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Background High-grade dysplasia (HGD) and intramucosal carcinoma (IMC) in Barrett’s esophagus (BE) are now well-established indications for endoscopic resection (ER). Radiofrequency ablation (RFA) can be combined with ER in case of flat or long-segment BE ablation. We report here our experience of complementary RFA after widespread ER of neoplastic BE in daily practice. Method We retrospectively reviewed data of 89 patients, treated between 2006 and 2013 by ER alone (group 1) or by ER combined with RFA (group 2). Results Fifty-five patients in group 1 (7F/48M, mean age 68 years) underwent widespread ER with eradication of residual non-dysplastic BE. Complete eradication of HGD/IMC and intestinal metaplasia (IM) was achieved in 32/32 (100%) and 48/55 (87.3%) patients, respectively. Thirty-four patients in group 2 (3F/31M, mean age 67 years) had a multimodal treatment strategy, with widespread ER followed by RFA. Mean Prague classification of BE in this group was significantly longer (C4.4M6.6 vs. C2.7M4.5, P

Background The aim of the study was to evaluate the current opinion and clinical decision-making process of international pancreatologists, and to systematically identify key study questions regarding the diagnosis and treatment of chronic pancreatitis (CP) for future research. Methods An online survey, including questions regarding the diagnosis and treatment of CP and several controversial clinical case vignettes, was send by e-mail to members of various international pancreatic associations: IHPBA, APA, EPC, ESGE and DPSG. Results A total of 288 pancreatologists, 56% surgeons and 44% gastroenterologists, from at least 47 countries, participated in the survey. About half (48%) of the specialists used a classification tool for the diagnosis of CP, including the Mayo Clinic (28%), Mannheim (25%), or Buchler (25%) tools. Overall, CT was the preferred imaging modality for evaluation of an enlarged pancreatic head (59%), pseudocyst (55%), calcifications (75%), and peripancreatic fat infiltration (68%). MRI was preferred for assessment of main pancreatic duct (MPD) abnormalities (60%). Total pancreatectomy with auto-islet transplantation was the preferred treatment in patients with parenchymal calcifications without MPD abnormalities and in patients with refractory pain despite maximal medical, endoscopic, and surgical treatment. In patients with an enlarged pancreatic head, 58% preferred initial surgery (PPPD) versus 42% initial endoscopy. In patients with a dilated MPD and intraductal stones 56% preferred initial endoscopic ± ESWL treatment and 29% preferred initial surgical treatment. Conclusion Worldwide, clinical decision-making in CP is largely based on local expertise, beliefs and disbeliefs. Further development of evidence-based guidelines based on well designed (randomized) studies is strongly encouraged.

A rare case of refractory ascites caused by benign portal vein stenosis after pancreatoduodenectomy (PD) is reported. A dogma claims that ascites is found in portal hypertension with an intrahepatic block only. However, in the postoperative state, the pathophysiologic condition is altered, which made diagnosis difficult. A 69-year-old man who had undergone PD for lower bile duct carcinoma in situ, developed in postoperative course a pseudoaneurysm of the common hepatic artery successfully treated by stent graft. Six months later, the patient developed refractory ascites. CT scan revealed a severe stricture in the main trunk of the portal vein, probably due to extrinsic compression by the stent in the hepatic artery. Percutaneous transhepatic portography was performed and stent-graft was placed over the stenotic segment. Portal blood flow was corrected immediately. One week after the stenting procedure the patient was free of ascites and control physical and biochemical examination three years later is completely normal.

