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OBJECTIVES: Endoscopic ultrasound-guided digestive anastomosis (EUS-A) is a new alternative under evaluation in patients presenting with afferent limb syndrome (ALS) after Whipple surgery. The aim of the present study is to analyze the safety and effectiveness of EUS-A in ALS. METHODS: This is an observational multicenter study. All patients ≥18 years old with previous Whipple surgery presenting with ALS who underwent an EUS-A using a lumen-apposing metal stent (LAMS) between 2015 and 2021 were included. The primary outcome was clinical success, defined as resolution of the ALS or ALS-related cholangitis. Furthermore, technical success, adverse event rate, and mortality were evaluated. RESULTS: Forty-five patients (mean age: 65.5 ± 10.2 years; 44.4% male) were included. The most common underlying disease was pancreatic cancer (68.9%). EUS-A was performed at a median of 6 weeks after local tumor recurrence. The most common approach used was the direct/freehand technique (66.7%). Technical success was achieved in 95.6%, with no differences between large (≥15 mm) and small LAMS (97.4% vs. 100%, P = 0.664). Clinical success was retained in 91.1% of patients. A complementary treatment by dilation of the stent followed by endoscopic retrograde cholangiopancreatography through the LAMS was performed in three cases (6.7%). There were six recurrent episodes of cholangitis (14.6%) and two procedure-related adverse events (4.4%) after a median follow-up of 4 months. Twenty-six patients (57.8%) died during the follow-up due to disease progression. CONCLUSION: EUS-A is a safe and effective technique in the treatment of malignant ALS, achieving high clinical success with an acceptable recurrence rate. ispartof: DIGESTIVE ENDOSCOPY vol:34 issue:7 pages:1433-1439 ispartof: location:Australia status: published

Background: Lumen apposing metal stent (LAMS) allows an easy access to peripancreatic fluid collections (PPFCs) and the possibility of performing direct endoscopic necrosectomy (DEN). The aim of our study was to evaluate the safety and efficacy of a new 20-mm LAMS in the management of PPFCs. This novel stent represents the largest diameter LAMS available on the market to date. Methods: This is an international, multicenter retrospective study involving 20 centers. Consecutive patients who underwent EUS-guided PPFC drainage using a 20-mm LAMS were included. Primary outcomes were technical and clinical success. Secondary outcomes were rate and the severity of adverse events. Results: A total 105 patients underwent PPFC drainage using the new 20-mm LAMS and 106 LAMS were placed. Technical success was 100% (106/106). 7/105 patients died due to causes not related to the stent. Clinical success was achieved in 92/98 patients (93.9%). Significant adverse events occurred in 8/98 patients (8.16%): 4 cases (4.08%) of bleeding, 3 cases (3.06%) of suprainfection, 1 case of gastric outlet obstruction. Conclusions: This multicenter study demonstrated acceptable rates of technical and clinical success using a new 20-mm LAMS for PPFC, including walled-off pancreatic necrosis (WOPN). The results of our study suggest that a new 20-mm LAMS is non-inferior in terms of safety, efficacy, and adverse events as compared to smaller diameter LAMS in the management of PPFCs, including pancreatic psuedocysts (PP) and WOPN. Randomized controlled studies will be needed to determine the ideal size of LAMS need to achieve the greatest clinical benefit with the minimized risk exposure for this high-risk patient population.

Background It seems that lumen-apposing metal stents (LAMS) are displacing plastic stents in the therapy of pancreatic-fluid collection in walled-off necrosis (WON). To date, there is no quality of evidence to recommend LAMS as the standard treatment in the management of WON. The theoretical benefit of LAMS over plastic stents needs to be proven. Methods/design This is a randomized controlled, multicenter, prospective clinical trial with two parallel groups, without masking. One-hundred and fourteen patients with WON will undergo endoscopic ultrasound (EUS)-guided transmural draining in nine tertiary hospitals in Spain and will be randomized to the LAMS or plastic-stent group. The primary endpoint is the short-term (4 weeks) clinical success determined by the reduction of the collection (to Discussion The PROMETHEUS trial has been designed to determine whether LAMS are superior to plastic stents in EUS-guided transmural drainage of WON. Trial registration ClinicalTrials.gov, ID: NCT03100578. Registered on 4 April 2017. https://clinicaltrials.gov/ct2/home

