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Background: The diagnostic efficacy of current tissue sampling techniques for upper GI subepithelial tumors (SETs) appears to be limited. Better tissue acquisition techniques are needed to improve the diagnostic yield in this setting. Objective: Our purpose was to determine the safety and diagnostic yield of EUS-guided needle-knife incision and forceps biopsy (SINK biopsy) of upper GI SETs. Design: Retrospective database review. Setting: Academic tertiary-care referral center. Patients: This study involved 14 consecutive patients referred for EUS evaluation of upper GI SETs with previous unsuccessful attempts at tissue diagnosis by conventional forceps biopsy. Intervention: EUS-guided needle-knife incision and forceps biopsy. Main Outcome Measurements: The safety and diagnostic yield of this method, compared with EUS-guided fine-needle aspiration (EUS-FNA), when possible. Results: SINK biopsy provided tissue samples that were sufficient for definite histologic diagnosis in 13 of 14 cases (diagnostic yield 92.8%). There were 8 gastric GI stromal tumors. In 7 of 8, the size of SINK specimens allowed immunohistochemical analysis, and the evaluation of malignant potential was carried out by means of mitotic index determination in 5 cases (71.42%). SINK biopsies determined the pathological diagnosis of all (4 of 4) nonmesenchymal lesions. Eight patients underwent both EUS-FNA and SINK, with final histologic diagnosis determined in 6 of 8 cases (75%) by SINK versus 1 of 8 cases (12.5%) by EUS-FNA (Fisher exact test, P = .023). There were no procedure-related complications. Limitations: A single-center, retrospective analysis with small sample size. Conclusion: SINK biopsy appears to be an easy, safe, and effective technique for determining the definitive pathological diagnosis, evaluation of the malignant potential, and planning management of SETs. It could be a reliable alternative to conventional FNA, providing larger samples that improve the histologic yield. [ABSTRACT FROM AUTHOR]

The treatment applied for children admitted to the pediatric intensive care unit (PICU) for severe acute bronchiolitis may differ from general recommendations. The first objective of our study was to describe the treatments offered to these children in a Spanish tertiary PICU. The second objective was to analyse the changes in management derived from the publication of the American Academy of Pediatrics (AAP) bronchiolitis guideline in 2014. This was a retrospective–prospective observational study conducted during two epidemic waves (2014–2015 and 2015–2016). The AAP guidelines were distributed and taught to PICU staff between both epidemic waves. A total of 138 children were enrolled (78 male). In the first period, 78 children were enrolled. The median age was 1.8 months (IQR 1.1–3.6). There were no differences between the management in the two periods, except for the use of high-flow oxygen therapy (HFOT); its use increased in the second period. Overall, 83% of patients received non-invasive ventilation or HFOT. Children older than 12 months received HFOT exclusively. In comparison, continuous positive airway pressure and bi-level positive airway pressure were used less during the period 2015–2016 (P = 0.036). Regarding pharmacological therapy, 70% of patients received antibiotics, 23% steroids, 33% salbutamol, 31% adrenaline, and 7% hypertonic saline. The mortality rate was zero. Our PICU did not follow the AAP recommendations. There were no differences between the two periods, except in the use of HFOT. All children older than 12 months received HFOT exclusively. The rate of using invasive mechanical ventilation was also low. [ABSTRACT FROM AUTHOR]

Abstract: Background: Biliary complications, a major source of morbidity after orthotopic liver transplantation (OLT), are increasingly being treated by endoscopic retrograde cholangiopancreatography (ERCP). Endoscopic management has been shown to be superior to percutaneous therapy and surgery. Covered self-expandable metal stents (CSEMSs) may be an alternative to the current endoscopic standard treatment with periodic plastic stent replacement. Objective: To assess the safety and efficacy of temporary CSEMS insertion for biliary complications after OLT. Methods: From November 2001 to December 2009, the 242 OLT performed in 226 patients included 67 cases that developed post-OLT leaks or strictures (29.6%), excluding ischemic biliary complications. CSEMSs were used in 22 patients (33%), 18 male and 4 female, with an overall median age of 55 years (range, 29–69). In-house OLT patients underwent an index ERCP at 26 days (range, 8–784) after OLT. Their records were reviewed to determine ERCP findings, technical success, and clinical outcomes. Results: ERCP with sphincterotomy was performed in all 22 patients, revealing 18 with biliary strictures alone (82%), 3 with strictures and leaks (14%), and 1 with strictures and choledocholithiasis (4%). All strictures were anastomotic. All patients had 1–2 plastic stents inserted across the anastomosis (11 had prior balloon dilation); stones were successfully removed, for an initial technical success rate of 100% (22/22). CSEMSs, were placed at the second ERCP in 14 patients, at the third in 7, and at the fourth in 1. With a median follow-up of 12.5 months (range, 3–25) after CSEMS removal, 21/22 patients (95.5%) remain stricture free and one relapsed, requiring repeat CSEMS insertion. Four patients experienced pain after CSEMS insertion. At CSEMS removal, migration was noted in 5 cases, into either the distal duodenum (n = 4) or the proximal biliary tree (n = 1), and embedding was seen in 1 case. There were no serious complications; no patients needed hepatojejunostomy. Conclusions: ERCP is a safe first-line approach for post-OLT biliary complications. It was highly successful in a population with anastomotic leaks and strictures. The therapeutic role of ERCP to manage biliary complications after OLT in the long term is not well known. In our experience, the high rate (close to 95%) of efficacy and its relative safety allowed us to use CSEMS to manage refractory biliary post-OLT strictures. CSEMS insertion may preclude most post-OLT hepatojejunostomies. [Copyright &y& Elsevier]