En este trabajo se presenta el primer caso reportado de hepatogastrostomía guiada por ultrasonido endoscópico, realizada en un paciente con antecedente de cirugía bariátrica (banda gástrica), y se revisan la evolución clínica y de la técnica, así como los accesorios utilizados. Se complementa este caso clínico con una revisión detallada y actualizada de la literatura médica referente a las derivaciones biliopancreáticas guiadas por ultrasonido endoscópico, las cuales son procedimientos en rápido desarrollo e incrementan el armamentarium terapéutico para los pacientes que requieren derivaciones biliares o pancreáticas, y en quienes ha fallado la derivación por colangiopancreatografía retrógrada endoscópica (CPRE) o no es posible realizarla; también lo es para quienes no son candidatos a la alternativa de la derivación biliar percutánea o la rechazan. Entre los mencionados procedimientos se incluyen la hepatogastrostomía guiada por ultrasonido endoscópico, el rendezvous biliopancreático guiado por ultrasonido endoscópico, la coledocoduodenostomía guiada por ultrasonido endoscópico, la colecistogastrostomía guiada por ultrasonido endoscópico y la pancreatogastrostomía guiada por ultrasonido endoscópico. Se hará, además, una descripción técnica de cada uno de estos procedimientos y de los accesorios requeridos. Finalmente, se plantea el manejo de los pacientes, guiados por los pioneros de mayor experiencia en estas técnicas en el mundo; procedimientos que ya tienen un lugar reconocido dentro del armamentarium terapéutico de los pacientes que ameritan tal tipo de derivaciones In this paper we present the first reported case of endoscopic ultrasound-guided hepatic-gastrostomy, performed on a patient with a history of bariatric surgery (gastric banding). We review the patient’s clinical history and the technology and accessories used. This case report is supplemented with a detailed and updated review of the medical literature regarding endoscopic ultrasound-guided biliary-pancreatic diversions. These procedures are rapidly developing in a way that is increasing the therapeutic armory for patients who require biliary or pancreatic derivations but who do not meet the requirements for endoscopic retrograde cholangiopancreatography (ERCP), and who are not candidates for, or who reject, the option of percutaneous biliary bypass. These procedures include the hepatic gastrostomy guided by endoscopic ultrasound, biliary-pancreatic rendezvous guided by endoscopic ultrasound, endoscopic ultrasound-guided choledochoduodenostomy, endoscopic ultrasonography-guided cholecystogastrostomy and endoscopic ultrasound-guided pancreatic gastrostomy. This article provides a technical description of each of these procedures and the accessories required. Finally, we present patient management following the guide of the most experienced pioneers of these techniques in the world. These procedures already have a well-recognized place in the therapeutic armory for patients who require this kind of diversion.

The echoendoscopic biliary drainage is an option to treat obstructive jaundices when ERCP drainage fails. These procedures compose alternative methods to the side of surgery and percutaneous transhepatic biliary drainage, and it was only possible by the continuous development and improvement of echoendoscopes and accessories. The development of linear setorial array echoendoscopes in early 1990 brought a new approach to diagnostic and therapeutic dimenion on echoendoscopy capabilities, opening the possibility to perform punction over direct ultrasonographic view. Despite of the high success rate and low morbidity of biliary drainage obtained by ERCP, difficulty could be found at the presence of stent tumor ingrown, tumor gut compression, periampulary diverticula, and anatomic variation. The echoendoscopic technique starts performing punction and contrast of the left biliary tree. When performed from gastric wall, the access is made through hepatic segment III. From duodenum, direct common bile duct punction. Dilatation is required before stent introduction, and a plastic or metallic stent is introduced. This phrase should be replaced by: diathermic dilatation of the puncturing tract is required using a 6F cystostome. The technical success of hepaticogastrostomy is near 98%, and complications are present in 36%: pneumoperitoneum, choleperitoneum, infection, and stent disfunction. To prevent bile leakage, we have used the 2 stent techniques, the first stent introduced was a long uncovered metallic stent (8 or 10 cm), and inside this first stent a second fully covered stent of 6 cm was delivered to bridge the bile duct and the stomach. Choledochoduodenostomy overall success rate is 92% and described complications include, in frequency order, pneumoperitoneum and focal bile peritonitis, present in 19%. By the last 10 years, the technique was especially performed in reference centers, by ERCP experienced groups, and this seems to be a general guideline to safer procedure execution.

