic fluid collection (PFC). Secondary outcomes were long-term complications and recurrence-associated factors. Competing risk regression analysis considered DPS removal or migration as time-varying covariates. RESULTS: Among 320 patients (median age 58; 36% women), DPSs were removed in 153 (47.8%), migrated spontaneously in 27 (8.4%), and remained indwelling in 140 (43.8%). PFC recurrence was observed in 57 patients (17.8%): after removal (n = 39; 25.5%); after migration (n = 4; 14.8%); in patients with indwelling DPSs (n = 14; 10.0%). In 25 patients (7.8%), drainage of recurrent PFC was indicated. Risk factors for recurrence were DPS removal or migration (hazard ratio [HR] 3.45, 95%CI 1.37-8.70) and presence of a disconnected pancreatic duct (HR 5.08, 95%CI 1.84-14.0). CONCLUSIONS: Among patients who undergo ETD of WON, leaving DPSs in situ seems to lower the risk of recurrent fluid collections, without any long-term DPS-related complications. These results suggest that DPSs should not be routinely removed and can be safely left indwelling indefinitely.

Walking the talk for dementia: A unique immersive, embodied, and multi-experiential initiative.

Coping with dementia requires an integrated approach encompassing personal, health, research, and community domains. Here we describe "Walking the Talk for Dementia," an immersive initiative aimed at empowering people with dementia, enhancing dementia understanding, and inspiring collaborations. This initiative involved 300 participants from 25 nationalities, including people with dementia, care partners, clinicians, policymakers, researchers, and advocates for a 4-day, 40 km walk through the Camino de Santiago de Compostela, Spain. A 2-day symposium after the journey provided novel transdisciplinary and horizontal structures, deconstructing traditional hierarchies. The innovation of this initiative lies in its ability to merge a physical experience with knowledge exchange for diversifying individuals' understanding of dementia. It showcases the transformative potential of an immersive, embodied, and multi-experiential approach to address the complexities of dementia collaboratively. The initiative offers a scalable model to enhance understanding, decrease stigma, and promote more comprehensive and empathetic dementia care and research.

The role of pancreatoscopy in the diagnostic work-up of intraductal papillary mucinous neoplasms: a systematic review and meta-analysis.

BACKGROUND: Confirming the diagnosis, invasiveness, and disease extent of intraductal papillary mucinous neoplasms (IPMNs) of the pancreas is challenging. The aim of this study was to summarize the literature on the efficacy and safety of peroral pancreatoscopy (POP) in the diagnosis of IPMN, including the impact of pre- and intraoperative POP on the management of IPMN. METHODS: The EMBASE, Medline Ovid, Web of Science, Cochrane CENTRAL, and Google Scholar databases were systematically searched for articles. Eligible articles investigated cohorts of patients who underwent POP for (suspected) IPMN. RESULTS: 25 articles were identified and included in this review; with 22 of these reporting on the diagnostic yield of POP in IPMN and 11 reporting on the effect of pre- or intraoperative POP on clinical decision-making. Cannulation and observation rates, and overall diagnostic accuracy were high across all studies. Frequently reported visual characteristics of IPMN were intraductal fish-egg-like lesions, hypervascularity, and granular mucosa. Overall, the adverse event rate was 12 %, primarily consisting of post-endoscopic retrograde cholangiopancreatography pancreatitis, with a pooled rate of 10 %, mostly of mild severity. Regarding the impact of POP on clinical decision-making, POP findings altered the surgical approach in 13 %-62 % of patients. CONCLUSION: POP is technically successful in the vast majority of patients with (suspected) IPMN, has a consistently high diagnostic accuracy, but an adverse event rate of 12 %. Data on intraoperative pancreatoscopy are scarce, but small studies suggest its use can alter surgical management. Future studies are needed to better define the role of POP in the diagnostic work-up of IPMN.

Women's disordered eating and sexual function: the role of interoception.

