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Pancreatic cancer produces disabling abdominal pain, and the pain medical management for pancreatic cancer is often challenging because it mainly relies on the use of narcotics (major opioids). However, opioids often provide suboptimal pain relief, and the use of opioids can lead to patient tolerance and several side effects that considerably reduce the quality of life of pancreatic cancer patients. Endosonography-guided celiac plexus neurolysis (EUS-CPN) is an alternative for pain control in patients with nonsurgical pancreatic cancer; EUS-CPN consists of the injection of alcohol and a local anesthetic into the area of the celiac plexus to achieve chemical ablation of the nerve tissue. EUS-CPN via the transgastric approach is a safer and more accessible technique than the percutaneous approach. We have reviewed most of the studies that evaluate the efficacy of EUS-CPN and that have compared the different approaches that have been performed by endosonographers. The efficacy of EUS-CPN varies from 50% to 94% in the different studies, and EUS-CPN has a pain relief duration of 4–8 wk. Several factors are involved in its efficacy, such as the onset of pain, previous use of chemotherapy, presence of metastatic disease, EUS-CPN technique, type of needle or neurolytic agent used, etc. According to this review, injection into the ganglia may be the best technique, and a good visualization of the ganglia is the best predictor for a good EUS-CPN response, although more studies are needed. However, any of the 4 different techniques could be used to perform EUS-CPN effectively with no differences in terms of complications between the techniques, but more studies are needed. The effect of EUS-CPN on pain improvement, patient survival and patient quality of life should be evaluated in well-designed randomized clinical trials. Further research also needs to be performed to clarify the best time frame in performing a EUS-CPN.

Objective: The aim of this study was to compare predictive factors and Radial Echoendoscopy (EUS) in the diagnosis of choledocholithiasis.Materials and Methods: Patients with suspected choledocholithiasis were recruited from April 2011 to January 2018. All patient characteristics, findings of EUS and findings of ERCP were recorded and analyzed.Results: Eighty patients were enrolled in this study. Clinical symptoms, blood chemistry and liver function test were similar in patients with and without choledocholithiasis. Using the findings of ERCP as the gold standard, Radial EUS had sensitivity and specificity for the detection of choledocholithiasis at 90.2% and 97.4%, and for choledocholithiasis and/or common bile duct sludge at 92.7% and 100%, respectively. For patients with intermediate likelihood and high likelihood from predictive factors (33 and 45), Radial EUS was positive for choledocholithiasis in 51.5% (17/33) and 46.7% (21/45), and ERCP was positive for choledocholithiasis in 54.5% (18/33) and 48.9% (22/45), respectively.Conclusion: Predictive factors, for both intermediate and high likelihood groups, were not accurate to diagnose these patients. Radial EUS is a good diagnostic tool and should done in both groups of patients to avoid unnecessary ERCP.

Resumen Objetivos: presentar el desarrollo de modelos educativos para el aprendizaje de dos técnicas endoscópicas vigentes, ampliamente difundidas y de gran implicación clínica, con la única intención de permitir la adquisición de destrezas básicas y avanzadas a residentes y gastroenterólogos. Materiales y métodos: se idearon dos modelos sencillos, de muy bajo costo, fácilmente reproducibles y reutilizables, con los cuales se logra ejecutar la totalidad de los procedimientos descritos. Además, permiten al operador integrar el desarrollo de habilidades y la adquisición de los conceptos teóricos mínimos requeridos, sin las presiones generadas por el riesgo existente de complicaciones. Resultados: la tendencia actual a nivel mundial se conduce hacia el desarrollo de modelos de enseñanza que aceleren la curva de aprendizaje, así como de procedimientos altamente exigentes y asociados a complicaciones potencialmente graves. Con estos modelos es posible poner a prueba al endoscopista, mediante una evaluación continua y supervisada. Su implementación en unidades de gastroenterología es sencilla, sin la necesidad de una inversión superlativa o el desplazamiento a otros países. Conclusiones: se trata de un gran aporte al desarrollo científico y educativo de nuestro país, ya que la creación y la implementación de nuevas técnicas endoscópicas y su aprendizaje no deben ser asumidos por los pacientes. En este punto, estamos de acuerdo con los conceptos emitidos por diferentes asociaciones médicas respecto a que los cursos teórico-prácticos de corta duración -y en algunas ocasiones virtuales- no constituyen una formación mínima, requerida para lograr la acreditación. Abstract Objectives: This article presents the development of educational models for learning two widespread recent endoscopic techniques which have great clinical implications. Its sole intention is to allow acquisition of basic and advanced skills by residents and gastroenterologists. Materials and methods: Two simple, very low cost, easily reproducible and reusable models were devised. Procedures are fully described in ways that allow the operator to integrate the development of skills and acquisition of the minimum theoretical concepts required without the pressures generated by risks of complications. Results: The current global trend is to develop teaching models that accelerate the learning curve for highly demanding procedures that are associated with potentially serious complications. With these models it is possible to test endoscopists through continuous supervised evaluations. Implementation by gastroenterology units can be done easily without the need for large investments or travel to other countries. Conclusions: This is a great contribution to the scientific and educational development of Colombia since neither development of new endoscopic techniques nor the process of learning how to perform them should put patients at risk. We agree with the ideas of numerous medical associations regarding theoretical-practical courses of short duration even though some virtual sessions, “do not constitute the minimum training required needed for accreditation”.