New parameters complementary to clinical TNM classification are needed, to orient preoperative on the possibility of a R0 gastric cancer resection. We analysed the possible predictive value of blood neutrophil/lymphocytic ratio (N/L) in relation to resectability.Two hundred and fifty-seven gastric cancers consecutively diagnosed and without neoadjuvant treatment were retrospectively studied. Univariate and multivariate analysis of the frequency of R0 cases was performed between groups with a normal N/L ratio (5) and pathological N/L ratio (≥5). Furthermore, we studied the subgroup of operated patients (n=156) analysing the frequency of R0 resection according to N/L ratio5 or≥5.One hundred and fifty-six patients underwent surgical intervention, of which 139 had R0 resections. A high N/L ratio was registered in 46 cases (17.9%). Globally, resectability was higher in patients with a N/L ratio5: 59.7% vs. N/L ratio≥5: 28.6% (P.001; OR=3.76; 95% CI=1.78-8.04). The relation between N/L ratio5 and R0 resection was confirmed in the multivariate (P=.006; OR=3.86; 95% CI=1.46-10.22). In the operated subgroup, the higher frequency of R0 resection achievement is maintained in cases with N/L ratio5: 91.3% vs. 72.2% (P=.015; OR=4.04; 95% CI=1.23-13.26).The presence of a N/L ratio5 at the diagnosis of a gastric carcinoma is related in a significant and independent way with a higher frequency of R0 tumoral resection, globally. This higher proportion of R0 resection cases in patients with a N/L5 ratio is confirmed in the subgroup of operated patients.

Fundamento: El Índice Pronóstico nutricional (IPN) combina los valores de los linfocitos circulantes y la albúmina sérica y, en la literatura asiática, se le ha relacionado con el pronóstico tras la resección R0 del cáncer gástrico, sin disponer de resultados en países occidentales. Estudiamos, en el momento del diagnóstico del tumor, el posible valor pronóstico independiente del IPN, sobre la supervivencia. Pacientes y Métodos: Revisamos 234 carcinomas gástricos consecutivos, determinando la supervivencia global y la específica por el tumor. Consideramos patológicos los valores del IPN pre-tratamiento < 40. Realizamos un análisis univariante y multivariante de las supervivencias según el IPN, incluyendo las siguientes variables de ajuste: edad > 70 años, ASA anestésico al diagnóstico, tamaño de la neoplasia > 5 cm, tipo macroscópico infiltrante, grado indiferenciado y estadificación clínica TNM mediante ecoendoscopia y/o TAC. Resultados: El análisis univariante registró una mayor supervivencia global y específica en los casos con IPN ≥ 40 versus IPN < 40: [HR = 2,28; IC 95% = (1,60-3,26); p< 0,001] y [HR = 2,35; IC 95% = (1,63-3,39); p< 0,001], respectivamente. El análisis multivariante confirmó un mejor pronóstico independiente en los casos con IO ≥ 40: supervivencia global: [HR = 1,48; IC 95% = (1,02-2,16); p = 0,040], supervivencia específica: [HR = 1,51; IC 95% = (1,03-2,23); p = 0,036]. Conclusiones: En el momento del diagnóstico del cáncer gástrico e incluyendo la totalidad de los casos registrados, un IPN ≥ 40 se acompaña de una supervivencia global y específica por el tumor significativamente mayor. En nuestra serie, este mejor pronóstico es independiente del grupo de edad del paciente, de su clasificación ASA, del tamaño y grado de diferenciación de la neoplasia y de su estadificación clínica TNM. Background: The Prognostic Nutritional Index (PNI) combines the values of circulating lymphocytes and serum albumin and, in the Asian literature; it has been related with the prognosis following R0 resection of gastric cancer. No results are available in Western countries. We study the possible independent prognostic value, at the moment of the tumour's diagnosis, of PNI on survival. Patients and methods: We review 234 consecutive gastric carcinomas, calculating global survival and tumour-specific survival. We considered pre-treatment PNI values of < 40 to be pathological. We carried out a univariate and multivariate analysis of cases of survival according to PNI, including the following adjustment variables: age > 70 years, ASA anaesthetic at the time of diagnosis, size of the neoplasia > 5cm, macroscopic type, undifferentiated degree and TNM clinical stage through echoendoscopy and/or CAT. Results: The univariate analysis registered greater global and specific survival in cases with PNI ≥ 40 versus PNI < 40: [HR = 2.28; CI 95% = (1.60-3.26); p< 0.001] and [HR = 2.35; CI 95% = (1.63-3.39); p< 0.001], respectively. The multivariate analysis confirmed a better independent prognosis in cases with OI ≥ 40: global survival: [HR = 1.48; CI 95% = (1.02-2.16); p = 0.040], specific survival: [HR = 1.51; CI 95% = (1.03-2.23); p = 0.036]. Conclusions: At the moment of diagnosis of gastric cancer and including all registered cases, a PNI ≥ 40 is accompanied by a significantly greater global and tumour-specific survival. In our series, this better prognosis is independent of the patient's age group, his/her ASA classification, the size and degree of differentiation of the neoplasia and its TNM clinical stage.