BACKGROUND: Among women, disordered eating and sexual difficulties commonly co-occur. AIM: We investigated whether interoceptive dysfunction (ie, altered processing of body cues) may be a common cause (ie, third variable) contributing to these concomitant outcomes above and beyond body mass index (BMI) and body image concerns. METHODS: Women (n = 1201; mean age = 25.92 years; mean BMI = 25.46 kg/m2; 61.6% heterosexual, 27.5% bisexual) were recruited from sexual education courses at a midsize southeastern university and Reddit communities related to women's health, sex, and disordered eating. Participants completed online measures of self-reported interoception (Multidimensional Assessment of Interoceptive Awareness Version 2), disordered eating attitudes and behaviors (Eating Disorder Examination Questionnaire), sexual function (Female Sexual Function Index), and demographic information, including height and weight. Regression, commonality, and dominance analyses were completed in R. OUTCOMES: Sexual function was assessed via the Female Sexual Function Index. RESULTS: Both general interoception and body trust (a facet of interoception concerned with trust of internal sensations) predicted dietary restraint and sexual function (Ps < .001). After accounting for both general interoception (ß = 0.27, P < .001) and body trust (ß = 0.32, P < .001) in hierarchal regression models predicting sexual function, dietary restraint either evidenced a reduction in its standardized beta or was no longer associated with sexual function. Body image concerns also emerged as a robust predictor of women's sexual function. Body trust accounted for the most unique variance (4.45%) in women's sexual function and commonly accounted for another 3.70% of variance with body image concerns. CLINICAL IMPLICATIONS: Interoceptive exposure interventions may contribute to better outcomes for women with disordered eating, sexual difficulties, or co-occurring concerns, a notion worthy of future investigation. STRENGTHS AND LIMITATIONS: Strengths include a large diverse sample in terms of sexual orientation (>35% sexual minority) and body size (BMIs from underweight to class 3 obesity). The cross-sectional nature of this study precludes any conclusions regarding temporal precedence or causality. Future studies should use different measures of dietary restraint for nonclinical populations (eg, objective measures of caloric intake). CONCLUSION: Findings suggest that both interoception and body image concerns contribute to the co-occurrence of disordered eating behaviors and sexual difficulties, and that both may be important risk/maintaining factors to consider in future work. Interoception should be integrated into models of women's sexual function, as it may be just as important to women's sexual well-being as body image concerns.

Machine learning uncovers the most robust self-report predictors of relationship quality across 43 longitudinal couples studies.

Given the powerful implications of relationship quality for health and well-being, a central mission of relationship science is explaining why some romantic relationships thrive more than others. This large-scale project used machine learning (i.e., Random Forests) to 1) quantify the extent to which relationship quality is predictable and 2) identify which constructs reliably predict relationship quality. Across 43 dyadic longitudinal datasets from 29 laboratories, the top relationship-specific predictors of relationship quality were perceived-partner commitment, appreciation, sexual satisfaction, perceived-partner satisfaction, and conflict. The top individual-difference predictors were life satisfaction, negative affect, depression, attachment avoidance, and attachment anxiety. Overall, relationship-specific variables predicted up to 45% of variance at baseline, and up to 18% of variance at the end of each study. Individual differences also performed well (21% and 12%, respectively). Actor-reported variables (i.e., own relationship-specific and individual-difference variables) predicted two to four times more variance than partner-reported variables (i.e., the partner's ratings on those variables). Importantly, individual differences and partner reports had no predictive effects beyond actor-reported relationship-specific variables alone. These findings imply that the sum of all individual differences and partner experiences exert their influence on relationship quality via a person's own relationship-specific experiences, and effects due to moderation by individual differences and moderation by partner-reports may be quite small. Finally, relationship-quality change (i.e., increases or decreases in relationship quality over the course of a study) was largely unpredictable from any combination of self-report variables. This collective effort should guide future models of relationships.

Development and Characterization of New Green Propolis Extract Formulations as Promising Candidates to Substitute for Green Propolis Hydroalcoholic Extract.