ilustraciones, fotografías, graficas Pancreatic Cancer (PC) is one of the most aggressive cancers, constituting the seventh leading cause of cancer-related death globally in 2020. Usually, the asymptomatic response of PC causes the delayed diagnosis of the disease. Diagnosis of PC usually includes ultrasonography (US), computed tomography (CT), magnetic resonance (MRI), and endoscopic ultrasound (EUS). Although EUS is the diagnostic method with the highest sensitivity reported, the procedure is highly operator-dependent. A gastroenterologist requires more than 150 supervised procedures to interpret the anatomy blurred by several noise sources. Therefore, a second reader may be desirable to support the procedure and assist the training process in a gastroenterology service. Some computational strategies have been developed to detect PC in EUS images, but those methods are semi-automatic in practice and very susceptible to noise. Hence, the main contribution of this work is an automatic strategy to detect PC in complete video sequences of EUS procedures. The proposed methodology describes the mixture of echo patterns using the Speeded-Up Robust Features (SURF) method. A set of interest points are defined and described correlating the echo patterns in a multiscale analysis, and filtering the noise sources, usually uncorrelated among different scales. Then, images with PC are differentiated by a binary classification method, evaluating Support Vector Machines and Adaboost models. Additionally, the proposed method is assessed using a public EUS database constructed and released in this work, with 55 cases. Finally, the proposed method was compared with typical Deep Learning approaches, reaching an accuracy of 92.1\% and 90.0\%, respectively. In addition, the method herein proposed is also stable in experiments with added noise, while the nets fail to maintain a similar performance. El Cáncer de Páncreas (CP) fue la séptima causa de muerte por cáncer en el mundo en 2020. Es uno de los más agresivos y en la mayoría de los casos se diagnostica en etapas avanzadas por su respuesta asintomática. El diagnóstico del CP se realiza mediante técnicas de imágen como ultrasonido (US), tomografía computarizada(TAC), resonancia magnética(RMN) y Ecoendoscopia(EE). Aunque la EE tiene la más alta sensibilidad, el proceso de entrenamiento de los especialistas requiere más de 150 procedimientos supervisados, convirtiendose en un procedimiento altamente dependiente de la experticia del gastroenterólogo y del manejo de las múltiples fuentes de ruido durante el procedimiento. Por lo tanto, es deseable un segundo lector para apoyar el procedimiento y asistir el proceso de entrenamiento. Se han desarrollado estrategias computacionales para apoyar la detección del CP, pero son semi-automáticos en la práctica y altamente suceptibles a las fuentes de ruido. La principal contribución de este trabajo es el desarrollo de una estrategia automática para detectar CP en secuencias de video completas de procedimientos de EE. El método describe los eco-patrones en imágenes de EE utilizando el algoritmo “SURF” por sus siglas en inglés. Se definen y describen un conjunto de puntos de interés correlacionados en un análisis multiecala y se filtran las fuentes de ruido que usualmente no se correlacionan entre escalas. Luego, las imágenes con CP se diferencian mediante una clasificación binaria utilizando métodos de soporte vectorial y árboles de decisión. Adicionalmente, el método se evalúa utilizando una base de datos pública construida en este trabajo con 55 casos en total. Finalmente, el rendimiento se compara con los enfoques típicos de aprendizaje profundo, obteniendo un rendimiento de 92.1\% y 90.0\%, respectivamente. Adicionalmente, el metodo propuesto es estable en experimentos al adicionar ruido, en los que las redes fallan en mantener un rendimiento similar. (Texto tomado de la fuente) Further author information: (Send correspondence to María Jaramillo) Diego Bravo: E-mail: marjaramillogon@unal.edu.co, Telephone: +57 3137214469 Maestría Magíster en Ingeniería Biomédica Digital Anatomy by Images Research Applied Computing - Image Processing