BACKGROUND: There are situations in which the specimens obtained after endoscopic mucosal resection of superficial adenocarcinoma arising from Barrett's esophagus are not adequate for histopathological assessment of the margins. In these cases, immunohistochemistry might be an useful tool for predicting cancer recurrence. AIM: To evaluate the value of p53 and Ki-67 immunohistochemistry in predicting the cancer recurrence in patients with Barrett's esophagus-related cancer referred to circumferential endoscopic mucosal resection. METHODS: Mucosectomy specimens from 41 patients were analyzed. All endoscopic biopsies prior to endoscopic mucosal resection presented high-grade dysplasia and cancer was detected in 23 of them. Positive reactions were considered the intense coloration in the nuclei of at least 90% of the cells in each high-power magnification field, and immunostaining could be classified as superficial or diffuse according to the mucosal distribution of the stained nuclei. RESULTS: Endoscopic mucosal resection samples detected cancer in 21 cases. In these cases, p53 immunohistochemistry revealed a diffuse positivity for the great majority of these cancers (90.5% vs. 20%), and Ki-67 showed a diffuse pattern for all cases (100% vs. 30%); conversely, patients without cancer revealed a superficial or negative pattern for p53 (80% vs. 9.5%) and Ki-67 (70% vs. 0%). During a mean follow-up of 31.6 months, 5 (12.2%) patients developed six episodes of recurrent cancer. Endoscopic mucosal resection specimens did not show any significant difference in the p53 and Ki-67 expression for patients developing cancer after endoscopic treatment. CONCLUSIONS: p53 and Ki-67 immunohistochemistry were useful to confirm the cancer; however, they had not value for predicting the recurrent carcinoma after circumferential endoscopic mucosal resection of Barrett's carcinoma. RACIONAL: Há situações nas quais o material obtido após mucosectomia endoscópica do adenocarcinoma superficial do esôfago de Barrett é inadequado para avaliação histopatológica de suas margens. Nesses casos, a imunoistoquímica poderia ser de auxílio para predição da recurrência tumoral. OBJETIVO: Avaliar o valor da detecção imunoistoquímica da p53 e do Ki-67 na predição da recurrência tumoral após mucosectomia endoscópica circunferencial do câncer no esôfago de Barrett. MÉTODOS: Foi analisado o material proveniente de mucosectomias de 41 pacientes. Todas as biopsias endoscópicas pré-mucosectomia apresentavam displasia de alto grau e câncer foi detectado em 23 casos. A imunorreatividade foi definida pela coloração de, pelo menos, 90% dos núcleos em cada campo de grande aumento, podendo ser classificada como superficial ou difusa, conforme a distribuição celular dos núcleos corados. RESULTADOS: A mucosectomia detectou o câncer em 21 casos. Nesses casos, a p53 revelou padrão difuso de positividade para a maioria dos casos (90,5% vs. 20%) e o Ki-67 demonstrou padrão difuso para todos os portadores de câncer (100% vs. 30%). Por sua vez, pacientes sem câncer revelaram padrão negativo ou apenas superficial para a p53 (80% vs. 9,5%) e para o Ki-67 (70% vs. 0%). Durante seguimento médio de 31,6 meses, cinco (12,2%) pacientes apresentaram seis episódios de câncer recurrente. Neste grupo, os fragmentos de mucosectomia não demonstraram nenhuma diferença significativa na expressão imunoistoquímica da p53 e do Ki-67 nos pacientes desenvolvendo câncer após o tratamento endoscópico. CONCLUSÕES: A imunoistoquímica da p53 e do Ki-67 é útil na confirmação do câncer; contudo não demonstra nenhum valor na predição da recurrência tumoral após mucosectomia endoscópica circunferencial do esôfago de Barrett com adenocarcinoma.