Survival after orthotopic liver transplantation (OLT) has increased over the last decades, focusing on the metabolic complications that contribute to patient morbidity and mortality. The aim of our study was to describe the prevalence of metabolic syndrome (MS), its components, and its associated factors in patients who underwent OLT in a hospital in Spain. From November 2001 to January 2014, we performed 415 transplantations in 386 patients. We analyzed 204 patients with a minimum follow-up of 1 year (77.6% were male and the mean age was 54.2+/−9.5 years). The most frequent etiology was alcohol (41%), followed by hepatitis C virus (29.1%). The indication was decompensated cirrhosis in 51.8% and hepatocellular carcinoma in 34%. According to modified National Cholesterol Education Program–Adult Treatment Panel-III (NCEP-ATP III) criteria, 5 years post-transplantation MS was diagnosed in 38.2% of patients. Significant independent predictors of post-transplantation MS on logistic regression analysis were as follows: pretransplantation obesity (odds ratio [OR], 3.09; P = .056), 1-year post-transplantation obesity (OR, 3.95; P = .009), pretransplantation diabetes (OR, 4.63; P = .001), 1-year post-transplantation diabetes (OR, 3.01; P = .015), 1-year post-transplantation hypertension (OR, 1.85; P = .176), and hypertriglyceridemia at the first year after transplantation (OR, 2.32; P = .063). In our center the prevalence of MS at 5 years after OLT is slightly lower than published. The most important risk factors were obesity and diabetes (both pretransplantation and the first year post-transplantation). [ABSTRACT FROM AUTHOR]

Abstract: Mucormycosis, although an infrequent fungal infection, has a high mortality in patients undergoing orthotopic liver transplantation. We present two cases of cutaneous Absidia mucormycosis in two successive patients undergoing liver transplantation in our hospital. In our literature search, we encountered only one published case of Absidia infection in liver transplantation. [Copyright &y& Elsevier]

Longer survival for orthotopic liver transplantation (OLT) patients over the last decade has focused emphasis on the metabolic complications that contribute to patient morbidity and mortality. The aim of our study was to analyze the prevalence of the metabolic syndrome (MS) and other risk factors after OLT among our patients at 1 year follow-up. From 2001 to 2008, we performed OLT in 210 patients with 62 exclusions leaving 148 patients for the study. We recorded age, gender, liver disease, smoking status, pre- and post-OLT body mass index, pre- and post-OLT arterial blood pressure, pre- and post-OLT fasting blood glucose, pre- and post-OLT high-density lipoproteins and triglycerides, family history of diabetes, hepatitis B and C virus status, immunosuppressive therapy, and corticosteroid bolus for rejection episodes. The MS was defined according to modified ATP III criteria. At month 12 after OLT, 29/148 patients (19.6%) developed the MS. The associated factors were obesity and hyperlipidemia pre-OLT, familial and personal history of diabetes as well as alcoholic cirrhosis. By multivariate analysis, pre-OLT body mass index (odds ratio, 3.7 [1.3–10.5]) and pre-OLT diabetes (odds ratio, 2.9 [1.1–7.9]) were independent risk factors. [Copyright &y& Elsevier]

Abstract: Introduction: Liver biopsy remains the gold standard to evaluate fibrosis. However, it is invasive and uncomfortable as well as associated with complications. Transient elastography (FibroScan) is a simple and noninvasive method to assess liver fibrosis by measuring liver stiffness in kilopascals. Body mass index (BMI) greater than 28 is associated with high rates of invalid tests. Liver transplant patients show increased rates of obesity. We do not yet have many data about the usefulness of FibroScan in liver transplantation. Aims: To analyze the applicability of FibroScan to assess fibrosis in liver transplantation and study the association between obesity and valid tests. Material and Methods: We prospectively assessed the performance of transient elastography in 29 liver transplant patients from February to May 2008. We prospectively studied the success rate, the elasticity (stiffness) in kilopascals, and the BMI. Results: The BMI was greater than 30 kg/m2 in four patients; 25 to 30 kg/m2 in eight; and 17 had BMI < 25 kg/m2. The overall success of FibroScan was 24/29 (82.7%). However, among patients with BMI > 30 kg/m2, it was 2/4 (50%), whereas for BMI <25 kg/m2 it climbed to 100%. The average duration of the procedure was 211.52 seconds for BMI <25 kg/m2; 236 seconds for BMI between 25 and 30 kg/m2; and 361 seconds in patients with a BMI > 30 kg/m2—differences that were statistically significant. Conclusions: FibroScan seemed to be a promising approach to assess liver fibrosis.BMI is a limiting factor toward achieving a valid test; FibroScan had limited usefulness in obese patients. [Copyright &y& Elsevier]