Studio di comparazione tra EUS-FNA ed EUS-FNB 22G nella caratterizzazione delle lesioni solide pancreatiche Abstract Introduzione La FNA (fine-needle aspiration) � la metodica ecoendoscopica (EUS) di scelta per la valutazione e campionamento delle lesioni solide pancreatiche. Negli anni recenti sono stati introdotti in commercio aghi da biopsia (FNB, fine-needle biopsy) in grado di consentire l?acquisizione di materiale senza la modificazione dell?architettura e morfologia tissutale, dimostrando una eccellente accuratezza diagnostica associata ad una maneggevolezza comparabile agli aghi standard da FNA. Acquire? (Boston Scientific, Natick, MA, USA) rappresenta un tipo di ago Franseen a tre punte in cromo-cobalto, costituito da tre uncini elettrolucidati, a cui corrispondono tre superfici di taglio simmetriche. Metodi Uno studio retrospettivo volto all?acquisizione dei dati delle procedure ecoendoscopiche con prelievo per esame citologico o istologico � stato condotto nel nostro centro, analizzando i dati relativi alle procedure ecoendoscopiche eseguite da Novembre 2019 a Settembre 2020 in pazienti con riscontro di nodulo solido pancreatico. Lo scopo dello studio � stato quello di comparare sensibilit�, specificit�, accuratezza diagnostica, valore predittivo positivo e valore predittivo negativo tra prelievo con ago da FNB 22G e prelievo con ago da FNA. Sono stati inoltre valutati l?impatto del grado di esperienza dell?operatore e il tasso di complicanze tra i differenti tipi di ago Risultati La diagnosi di adenocarcinoma pancreatico � risultata la pi� frequente in entrambi i gruppi, seguita rispettivamente dalle diagnosi di tumore neuroendocrino, lesione benigna, lesione di natura secondaria e da un caso di tumore solido pseudopapillare (70.0%, 6.7%, 5.0%, 3.3%, 1.7%). Le diagnosi non conclusive sono risultate rispettivamente del 15.6% (7/45) nel gruppo FNA e del 6.7% (1/15) nel gruppo FNB. In relazione alle diagnosi ottenute non sono state riscontrate differenze statisticamente significative nell?ambito dei due gruppi (p > 0.05). FNA e FNB hanno dimostrato performance diagnostiche sovrapponibili, con una accuratezza diagnostica per la FNB del 93.33% e per la FNA del 84.4% (p>0.05). In nessun caso si � verificata una complicanza maggiore. In 2 casi � stato registrato un minimo sanguinamento endoluminale a livello del sito di accesso dell?ago, entrambi i casi sono stati registrati nel gruppo FNB (p < 0.05). In entrambi i gruppi la maggioranza delle procedure � stata eseguita da un operatore esperto, rispettivamente nel 71.1% (32/45) del gruppo FNA e nel 60.0% (9/15) del gruppo FNB. Nel gruppo FNA � emersa una correlazione statisticamente significativa tra diagnosi ottenuta ed esecuzione dell?esame da parte di un operatore esperto (p < 0.01). Tale correlazione non � emersa nel gruppo FNB (p > 0.05). Conclusioni La EUS-FNA e la EUS-FNB presentano entrambe una elevata accuratezza diagnostica con un tasso di complicanze trascurabile, ricoprendo sempre pi� un ruolo fondamentale nel percorso diagnostico del paziente con nodulo pancreatico. Nel nostro studio non si � dimostrata una differenza statisticamente significativa tra le due metodiche per quanto concerne sensibilit�, specificit� e accuratezza diagnostica, sebbene si sia confermata la percezione attuale di un trend a favore della FNB. L?esperienza dell?endoscopista appare il parametro in grado di influenzare maggiormente la resa diagnostica nel gruppo sottoposto a prelievo con ago da FNA, mentre tale correlazione non si � evidenziata nel gruppo FNB.

Introduction. Primary non-Hodgkin’s lymphoma of the extrahepatic bile duct presenting as obstructive jaundice is an extremely rare disease. Case presentation. We report a case of obstructive jaundice caused by primary non-Hodgkin’s lymphoma of the common bile duct (CBD), in a 67-year-old male patient. Our patient showed clinical evidence of obstructive jaundice, and tomography revealed a dilated common bile duct with the suspicion of intra ductal lithiasis. Endoscopic retrograde cholangiopancreatography (ERCP) was performed, with efficient drainage and clinical resolution of the obstructive jaundice. One month later, the patient presented the same clinical signs of obstructive jaundice, only this time the ERCP revealed common bile duct distal stenosis. The next step was to perform an echoendoscopy (EUS), that visualized a homogeneous mass at the common bile duct distal level and cholangiocarcinoma was suspected. Fine needle aspiration (FNA) of the lesion obtained tissue fragments for histological examination. The diagnosis was diffuse B-cell type non-Hodgkin’s lymphoma in the marginal area, and the patient was evaluated in the Oncology Department for chemotherapy. Conclusions. It is very important to differentiate primary non-Hodgkin’s lymphoma of the bile ducts from other causes of obstructive jaundice, as the treatment approach and prognosis are fundamentally different. Endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) is the definitive diagnosis technique, avoiding surgical interventions and the classic exploratory laparotomy.

