Rapid diagnosis of mucinous cystic pancreatic lesions by on-site cyst fluid glucometry.

INTRODUCTION: Available intracystic biomarkers show a limited accuracy for characterizing cystic pancreatic lesions (CPL). Glucose is an attractive alternative due to its availability, low cost and the possibility of on-site quantification by glucometry. AIM: To evaluate the diagnostic accuracy of on-site glucometry from samples obtained by EUS-FNA in the differential diagnosis between mucinous from non-mucinous CPL. METHODS: Retrospective, multicentre, cross-sectional study of patients who underwent EUS-FNA of a CPL. A derivation and a validation cohorts were evaluated. Intracystic glucose was quantified by on-site glucometry and colorimetry in the lab. Final diagnosis was based on surgical specimens or global evaluation of clinical and imaging data, cytology and intracystic CEA. Diagnostic accuracy was based on Receiver Operating Curve (ROC) curve analysis. Intraclass correlation coefficient (ICC) between on-site and lab glucose levels was calculated. RESULTS: Seventy two patients were finally analysed (40 in the derivation cohort and 32 in the validation cohort). Intracystic glucose levels by on-site glucometry was 12.3 ± 28.2 mg/dl for mucinous CPL and 103.3 ± 58.2 mg/dl for non-mucinous CPL, p < 0.001. For an optimal cut-off point of 73 mg/dl, on-site glucose had a sensitivity, specificity, and positive and negative predictive value for the diagnosis of mucinous CPL of 0.89, 0.90, 0.94, 0.82 respectively in the derivation cohort, and 1.0, 0.71, 0.91, 1.0 respectively in the validation cohort. Correlation of on-site and lab glucose quantification was very high (ICC = 0.98). CONCLUSION: On-site glucometry is a feasible, accurate and reproducible method for the characterization of CPL after EUS-FNA. It shows an excellent correlation with laboratory glucose values. REGISTRATION NUMBER: 2019/612.

[Flexible endoscopic treatment for Zenker's diverticulum: preliminary results in a single center experience in a public hospital in Argentina.] / Tratamiento del divertículo de Zenker con endoscopio flexible: experiencia en us hospital público de la Arfgentina.

Zenker's diverticulum (ZD) is an acquired protrusion of the esophageal wall. Treatment is reservedfor symptomatic cases. In Argentina, ZD has historically managed exclusively by surgical intervention. In 1995, Ishioka, et al and Mulder, et a1published their experience using flexible endoscopes for diverticulotomy. Since then, a wide variety ofdifferent techniques have been published. Objetive. To present technique modifications and results ofour center. MATERIAL AND METHODS: We reviewed the database of57patients (36 men), with a mean age of 71.9 years (range 37-98), with symptomatic Zenker ' diverticulum, who underwent endoscopic myotomy, from December 1997 to April 2015. All procedures were performed in our center, by the same endoscopist (HM). The most common symptom was dysphagia (94.7%), which was recorded by a 0-4 score (0=no dysphagia, 1 =solids, 2=semisolids, 3=liquids, 4=saliva). The first nine cases were done exposing the septum with a nasogastric tube, and the others with a soft diverticuloscope. Allprocedures were carried out with the patient under deep sedation, adminis- tered by an anesthesiologist. A myotomy was done in all cases with a needle-knife, using a coagulation current, to prevent bleeding. Clips were placed to close mucosalilaps, decrease the risk of unsuspected perforation and postprocedure bleeding. RESULTS: Seventy procedures were performed, in 56 patients. One patient was excluded because of incomplete myotomy due to a severe adverse event. Ninety-eight percent ofpatients had resolution or improvement of the dysphagia score, at 30 days. Three patients with regurgitation as their sole complaint completely resolved their symptom. Median follow-up was 25 months (1-99). Thirty-seven patients were followed for at least 1 year and 97.3% showed a favorable outcome. In 13 cases (22.8%) a reintervention was needed, with positive results in all cases. Bleeding occurred in one patient (1.4%), who required surgery. Another patient required surgical intervention due to technical issues. There were no perforations or infections. CONCLUSION: Treatment of ZD with flexible endoscope is a safe and effective option, with good long-term results. We need randomized clinical trials comparing different therapeutic options to be able to recommend a definitive strategy. Until then, we suggest using the technique with which each center has the most experience and feels most comfortable performing.

[Intraparenchymal hepatic haematoma after endoscopic retrograde cholangiopancreotography overinfected by Citrobacter freundii and Klebsiella pneumoniae BLEE]. / Hematoma intraparenquimatoso hepático post- colangiopancreatografía retrógrada endoscópica sobreinfectado por Citrobacter freundii y Klebsiella pneumoniae BLEE.

This case report describes a 37-year-old woman who develops an intraparenchymal hepatic haematoma after an endoscopic retrograde cholangiopancreatography with papillotomy and stone extraction. The procedure requires the passage of a guidewire. The patient develops acute abdominal pain 72 hours later and a magnetic resonance shows a hematoma of 124 x 93 mm. She remains under observation. Twenty one days later she complains of upper right abdominal pain and fever. Consequently, a percutaneous drainage is performed isolating Citrobacter freundii and Klebsiella pneumoniae BLEE. The patient has a good evolution.

[N-butyl-2-cyanoacrylate for the treatment of gastric varices]. / N-butil-2-cianoacrilato en el tratamiento de las várices gástricas.