The technologies used to produce the different dosage forms of propolis can selectively affect the original propolis compounds and their biological activities. The most common type of propolis extract is hydroethanolic. However, there is considerable demand for ethanol-free propolis presentations, including stable powder forms. Three propolis extract formulations were developed and investigated for chemical composition and antioxidant and antimicrobial activity: polar propolis fraction (PPF), soluble propolis dry extract (PSDE), and microencapsulated propolis extract (MPE). The different technologies used to produce the extracts affected their physical appearance, chemical profile, and biological activity. PPF was found to contain mainly caffeic and p-Coumaric acid, while PSDE and MPE showed a chemical fingerprint closer to the original green propolis hydroalcoholic extract used. MPE, a fine powder (40% propolis in gum Arabic), was readily dispersible in water, and had less intense flavor, taste, and color than PSDE. PSDE, a fine powder (80% propolis) in maltodextrin as a carrier, was perfectly water-soluble and could be used in liquid formulations; it is transparent and has a strong bitter taste. PPF, a purified solid with large amounts of caffeic and p-Coumaric acids, had the highest antioxidant and antimicrobial activity, and therefore merits further study. PSDE and MPE had antioxidant and antimicrobial properties and could be used in products tailored to specific needs.

Development and Characterization of High-Absorption Microencapsulated Organic Propolis EPP-AF® Extract (i-CAPs).

The demand for organic and functional food continues to increase yearly. Among the available functional foods, propolis is a bee product that has various beneficial properties, including antimicrobial, antioxidant, and anti-inflammatory activities. However, it generally is only available in ethanol solution, which has poor bioavailability, as it is relatively insoluble in water. The use of such ethanol extracts is often objectionable because of the alcohol content and because they have a strong and striking taste. Development of alternatives that can efficiently and safely increase solubility in water, and that meet organic production specifications, has been a challenge. To address these concerns, microcapsules were developed using spray-dryer technology from an emulsion based on EPP-AF® propolis and gum arabic (i-CAPS). These propolis-loaded microcapsules were characterized using FT-IR, SEM, TGA, HPLC, and spectrophotometric techniques, along with determination of antimicrobial, antioxidant, antitumor, anti-inflammatory, and antihypercholesterolemic activities, as well as permeability in in vitro models. The production system resulted in microcapsules with a spherical shape and an encapsulation efficiency of 93.7 ± 0.7%. They had IC50s of 2.654 ± 0.062 and 7.342 ± 0.058 µg/mL by FRAP and DPPH antioxidant methods, respectively. The EPP-AF® i-CAPS also had superior antimicrobial activity against Gram-positive bacteria. Antitumor activity was calculated based on the concentration that inhibited 50% of growth of AGS, Caco-2, and MCF-7 cell strains, giving results of 154.0 ± 1.0, 117 ± 1.0, and 271.0 ± 25 µg/mL, respectively. The microcapsule presentation reduced the permeation of cholesterol by 53.7%, demonstrating antihypercholesterolemic activity, and it improved the permeability of p-coumaric acid and artepillin C. The IC50 for NO production in RAW 264.7 cells was 59.0 ± 0.1 µg/mL. These findings demonstrate the potential of this new propolis product as a food and pharmaceutical ingredient, though additional studies are recommended to validate the safety of proposed dosages.

Clinical outcome of endoscopic treatment of symptomatic Hepaticojejunal anastomotic strictures after pancreatoduodenectomy.

BACKGROUND: Hepaticojejunostomy anastomotic stricture (HJAS) is an adverse event after pancreatoduodenectomy (PD) which can result in jaundice and/or cholangitis. With endoscopy, HJAS can be managed. However, few studies report the specific success and adverse event rates of endoscopic therapy after PD. METHODS: Patients with symptomatic HJAS, who underwent an endoscopic retrograde cholangiopancreatography at the Erasmus MC between 2004-2020, were retrospectively included. Primary outcomes were short-term clinical success defined as no need for re-intervention <3 months and long-term <12 months. Secondary outcome measures were cannulation success and adverse events. Recurrence was defined as symptoms with radiological/endoscopic confirmation. RESULTS: A total of 62 patients were included. The hepaticojejunostomy was reached in 49/62 (79%) of the patients, subsequently cannulated in 42/49 (86%) and in 35/42 patients (83%) an intervention was performed. Recurrence of symptomatic HJAS after technically successful intervention occurred in 20 (57%) patients after median time to recurrence of 7.5 months [95%CI, 7.2-NA]. Adverse events were reported in 4% of the procedures (8% of patients), mostly concerning cholangitis. DISCUSSION: Endoscopic treatment for symptomatic HJAS after PD has a moderate technical success rate and a high recurrence rate. Future studies should optimize endoscopic treatment protocols and compare percutaneous versus endoscopic treatment.