В статье рассматриваются вопросы эндоскопической внутрипросветной ультразвуковой диагностики патологических изменений большого дуоденального сосочка (БДС) радиальными датчиками, определяется возможность применения методики при выборе метода транспапиллярного вмешательства, а именно целесообразности выполнения эндоскопической папиллосфинктеротомии (ЭПСТ), приводятся собственные клинические наблюдения, обосновывается потребность в дооснащении эндоскопических кабинетов ультразвуковой эндоскопической аппаратурой и эндоскопическими водоструйными насосами для отмывания обследуемых участков слизистых и создания стабильной водной среды в просвете ДПК для обеспечения технической возможности проведения ультразвуковых эндоскопических обследований БДС., №11(179) (2020)

Background: Despite the increasing number of national departments performing endoscopic ultrasound (EUS), there are no official data regarding clinical EUS practice in Portugal. Objectives: We aimed to evaluate the current practice of EUS in Portugal. Methods: By email, we invited 1 physician of each one of the 26 national Gastroenterology Departments which perform EUS to complete a survey questionnaire available on the Google Forms platform. The online questionnaire was available from September 2017 until February 2018 and was answered only by physicians who perform EUS. Results: A total of 21/26 (80.8%) national Gastroenterology Departments answered the questionnaire. In Portugal, there are 42 echoendoscopes in total; most of the echoendoscopy units have only 1 EUS processor (81%), 1 radial echoendoscope (66.7%), 1 linear echoendoscope (76.2%), 1 anorectal probe (57.1%), but no miniprobes (85.7%). About 81% have histological core acquisition needles. In 81% of the units, there are at least 2 ultrasonographers who perform echoendoscopy together (at least 2 ultrasonographers per EUS) in 47.6% of these departments. The ultrasonographers also performed abdominal ultrasound (US), anal US, and endoscopic retrograde cholangiopancreatography in 71.4, 66.7, and 42.9%, respectively. The echoendoscopy units have 2.4 ± 1.1 periods of echoendoscopy per week and 4 ± 1.5 EUS per period (499.2 ± 416.8 EUS per year). Subepithelial lesions and biliopancreatic lesion evaluation as well as gastrointestinal neoplasia staging were the most common EUS indications. The number of FNA (fineneedle aspirations) ranges from 10 to 160/year. Rapid on-site evaluation (ROSE) is available in 60% of units and is performed by the cytopathologist (66.7%) in the majority of cases. The main reason for omitting ROSE is the limited pathology staff. Cytopathological material is prepared by the ultrasonographer in 25% of the units. Air drying (50%) and formalin (50%) are most frequently used to fix and preserve smears, respectively. Pancreatic pseudocyst drainage (66.7%), celiac plexus neurolysis (52.4%) and pancreatic necrosectomy (42.9%) are the most widespread therapeutic procedures. Conclusions: This survey provides the first insight into the current status of digestive echoendoscopy in Portugal. There is a great variability in diagnostic and therapeutic echoendoscopy practice. Introdução: Apesar do crescente número de serviços nacionais a realizar ecoendoscopia digestiva, não existem dados sobre a prática da ecoendoscopia no nosso país. Objetivos: Pretendemos avaliar a prática da ecoendoscopia em Portugal. Métodos: Por e-mail convidámos um elemento de cada dos 26 serviços nacionais de Gastrenterologia que realizam ecoendoscopia a preencher um questionário disponível na plataforma google forms. O questionário esteve disponível via online de setembro de 2017 a fevereiro de 2018 e foi respondido apenas por médicos que realizam ecoendoscopia. Resultados: Obtivemos resposta de 21 dos 26 serviços convidados (80.8%). Em Portugal existe um total de 42 ecoendoscópios. A maioria das unidades possui 1 ecógrafo (81%), 1 ecoendoscópio radial (66.7%), 1 eco endoscópio linear (76.2%), 1 sonda rectal (57.1%) mas não dispõem de mini-sondas (85.7%). 81% dispõem de agulhas de aquisição de core histológico. Em 81% dos serviços existem pelo menos 2 ecoendoscopistas que realizam ecoendoscopia em conjunto em 47.6% dos serviços. Os ecoendoscopistas também realizam ecografia abdominal, ecografia anal e colangiopancreatografia retrógrada endoscópica em 71.4, 66.7 e 42.9% respectivamente. Os serviços têm em média 2.4 ± 1.1 períodos de ecoendoscopia/semana realizando em média 4 ± 1.5 ecoendoscopia/período (499.2 ± 416.8 ecoendoscopias/ano). A avaliação de lesões subepiteliais e bilio-pancreática, assim como o estadiamento de neoplasias do tubo digestivo são as indicações mais frequentes para a realização de ecoendoscopia. O número de punções diagnósticas guiadas por ecoendoscopia varia entre 10 e 160/ano. A maioria dos serviços (60%) dispõe de rapid on-site pathological evaluation (ROSE) que é realizada pelo citopatologista na maioria das vezes (66.7%). A carência de funcionários nas unidades de Anatomia Patológica é o principal motivo para a ausência de ROSE. A preparação do material citopatológico é realizada pelo ecoendoscopista em 25% dos serviços. A secagem ao ar (50%) e o formol (50%) são o método de fixação dos esfregaços e o meio de preservação mais usados, respetivamente. A drenagem de pseudocisto pancreático (66.7%), neurólise do plexo celíaco (52.4%) e necrosectomia pancreática (42.9%) são os procedimentos terapêuticos mais disseminados. Conclusões: Este trabalho fornece os primeiros dados sobre a prática de ecoendoscopia digestiva em Portugal. Existe uma grande variabilidade nos exames diagnósticos e terapêuticos.