Nowadays, capsule endoscopy is the first-line procedure for the visualization of the small bowel. Although it was primarily designed with this goal, it may also identify other segments of the gastrointestinal tract. The aim of the current study is to evaluate the incidence of esophageal abnormalities detected in patients undergoing small bowel capsule endoscopy and its impact on patient management.This study is a retrospective analysis of data from 2217 consecutive capsule endoscopy procedures performed at a single tertiary-care centre between January 2008 and February 2016. Patient baseline characteristics, esophageal lesions, diagnosis and management before and after capsule endoscopy were recorded and a descriptive analysis was then performed.2217 patients were finally included in the analysis. 1070 were male (48.2%) and the mean age was 56.1 ± 19.5 years (12-93). Obscure gastrointestinal bleeding (52.3%) and inflammatory bowel disease (18.3%) were the main procedure indications. Esophageal abnormalities were detected in 105 out of 2217 patients (4.7%). The most common lesions detected were peptic esophagitis (58.1%) and esophageal varices (17.1%). This information had a clinical/diagnostic impact of 3.3% and a therapeutic impact of 3.2%.Capsule endoscopy detects not only small bowel lesions, but also significant esophageal lesions that may be overlooked during initial gastroscopy. Therefore, all images of the esophagus should be read during small bowel capsule endoscopy, since it could provide relevant information that may result in changes on patient´s management.

Introduction: the incidence of cystic pancreatic lesions (CPL) in the asymptomatic population is increasing. Achieving a preoperative diagnosis of CPL still remains a challenge. Objectives: to evaluate the diagnostic accuracy of the cytological diagnosis of CPL from samples obtained by cytology brush versus standard endoscopic ultrasound fine needle aspiration (EUS-FNA). Methods: a multicenter, randomized, open-label trial was performed of EUS-cytology brush (EUS-EB) versus EUS-FNA for the cytological diagnosis of CPL. Patients that underwent EUS-FNA with a CPL > 15 mm were included and randomized into two groups: group I, EUS-EB; group II, EUS-FNA. The final diagnosis was based on the histological evaluation of surgical specimens and clinical parameters, imaging and a five year follow-up in non-operated patients. The main outcome was the diagnostic accuracy of both methods. Secondary outcomes were the diagnostic adequacy of specimens and the rate of adverse events. Data were compared using the Chi-squared test. An intention to treat (ITT) and per-protocol (PP) analysis were performed. Results: sixty-five patients were included in the study, 31 in group I and 34 in group II. Three patients initially randomized to group I were changed to group II as it was impossible to obtain a sample using the brush. The mean size of the CPL was 28.2 mm (range 16-60 mm). The diagnostic accuracy of EUS-EB was not superior to EUS-FNA, neither in the ITT nor the PP analysis (44.8% vs 41.1%, p = 0.77 and 38.4% vs 45.9%, p = 0.55). Conclusions: EUS-EB does not improve the diagnostic accuracy of CPL in comparison with EUS-FNA.