OBJECTIVE: To evaluate the success of the treatment with cyanoacrylate in primary hemostasis, rebleeding, and gastric varices eradication. MATERIAL AND METHODS: In this retrospective study 65 patients with gastric varices treated with N-butyl-2-cyanoacrylate (Histoacryl) were included from January 1999 to January 2008. We used a solution of 0,5 mL of cyanoacrylate and 0.9 mL of lipiodol, utilizing an average of 3.46 mL of this mixture per session (range 1 to 6 mL). Sclerosing needles of 21 gauge were used. Patients were sedated. Data were analyzed using a chi-squared test. RESULTS: Sixty-five patients were included, 42 men and 23 women with an average age of 53.8 years (range 18 to 76 years). The etiology of the portal hypertension (PH) was cirrhosis in 52 patients (80%), prehepatic PH in 7 (10.8%), and segmentary PH in 3 (4.6%), and non-classified in 3 (4.6%). Cirrhotic patients were classified as Child A in 21 cases, Child B in 25 and Child C in 6. According to the Sarin classification, 7 patients had gastric-oesophageal varices (GOV) type 1, 32 GOV2, 8 GOV1 and 2, and 8 isolated gastric varices (IGV) type 1. Fifty-six patients (86%) presented active bleeding or stigmata of recent bleeding at time of initial endoscopy. Primary hemostasis was achieved in 50 of them (89%) and the remaining 6 required a second session. Eleven patients presented rebleeding within the following 6 weeks and were again treated with cyanoacrylate. Hemostasis was achieved in 8 of them, 2 were referred for surgical management, and 1 received endovascular treatment. Follow-up was able in 53 patients for an average period of 11 months (range 1 to 81 months). During this period, 7 patients presented an episode ofrebleeding and were treated with cyanoacrylate, achieving hemostasis. Eradication of varices was documented on 21 patients (39.6%). The global rate of rebleeding was 37%. One patient developed splenic vein thrombosis as a major complication of treatment. CONCLUSION: Definitive hemostasis was achieved in 94.6% of patients, with primary hemostasis in 89%. The global rate of rebleeding was 37% and the rate of major complications associated with treatment 0.6%. Eradication of gastric varices was achieved in 35.8% of cases. As these data show, it can be concluded that butyl-cyanoacrylate constitutes an effective method for the treatment of gastric variceal bleeding.

Primary lymphoma of the entire esophagus diagnosed by endoscopic ultrasound-guided fine needle aspiration (EUS-FNA).

Primary esophageal lymphoma is extremely rare, with fewer than 30 cases reported in the literature. Presentation is nonspecific with multiple radiological and endoscopic appearances, posing its diagnosis a challenge. We report a case of a primary esophageal lymphoma diagnosed by endoscopic ultrasound-fine needle aspiration in a 68-year-old woman referred to our hospital for evaluation of a submucosal tumor spreading all over the esophageal wall. We describe its clinical and imaging features and stand out the importance of having a specific preoperatory diagnosis in order to avoid a major surgery.

Endoscopic Ultrasound in the Diagnosis of Pancreatoduodenal Groove Pathology: Report of Three Cases and Brief Review of the Literature.

The pancreatoduodenal groove is a small area where pathologic processes involving the distal bile duct, duodenum, pancreatic head, ampulla of Vater, and retroperitoneum converge. Despite great advances in imaging techniques, a definitive preoperative diagnosis is challenging because of the complex anatomy of this area. Therefore, surgical intervention is frequently required because of the inability to completely exclude malignancy.
We report 3 cases of patients with different groove pathologies but similar clinical and imaging presentation, and show the essential role of endoscopic ultrasound (EUS) in making a specific preoperative diagnosis, excluding malignancy in the first case, changing diagnosis in the second case, and confirming malignancy in the third case. EUS was a fundamental tool in this cohort of patients, not only because of its ability to provide superior visualization of a difficult anatomical region, but because of the ability to guide precise, realtime procedures, such as fine-needle aspiration.

Malignant gastroenteric obstruction: therapeutic options.

Malignant gastric outlet obstruction is a complication of advanced pancreatic cancer, manifesting endoscopically or radiographically as a stricture of the proximal duodenum. Until recently, management consisted of surgical gastroenteric bypass with or without associated biliary bypass. Over the past decade, the endoscopic deployment of self-expanding metal stents (SEMS) emerged as a new option for restoration of enteric patency. Compared with surgical bypass, SEMS placement is less invasive with good clinical outcomes. Aside from SEMS placement and surgical bypass, recent reports of magnetic gastroenteric anastamosis have emerged. This article critically examines each of the different therapeutic options for malignant gastric outlet obstruction, defines their clinical utility, and provides the exact recommendations as to how they may be usefully employed.

Hematoma intraparenquimatoso hepático post- colangiopancreatografía retrógrada endoscópica sobreinfectado por Citrobacter freundii y Klebsiella pneumoniae BLEE / [Intraparenchymal hepatic haematoma after endoscopic retrograde cholangiopancreotography overinfected by Citrobacter freundii and Klebsiella pneumoniae BLEE].

This case report describes a 37-year-old woman who develops an intraparenchymal hepatic haematoma after an endoscopic retrograde cholangiopancreatography with papillotomy and stone extraction. The procedure requires the passage of a guidewire. The patient develops acute abdominal pain 72 hours later and a magnetic resonance shows a hematoma of 124 x 93 mm. She remains under observation. Twenty one days later she complains of upper right abdominal pain and fever. Consequently, a percutaneous drainage is performed isolating Citrobacter freundii and Klebsiella pneumoniae BLEE. The patient has a good evolution.