Introdução: O adenocarcinoma de esôfago e transição esofagogástrica tem sido a neoplasia de maior aumento na sua incidência nas últimas décadas, sendo atualmente um problema de saúde global. Apresenta um mau prognóstico e tem uma baixa taxa de sobrevida em 5 anos. Seu tratamento é definido com base no estadiamento clínico pré-operatório, no qual a Ecoendoscopia tem um papel fundamental. Objetivo: Avaliar a acurácia atual da Ecoendoscopia no estadiamento do adenocarcinoma de esôfago e junção esofagogástrica. Método: Revisão sistemática no Pubmed, Embase e Portal BVS com os termos: Esophageal Neoplasm, Esophagus Neoplasms, Esophagus Cancers, Esophageal Cancers, EUS, EUSFNA, Endoscopic Ultrasonography, Echo Endoscopy, Endosonographies e Endoscopic Ultrasound, com posterior meta análise dos dados encontrados. Resultados: A acurácia do estadiamento T é de 65.55%. Para o T1, a sensibilidade foi de 64.7% e a especificidade de 89.1%, com acurácia de 89.6%. Na subdivisão T1a e T1b a sensibilidade foi respectivamente de 48.6% e 47.2%, a especificidade de 72.6% e 81% e acurácia de 67.9% e 74.3% respectivamente. Para o T2 a sensibilidade e especificidade foram de 35.7% e 89.2% respectivamente, com acurácia de 87.1%. Para o T3 a sensibilidade e a especificidade foram de 82.5% e 83% respectivamente, com acurácia de 87%. Para T4 a sensibilidade e a especificidade foram de 38.6% e 94% respectivamente, com acurácia de 66.4%. Para o estadiamento N a sensibilidade foi de 77.3% e a especificidade de 67.4%, com acurácia de 77.9%. Conclusão: A Ecoendoscopia apresenta uma acurácia subótima no estadiamento preoperatório do adenocarcinoma de esôfago e junção esofagogástrica. Background: Esophageal adenocarcinoma and esophagogastric junction is a global health problem, with an increase in its incidence in the last decades. It has a poor prognosis and has a low survival rate in 5 years. Its treatment is based on the preoperative clinical staging, in which the Ecoendoscopy plays a fundamental role. Aim: To evaluate the current accuracy of the echoendoscopy in the staging of esophageal adenocarcinoma and esophogogastric junction. Methods: Systematic review in Pubmed, Embase and BVS Portal with the terms: Esophageal Neoplasm, Esophagus Neoplasms, Esophagus Cancers, Esophageal Cancers, EUS, EUS-FNA, Endoscopic Ultrasonography, Echo Endoscopy, Endosonographies, and Endoscopic Ultrasound with subsequent meta-analysis of the data found. Results: The accuracy of the T staging is 65.55%. For T1 the sensitivity was 64.7% and the specificity was 89.1%, with accuracy of 89.6%. In the subdivision T1a and T1b the sensitivity was respectively 48.6% and 47.2%, the specificity of 72.6% and 81% and accuracy of 67.9% and 74.3% respectively. For T2, the sensitivity and specificity were 35.7% and 89.2%, respectively, with accuracy of 87.1%. For T3, the sensitivity and specificity were 82.5% and 83%, respectively, with accuracy of 87%. For T4 the sensitivity and specificity was 38.6% and 94%, respectively, with accuracy of 66.4%. For staging N the sensitivity was of 77.3% and the specificity of 67.4%, with accuracy of 77.9%. Conclusion: Echoendoscopy presents suboptimal accuracy in the preoperative staging of esophageal adenocarcinoma and esophagogastric junction.

Resumen Introducción: los pseudoquistes pancreáticos pueden ser drenados por métodos quirúrgicos, laparoscópicos, percutáneos y endoscópicos. Este último es el más aceptado en la actualidad dado que es más simple y genera menos morbimortalidad; sin embargo, siempre se ha descrito asociado con el uso de la fluoroscopia, lo cual le suma complejidad. En este trabajo presentamos nuestra técnica de drenaje sin fluoroscopia guiado por ecoendoscopia. Materiales y métodos: el objetivo de este trabajo es describir una técnica de drenaje de pseudoquistes pancreáticos sin el uso de fluoroscopia y con la guía del ecoendoscopio. Se reporta una serie de casos de 10 pacientes a quienes se les realizó drenaje transgástrico, en los que se describen la técnica, complicaciones y resultados en el seguimiento. Resultados: se incluyeron 10 pacientes consecutivos, 5 pacientes eran mujeres y 5 hombres. El 90% de los casos comprometía el cuerpo del páncreas. Se implantó exitosamente 1 stent (metálico) transmural (cistogastrostomía) solo con guía ecoendoscópica en 9 pacientes; en 1 paciente no se logró liberar el stent, por lo cual se realizó el drenaje por aspiración. Los 9 pacientes a quienes se les implantó stent no presentaron recidiva; la paciente a quien se realizó drenaje por aspiración presentó recidiva a nivel del cuerpo de páncreas. La principal complicación fue la migración del stent hacia la cavidad del pseudoquiste en 1 paciente, el cual requirió segundo tiempo endoscópico para retirarlo. Conclusiones: el drenaje transmural del pseudoquiste pancreático con implante de stent es una técnica mínimamente invasiva, segura y efectiva para el tratamiento del pseudoquiste pancreático. Abstract Introduction: Pancreatic pseudocysts can be drained by surgical, laparoscopic, percutaneous, and endoscopic methods. Endoscopic methods have become the most widely accepted nowadays since they are simpler and generate less morbidity and mortality. They have always been associated with the use of fluoroscopy, which adds complexity. This study presents our drainage technique which is guided by echoendoscopy rather than fluoroscopy. Materials and methods: The objective of this study is to describe a technique for drainage of pancreatic pseudocysts which does not use fluoroscopy to guide the endoscope. Instead, echoendoscopy guides the instrument. We report a case series of 10 patients who underwent transgastric drainage and describe the technique, complications and results during follow-up. Results: Ten consecutive patients, five women and five men, were included in this study. Ninety percent were cases in which the body of the pancreas had been compromised. Cystogastrostomy was successfully performed in nine patients. It consisted of implantation of a transmural metallic stent under single endoscopic guidance. In one patient the stent was not released and aspiration drainage was performed. The nine patients who had stents implanted have presented no recurrences, but the patient who underwent aspiration drainage presented recurrence in the body of the pancreas. The main complication was migration of the stent into the pseudocyst cavity which occurred in one patient and which required a second endoscopic procedure to remove the stent. Conclusions: Transmural drainage of pancreatic pseudocysts through placement of stents is a safe, effective and minimally invasive technique for the treatment of pancreatic pseudocysts.