Long-term efficacy of metal versus plastic stents in inoperable perihilar cholangiocarcinoma; a multicenter retrospective propensity score matched comparison.

BACKGROUND: For palliative drainage of inoperable perihilar cholangiocarcinoma (pCCA) uncovered metal stents are preferred over plastic stents. However, there is a lack of data on re-interventions at the long-term. The aim is to evaluate the potential difference in the number of re-interventions in patients surviving at least 6 months. METHODS: Retrospective study including patients with pCCA who underwent plastic stent placement(s) or had metal stent(s) in situ for at least 6 months. The primary outcome was the number of re-interventions per patient-year. A propensity score matching (1:1) analysis was performed using age, Bismuth classification, reason for inoperability, pathological confirmation, systemic therapy and initial approach (endoscopic vs percutaneous). RESULTS: Patients in the metal stent group (n = 87) underwent fewer re-interventions compared with the plastic stent group (n = 40) (3.0 vs. 4.7 per patient-year; IRR, 0.64; 95% CI, 0.47 to 0.88). When only non-elective re-interventions were included, there was no significant difference (2.1 vs. 2.7; IRR, 0.76; 95% CI, 0.55 to 1.08). Results were similar in the propensity score-matched dataset. CONCLUSIONS: This study shows that, also in patients with inoperable pCCA who survive at least 6 months, placement of metal stent(s) leads to fewer re-interventions in comparison with plastic stents.

Pancreatoscopy-guided electrohydraulic lithotripsy for the treatment of obstructive pancreatic duct stones: a prospective consecutive case series.

BACKGROUND AND AIMS: Pancreatoscopy-guided electrohydraulic lithotripsy (EHL) has shown potential in the treatment of patients with obstructive chronic calcifying pancreatitis (CCP). We aimed to prospectively investigate the efficacy and safety of EHL as first-line therapy in patients with CCP of the pancreatic duct (PD). METHODS: A prospective single-center consecutive case series was performed including symptomatic CCP patients with obstructing stones >5 mm in the head or neck of the pancreas. Stone fragmentation was performed using EHL. Primary study outcome was technical success. Secondary outcomes were clinical success, adverse events, and number of interventions. RESULTS: Thirty-four consecutive patients were included. Complete or partial stone clearance after EHL was achieved in 24 patients (70.6%). Pancreatoscopy was not performed because of failure to cannulate the PD (n = 5) or resolution of stones after stent placement at the index endoscopic retrograde pancreaticography (ERP) procedure (n = 3). After successful PD cannulation, pancreatoscopy was technically successful in 24 of 26 patients (92.3%). In 1 patient, the stone could not be visualized because of a resilient stricture. Complete stone clearance was achieved in 20 patients (80%) and partial clearance in 5 patients (20%), after a median of 2 ERP procedures (interquartile range, 2) and 1 EHL procedure (interquartile range, 1). In patients who underwent pancreatoscopy with EHL, mean Izbicki pain score at baseline was 62.3 ± 23.1 (25/25) and dropped significantly to 27.5 ± 35.0 (22/25) at the 6-month follow-up (P < .001). The most common adverse event was acute pancreatitis, all mild and treated conservatively (n = 7). CONCLUSIONS: Pancreatoscopy-guided EHL is a promising treatment for symptomatic CCP patients with obstructive PD stones. (Clinical trial registration number: NTR6853.).

The Roles of Body Image, Sexual Motives, and Distraction in Women's Sexual Pleasure.