Background EUS-guided cholangiopancreatography (ESCP) allows transmural access to biliopancreatic ducts when ERCP fails. Data regarding technical details, safety, and outcomes of ESCP are still unknown. Objective To evaluate outcomes of ESCP in community and referral centers at the initial development phase of this procedure, to identify the ESCP stages with higher risk of failure, and to evaluate the influence on outcomes of factors related to the endoscopist. Design Multicenter retrospective study. Setting Public health system hospitals with experience in ESCP in Spain. Patients A total of 125 patients underwent ESCP in 19 hospitals, with an experience of Intervention ESCP. Main Outcome Measurements Technical success and complication rates in the initial phase of implantation of ESCP are described. The influence of technical characteristics and endoscopist features on outcomes was analyzed. Results A total of 125 patients from 19 hospitals were included. Biliary ESCP was performed in 106 patients and pancreatic ESCP was performed in 19. Technical success was achieved in 84 patients (67.2%) followed by clinical success in 79 (63.2%). Complications occurred in 29 patients (23.2%). Unsuccessful manipulation of the guidewire was responsible for 68.2% of technical failures, and 58.6% of complications were related to problems with the transmural fistula. Limitations Retrospective study. Conclusion Outcomes of ESCP during its implantation stage reached a technical success rate of 67.2%, with a complication rate of 23.2%. Intraductal manipulation of the guidewire seems to be the most difficult stage of the procedure.

Due to the potential risks associated with stent placement, European Society Gastrointestinal Endoscopy does not recommend prophylactic insertion of stents in patients without symptoms. The aim was to compare complication rates, need of surgery, colostomy formation, and survival between stent placement prior to start of chemotherapy (SEMS group) and upfront ChT (ChT group) in patients with endoscopically non-transverable metastatic left-sided colorectal cancer.Gender, age, CEA, tumor location, sites of metastatic disease, peritoneal involvement, liver involvement, and angiogenesis inhibitors administration, were recorded. Complication rates, need of surgery, stoma creation, and survival were compared between both groups by univariate and multivariate test. Complications of SEMS placement in both groups were compared.We studied 75 men and 40 women, with a mean age of 66.3 years. Overall complication and perforation rates were similar but patients in the ChT group had a significant higher need of surgery and subsequent stoma creation. Perforation after SEMS placement rates were higher in patients receiving ChT than in patients without ChT. Survival was related to peritoneal carcinomatosis and administration of biological agents.SEMS placement prior to ChT administration dismissed the need of subsequent surgery and decreased the rates of permanent stoma formation.

To evaluate the diagnostic yield of endoscopic ultrasonography (EUS) in patients with idiopathic acute pancreatitis (IAP), find factors predictive of a positive EUS finding in these patients and investigate whether these etiological findings are maintained during follow-up.We performed EUS in patients with IAP between July 2004 and August 2007. We recorded epidemiological data, the number and severity of previous bouts of pancreatitis and gallbladder status.A total of 44 patients were included in the study. EUS was normal in seven patients (16%). In the remaining 37 patients (84%) we found cholelithiasis (n = 3), microlithiasis (n = 20), chronic pancreatitis (n = 14), pancreas divisum (n = 3), pancreatic mass (n = 1), apudoma (n = 1), cystic tumor of the pancreas (n = 2) and choledocholithiasis (n = 2). Positive EUS findings were not influenced by sex, severity of pancreatitis or recurrent disease. Patients aged65 years (ageor65 years: 73.9% versus 95.2%; P = 0.097) and patients with gallbladder in situ (cholecystectomy versus non-cholecystectomy: 63.6% versus 90.9%; P = 0.054) showed a tendency to have positive EUS findings. Mean follow-up was 28.95 +/- 10.86 months (range 12-64 months; median 28 months). During follow-up the etiological diagnosis was changed in two patients, lowering the diagnostic yield to 79%.EUS identified the cause of IAP in 79% of patients. Patients with gallbladder in situ and patients aged65 years showed a tendency to have positive EUS findings. The majority of the diagnoses provided by EUS are maintained during follow-up and seem to be reliable.