Introducción: El reemplazo graso del páncreas, esteatosis o lipomatosis pancreática es un proceso difuso o focal en cualquier segmento del órgano y se ha asociado a obesidad, diabetes mellitus y fibrosis quística. El ultrasonido abdominal y en especial la ecoendoscopia , permiten una mejor caracterización del parénquima de la glándula. Caso Clínico: adolescente femenina de 13 años referida por dolor abdominal crónico. Antecedentes: Gastritis crónica por Helicobacter pylori, Alergia alimentaria múltiple y en tratamiento con Metilprednisolona durante siete años por Artritis Reumatoidea Juvenil. Examen físico : Peso 40,9Kg y talla 134cm, fascie redondeada, catarata bilateral, cuello con hiperqueratosis e hiperpigmentación . Abdomen: globoso, blando, sin visceromegalia. Hipotrofia muscular miembros inferiores. Laboratorio : amilasa: 32U/L, lipasa 12.3U/L, colesterol 206mg%, triglicéridos 117 mg%, aminotransferasa pirúvica 60U/L, PCR ultrasensible 11,6 mg/l, relación insulina/glicemia postprandial alta, 25OHvitamina D: 5,5ng/ ml (déficit), cortisol y androstenediona bajos, exámenes negativos para enfermedad autoinmune En heces: esteatocrito 4.5% y Sudan III:15 a 20 gotas pequeñas. Edad ósea radiológica 11años. Ultrasonido abdominal: hiperecogenicidad periportal, páncreas ligeramente aumentado de tamaño con aumento difuso de su ecogenicidad, cabeza: 30mm, cuerpo:13mm y cola:30mm. Ultrasonido endoscópico: Proceso uncinado y cabeza con parénquima homogéneo, ecogenicidad conservada. En el itsmo, cuerpo y cola parénquima heterogéneo , con tendencia a la hiperecogenicidad. Wirsung: calibre normal. Diagnóstico clínico: Esteatosis pancreática, Síndrome de Cushing Exógeno y Resistencia a la Insulina con déficit vitamina D. Discusión : Se considera que existe relación positiva entre el uso prolongado de esteroide para el reemplazo graso del páncreas y las patologías asociadas como se evidencia en este caso. Introduction: Fatty pancreas replacement, steatosis or pancreatic lipomatosis is a diffuse or focal process in any organ segment and has been associated with obesit y, diabetes mellitus and cystic fibrosis. Abdominal ultrasound and, in particular, ultrasound endoscopy allow a better characterization of the parenchyma of the gland. Case Clinical: 13 - year - old female adolescent referred for chronic abdominal pain. Backgr ound: Chronic gastritis by Helicobacter pylori, multiple food allergy and treatment with Methylprednisolone for seven years for Juvenile Rheumatoid Arthritis. Physical examination: Weight 40.9Kg and size 134cm, rounded fascia, bilateral cataract, neck with hyperkeratosis and hyperpigmentation. Abdomen: globose, soft, without visceromegaly. Muscle lower limb hypotrophy. Laboratory: amylase: 32U / L, lipase 12.3U / L, cholesterol 206mg%, triglycerides 117mg%, pyruvic aminotransferase 60U / L, ultrasensitive 1 1.6mg / l, insulin ratio / high postprandial glycemia, 25OH vitamin D: 5ng / ml (deficit), cortisol and low Androstenedione, negative tests for autoimmune disease Feces: steatocrit 4.5% and Sudan III: 15 to 20 small drops. Radiologic bone age 11 years. Abd ominal ultrasound: periportal hyperechogenicity, slightly enlarged pancreas with diffuse increase of its echogenicity, head: 30mm, body: 13mm and tail: 30mm. Endoscopic ultrasound: Uncinate process and head with homogeneous parenchyma, preserved echogenici ty. In the ismo, body and parenchyma heterogeneous, with tendency to hyperechogenicity. Wirsung: normal caliber. Clinical diagnosis: Pancreatic steatosis, Exogenous Cushing's Syndrome and Insulin Resistance with vitamin D deficit. Discussion: It is considered that t here is a positive relationship between prolonged steroid use for fatty replacement of the pancreas and associated pathologies as evidenced in this case.