Women with body image concerns are more likely to experience sexual difficulties (e.g., with arousal, lubrication, orgasm). However, the processes by which body image impacts sexual well-being are poorly understood. We theorized that women with negative body image are less likely to view sex in terms of reward, leading them to have weaker approach sexual motives (i.e., to pursue positive experiences such as pleasure). Rather, women with negative body image may have sex to avoid personal insecurities and negative emotions, leading them to have stronger avoidance sexual motives (i.e., to cope with negative affect or to avoid partner conflict). In turn, we theorized that stronger approach sexual motives may allow women to be more focused on erotic cues during sex, thereby enhancing sexual pleasure, whereas avoidance motives may lead to greater distraction, interfering with sexual pleasure. Women (N = 1619) were recruited from online venues and reported on their body image and most recent sex. We found that body dissatisfaction was associated with weaker self-focused approach motives and in turn more distraction. Additionally, body dissatisfaction was associated with stronger self- and partner-focused avoidance motives and in turn more distraction. In turn, more distraction was associated with less pleasure and worse sexual function. To the best of our knowledge, this is the first investigation of whether body image in women is associated with their sexual motives. Findings highlight the importance of sexual motives in explaining the link between body image and sexual pleasure and function.

Roles of Genital Self-Image, Distraction, and Anxiety in Women's Sexual Pleasure: A Preregistered Study.

Women with negative genital self-image are more likely to experience sexual dysfunction , but the processes underlying this association are unknown. We theorized that this association is mediated by distraction from the arousing sexual cues that foster pleasure and orgasm . In a sample of 1,619 women who had sex in the previous four weeks, women with negative genital self-image were more likely to be distracted by self-critical concerns (i.e., appearance- and performance-based distraction and embarrassment) during sex, and in turn, experienced less sexual pleasure and worse sexual function. Additionally, this indirect effect via appearance-based distraction was strongest among women with trait-level anxiousness and social anxiety. We found a similar pattern of results when investigating the indirect effect of genital self-image on sexual function. Implications for understanding sexual function and therapeutic approaches are discussed.

Roles of Religiosity, Obsessive-Compulsive Symptoms, Scrupulosity, and Shame in Self-Perceived Pornography Addiction: A Preregistered Study.

This study examined the roles of religiosity, shame, obsessive-compulsive symptoms, and scrupulosity in perceived pornography addiction. We theorized that religiosity causes pornography users to feel shame regarding their use, and in turn, self-identify as addicted to pornography, especially for individuals high on one of several proposed moderators. Participants were 645-646 pornography users who believe in a theistic God. Confirmatory analyses indicated that religious primes did not have indirect or moderated indirect effects on perceived addiction. However, exploratory analyses revealed that religious primes were associated with higher shame, and in turn, perceived addiction among individuals high on both organizational religiosity and Obsessive-Compulsive Disorder compulsivity subscales. Additionally, self-reported religiosity had indirect effects on perceived addiction via shame, especially among individuals high on scrupulosity or moral disapproval of pornography.

Anxiousness and Distractibility Strengthen Mediated Associations Between Men's Penis Appearance Concerns, Spectatoring, and Sexual Difficulties: A Preregistered Study.

Men with penis appearance concerns are more likely to experience sexual difficulties because they engage in spectatoring (i.e., negative self-critical attentional focus during sex). This preregistered study investigated whether anxious and distractible personality traits make men with penis appearance concerns more likely to engage in spectatoring and, in turn, experience sexual difficulties. In a sample of 858 sexually active men in predominantly mixed-gender relationships, we replicated previous findings that penis appearance concerns were associated with greater spectatoring, and in turn greater problems with erection and orgasm. Additionally, our novel hypotheses that anxiousness and distractibility would strengthen these associations were partially supported. Anxiousness strengthened associations between penis appearance concerns and sexual embarrassment, and in turn was associated with greater reports of erectile and orgasmic difficulties. However, anxiousness did not strengthen the mediated associations between penis appearance concerns, self-focus, and erectile and orgasmic difficulties. Distractibility strengthened associations between sexual embarrassment and erectile difficulties, and in turn strengthened the mediated associations between penis appearance concerns, sexual embarrassment, and erectile difficulties. However, distractibility did not strengthen associations between sexual embarrassment and orgasmic difficulties, between sexual self-focus and erectile difficulties, nor between sexual self-focus and orgasmic difficulties. Implications for therapeutic treatments are discussed.