In the setting of stage-IV obstructive colorectal cancer, self-expanding metallic stents (SEMS) placement and palliative surgery may be appropriate options. The aim of the present study is to evaluate the long-term results of surgery compared with stent implantation and to identify patients in whom one of these options can provide more benefit. From November 2000 to November 2008, 98 patients with incurable stage-IV colorectal cancer were treated with palliative surgery (n=53) or SEMS (n=45). Data were recorded with respect to age, gender, tumor location, carcinoembryogenic antigen, ASAclass, presence of metastatic disease in one or multiple organs, volume of liver metastases, urgency of the procedure and treatment with chemotherapy. Comparison between surgery and stent placement was performed for all group and for patients who received and did not receive chemotherapy. Both groups were comparable regarding age, ASA-class, chemotherapy treatment, tumor location and presence of metastatic disease in one or multiple organs but not in gender, rate of urgent procedures, abnormal CEA and of volume of liver metastases >25%. Survival in surgical group was significantly higher (11.9 vs 7.3 months; log-rank test, p = 0.002). SEMS group had lower early morbidity, hospital stay and stoma creation. For patients who received chemotherapy, surgery provided benefit in survival (6.8 vs 3.9 months; log-rank test, p = 0.101); in this subgroup, long-term complications from the primary tumour were more common in stented group, and time to chemotherapy was longer in the group of surgery. No differences in survival were shown in patients who did not receive chemotherapy. Stent placement offers advantages regarding early morbidity, hospital stay and stoma creation. Surgery offers a benefit in survival in patients who receive chemotherapy but not in non-candidates to chemotherapy.

Submitted by Gestor HospitalBraga (bibliotecaria@hospitaldebraga.com.pt) on 2016-09-16T13:58:02Z No. of bitstreams: 1 Endoscopy.pdf: 327978 bytes, checksum: 7124d9e0d42685bf58c4a97b183d1f8f (MD5) Made available in DSpace on 2016-09-16T13:58:02Z (GMT). No. of bitstreams: 1 Endoscopy.pdf: 327978 bytes, checksum: 7124d9e0d42685bf58c4a97b183d1f8f (MD5) Previous issue date: 2015

Background and Aim Endoscopic ultrasonography-guided biliary drainage (EUS-BD) using expandable biliary metal stents has emerged as an acceptable alternative in patients with failed endoscopic retrograde cholangiopancreatography for malignant biliary obstruction. However, there is no consensus over the preferred access route (transhepatic or extrahepatic), direction of stent insertion (antegrade or retrograde) or drainage route (transluminal or transpapillary) in patients potentially suitable for multiple methods. The present study compares success and complication rates in patients undergoing EUS-BD via different methods. Methods This was a multicenter retrospective analysis. Records of patients who underwent EUS-BD for malignant obstructive jaundice at four centers were entered in a standard database. Success and complications were compared for different techniques. Results Sixty-eight patients were analyzed. EUS-BD was successful in 65 patients (95.6%). There was no significant difference in the success rates of different techniques. Complications wereseen in 14 patients (20.6%) and mortality in three patients (4.4%). Complications were significantly higher for the transhepatic route compared to the transduodenal route (30.5% vs 9.3%, P = 0.03). There was no significant difference in complication rates among transluminal and transpapillary stent placements, or direct and rendezvous stenting. Logistic regression analysis showed transhepatic access to be the only independent risk factor for complications (P = 0.031, t = 2.2). Conclusion EUS-BD can be carried out with high success rates regardless of the choice of access route, stent direction or drainage route. However, complications are significantly higher with transhepatic access. The transduodenal route should be chosen for EUS-guided and rendezvous stent placements, when both routes are available.

Objective: we wanted to know if patients read and understand the informed consent (IC) document used for endoscopic procedures, and to evaluate the readability of IC. Method: during two months we gave patients studied in our endoscopy unit an anonymous questionnaire with different items concerning reading degree, knowledge of the technique, complications, sedation used, and information received. We evaluated IC readability using the Flesch index. Results: 309 patients were included (mean age: 53 years, 55% males, 86% outpatients, 50% with basic education); 85% of patients read the IC, 96% considered they understood the exploration technique, 22% were not aware of severe complications, and 82% knew which kind of sedation would be used; 88% of patients received additional information from their doctors. Outpatients read the IC in a greater percentage versus inpatients (p < 0.05); patients with only basic education tended to ignore the possibility of complications (p < 0.05). Doctors gave more information to rural patients (p = 0.08), offered better information about complications to urban patients (p = 0.09), and offered more information on other diagnostic procedures to patients older than 50 years (p < 0.05). With the Flesch index we found that gastroscopy and colonoscopy ICs had a "standard" level of readability, while ERCP ICs were more complex. Conclusions: the majority of our patients read and understands the IC. Doctors adapt information to patient characteristics. Our IC documents have an acceptable level of readability, but given that 50% of our patients have only a basic educational status, we should attempt to provide an easier IC document.