Metastatic cancersmake up fewer than 2% of pancreaticmalignancies, and themajority of them mimic a primary adenocarcinoma [1]. Limited data are available concerning the assessment of pancreatic secondary cancers using endoscopic ultrasound-guided fine needle biopsy (EUSFNB) [2]. In this study we report the first case of metastatic pancreatic melanoma to be diagnosed by combining EUS with biopsy sampling using the SharkCore needle (SharkCore Fine Needle Biopsy System, Covidien IIc, NewtonMassachusetts, USA). A 57-year-old woman presented with evidence of a pancreatic mass. Her past medical history included a choroidal melanoma in 2009, which had been treated by iodine-125 brachytherapy. At the time of treatment no metastatic lesions had been documented. In May 2015, a magnetic resonance imaging (MRI) scan performed for clinical surveillance demonstrated a nodular liver consistent with metastasis. The patient underwent transarterial chemoembolization with irinotecan. A subsequent MRI scan showed a nodular lesion of the pancreatic tail (20×17mm), which was a mixture of isointense and hyperintense on T1-weighted images (●" Fig.1), and was hypointense on T2-weighted images, compatible with either primary cancer or metastatic disease. The patient was asymptomatic, with no suspicious skin lesions and no palpable lymphadenopathy. Laboratory test results were within normal limits. The patient was referred to our institution for EUS evaluation. The EUS (Olympus UCT 140 linear arrayechoendoscope) showed a 2-cm hypoechoic mass in the pancreatic tail (●" Fig.2). Five transduodenal FNB passes (22-gauge SharkCore needle) into the mass resulted in multiple tissue samples (maximum diameter 0.08–0.1cm) (●" Video1). Histological examination showed malignant pigmented epithelioid lesions, which were immunohistochemically confirmed as metastatic melanoma (●" Fig.3). The patient underwent chemotherapy and has currently completed her induction cycleswith fotemustine.

Purpose. The authors compared multidetector-row computed tomography (MDCT) and endoscopic ultrasound (EUS) in the identifi cation of pancreaticoduodenal endocrine tumours (PETs) in patients with multiple endocrine neoplasia type 1 (MEN 1). Materials and methods. Fourteen consecutive patients (eight men and six women, aged 26–54 years) with MEN 1 underwent MDCT performed with a 4- (n=5) or 64- (n=9) detector-row system and EUS done with a radial transducer (7.5–20 MHz) within 7–28 days of each other. Prior to MDCT examination, patients were given 750 cc of water and asked to lie down in the right lateral decubitus for 15 min. Multiphase MDCT images were acquired both before and after the injection of nonionic iodinated contrast material (2 cc/kg) at an injection rate of 4 ml/s, with technical parameters and scan delay varying in relation to the system used. Images were all reconstructed at 3-mm intervals for the three phases (arterial, pancreatic and portal) and evaluated on a dedicated workstation. Results. MDCT detected a total of 25 PETs (3–18 mm) in nine patients. Of these lesions, nine were situated within the duodenal wall and 16 in either the pancreatic head (n=3), body (n=7), or tail (n=6). Three additional lesions were detected retrospectively after EUS imaging. Most (18/22,81%) were hypervascular nodules, and four appeared as either hypoattenuating or cystic lesions. EUS detected a total of 32 PETs (2–18 mm) in 11 patients. Most lesions (29/32, 90%) appeared hypoechoic and were situated in the duodenal wall (n=15) or in either the pancreatic head (n=10), body (n=6) or tail (n=1). Conclusions. Our preliminary data indicate that MDCT is complementary to EUS in the identifi cation of PETs in MEN-1 patients.