Spectatoring Mediates the Association Between Penis Appearance Concerns and Sexual Dysfunction.

Men with penis appearance concerns are more likely to experience sexual dysfunction, but the processes underlying this association are unknown. This study investigated whether spectatoring (i.e., negative self-directed attentional focus during sex) mediates the association between penis appearance concerns and sexual dysfunction. Men in romantic relationships (N = 512, in predominantly mixed-gender relationships) reported on sex they had with their partner in the previous month. Indirect effects indicated that penis appearance concerns predicted greater spectatoring, and in turn predicted greater erectile and orgasmic dysfunction. Results suggest that spectatoring is a conduit through which penis appearance concerns impede sexual function.

Bacterascites: A study of clinical features, microbiological findings, and clinical significance.

BACKGROUND: Knowledge about bacterascites is limited and management guidelines are based on small patient series. The purpose of this study was to add further insight into the clinical characteristics, microbiological findings, and prognosis of patients diagnosed with bacterascites. METHODS: Retrospective analysis of patients with advanced chronic liver disease diagnosed with bacterascites and SBP between January 2003 and August 2016. RESULTS: In this study, 123 patients were included with 142 episodes of bacterascites. The median MELD score was 20 and clinical symptoms of infection were present in 78%. Empiric antibiotic treatment was initiated in 68%. In 26 untreated patients undergoing repeated paracentesis, 42% were diagnosed with either ongoing bacterascites or SBP. The presence of signs or symptoms of infection was not an independent predictor for mortality or spontaneous resolution of infection. The 1-month and 1-year mortality rates of the 123 patients studied, were 32% and 60%, respectively; these results were in line with data pertaining to the prognosis of SBP. CONCLUSIONS: Patients with bacterascites and SBP are highly comparable with respect to severity of liver disease and overall prognosis. If left untreated, bacterascites is likely to persist or to evolve to SBP in a significant proportion of patients. The results of this study support current guidelines regarding the treatment of ascitic fluid infection, but could not confirm the prognostic relevance of symptomatic disease at the time of diagnosis. We suggest that the threshold to initiate antibiotic treatment, in particular in cases with severely advanced liver disease, should be low.

Endoscopic ultrasound in patients with resectable perihilar cholangiocarcinoma: impact on clinical decision-making.

Background and study aims Accurate assessment of the lymph node (LN) status is crucial in resectable perihilar cholangiocarcinoma (pCCA) to prevent major surgery in patients with extraregional metastatic LNs (MLNs). This study investigates the added value of preoperative endoscopic ultrasound (EUS) with or without tissue acquisition (TA) for the detection of MLNs in patients with resectable pCCA. Patients and methods In this retrospective, multicenter cohort study, patients with potentially resectable pCCA who underwent EUS preoperatively between 2010-2020, were included. The clinical impact of EUS-TA was defined as the percentage of patients who did not undergo surgical resection due to MLNs found with EUS-TA. Findings of cross-sectional imaging were compared with EUS-TA findings and surgery. Results EUS was performed on 141 patients, of whom 107 (76 %) had suspicious LNs on cross-sectional imaging. Surgical exploration was prevented in 20 patients (14 %) because EUS-TA detected MLNs, of which 17 (85 %) were extraregional. Finally, 74 patients (52 %) underwent surgical exploration followed by complete resection in 40 (28 %). MLNs were identified at definitive pathology in 24 (33 %) patients, of which 9 (38 %) were extraregional and 15 (63 %) regional. Conclusions EUS-TA may be of value in patients with potentially resectable pCCA based on preoperative cross-sectional imaging, regardless of lymphadenopathy at cross-sectional imaging. A prospective study in which a comprehensive EUS investigation with LN assessment and EUS-TA of LNs is performed routinely should confirm this promise.