BACKGROUND: Echoendoscopy is a mixed technique which adds the advantages of endoscopy to those of transabdominal ultrasonography through an endoscope with transductor in its distal extremity, allowing for the evaluation of the abdominal organs reached by the endoscope and in contact with the intestinal wall. AIM: To verify the positivity rate of the echoendoscopy with puncture with thin needle (EEPTN) or (EE-PAF) in solid pancreatic mass based on the technique used in the Gastrointestinal Endoscopy Unit of Hospital das Clínicas, University of São Paulo. METHODS: Retrospective evaluation - cohort study - of 138 patients who were submitted to echoendoscopy through aspiration puncture between May 2004 and June 2007. The data were collected through the medical charts present in the medical files of Hospital das Clínicas (Clinical Hospital) of the University of São Paulo, having as inclusion criterion the presence of solid pancreatic mass in computerized tomography and as exclusion criterion the presence of non solid pancreatic tumor. The routine technique was the one used in the Gastrointestinal Endoscopy Unit focusing the following variables: mass characteristics (size, location, presence of peripancreatic lymph node, presence of lymph node in celiac trunk); number of punctures to obtain microfragment for cytology, and experience of the professional in charge. The equipment used was an echoendoscopy device model Olympus EUS (EYES) Exera EU - C60, with electronic sectorial transductor and 22 gauges Wilson-Cook needles. RESULTS: Seventy six (55,4 %) male patients and 61 (44.5 %) female were enrolled. Age ranged from 16 to 87 years and means 59,9 years. The lesions were cephalic in 94 (68,1 %). Mass larger than 4 cm had a higher percentage of positivity reaching 40%, but lesions smaller than 2 cm had a percentage of 43% of inconclusive. Microfragments were obtained in 100% of the positive cases and only 73,1 % when negative (P=0,004). There was no statistic difference regarding the experience of the endoscopy professional. Only 80 patients had the number of punctures written down and it was noticed that there is better performance as the number of punctures was increased. The definitive histopathologycal diagnosis of pancreatic neoplasia occurred in only 41(29,7 %) patients. CONCLUSIONS: Regarding mass characteristics, when larger is the mass, larger is the positivity of the method; the location didn't correlate with higher positivity; when the lymph nodes were present, there was a tendency to positivity; concerning the number of punctures, the higher number, higher positivity; in relationship to the professional experience in endoscopy, there was no difference in the rate of positivity of the puncture of the solid pancreatic mass. RACIONAL: Ecoendoscopia é técnica mista que adiciona as vantagens da endoscopia àquelas da ecografia, somente que o procedimento ecográfico é realizado do interior dos órgãos para fora deles, no sentido centrífugo. OBJETIVO: Verificar a positividade da ecoendoscopia na punção com agulhas (EEPTN) ou (EE-PAF) em tumores sólidos pancreáticos baseados na técnica utilizada pelo Serviço de Endoscopia Digestiva do Hospital de Clínicas da Universidade de São Paulo. MÉTODOS: Cohorte retrospectiva de 138 pacientes que realizaram ecoendoscopia com punção aspirativa por agulha fina (EE-PAAF) no período de maio de 2004 a junho de 2007. Os dados foram coletados por meio de consulta aos prontuários, constantes do arquivo médico. O critério de inclusão foi a presença de massa pancreática sólida à tomografia computadorizada e o critério de exclusão a presença de tumor pancreático não sólido. Foram utilizadas as seguintes variáveis: característica da massa (tamanho, localização, presença de linfonodo peripancreático, presença de linfonodo em tronco celíaco); número de punções para obtenção de microfragmento; citologia e experiência do profissional executante. O aparelho utilizado foi um ecoendoscópio da marca Olympus, modelo OLYMPUS EUS (EYS) EXERA EU-C60, com transdutor setorial eletrônico e agulhas de 22 gauges da marca Boston Scientific. RESULTADOS: Setenta e seis (55,4 %) deles eram do sexo masculino e 61 (44,5 %) do feminino. A idade variou de 16 a 87 anos, com média de 59,9 anos. As lesões foram cefálicas em 94 (68,1 %) dos casos. Massas maiores que 4 cm tiveram percentual de positividade maior, chegando a 40%, mas as lesões menores que 2 cm obtiveram percentual de 43 % de inconclusivo. A obtenção de microfragmentos foi conseguida em 100% dos casos positivos e apenas 73,1 %, quando negativo (P=0,004). Não houve diferença estatística em relação à experiência do endoscopista. Apenas 80 pacientes tiveram anotado o número de punções e notou-se que existe melhor desempenho quanto maior for o número delas. O diagnóstico anatomopatológico definitivo de neoplasia pancreática ocorreu em apenas 41 (29,7 %) indivíduos. CONCLUSÕES: Em relação às características da massa, quanto maior ela era maior a positividade do método; a localização não correlacionou com maior positividade; há tendência de positividade quando presentes os linfonodos peripancreáticos; em relação ao número de punções, quanto maior o número delas, maior a positividade do método; em relação à experiência do profissional, não houve diferença no índice de positividade da punção da massa pancreática sólida.

O diagnóstico das lesões císticas pancreáticas pelos métodos de imagem, especialmente as de pequeno tamanho, é cada vez mais freqüente. Em alguns casos, ele representa um dilema em relação à terapêutica, podendo ser pseudocistos inflamatórios, neoplasias primárias ou secundárias. Para a decisão terapêutica, é necessário definir se a neoplasia é benigna, maligna ou potencialmente maligna. Hoje, a ecoendoscopia é considerada o exame padrão-ouro para a investigação do pâncreas, fornecendo dados sobre a morfologia destas lesões e possibilitando, por meio da punção guiada em tempo real, a colheita de material para avaliação citológica e dos marcadores tumorais. Este procedimento é considerado seguro e eficiente e apresenta taxas de sensibilidade e especificidade altas e de morbidade e de complicações baixas. No diagnóstico das lesões mucinosas do pâncreas, os fatores preditivos mais significativos para o diagnóstico diferencial são a presença de septos, os nódulos murais e as alterações parenquimatosas, para o qual as taxas de sensibilidade, especificidade e grau de exatidão são, respectivamente, 94%, 85% e 88%. Os autores têm por objetivo revisar as principais neoplasias císticas primárias do pâncreas, enfatizando a aplicação da ecoendoscopia no diagnóstico definitivo dessas neoplasias.Pancreatic cystic lesions, particularly small lesions, are more easily diagnosed nowadays with the use of imaging methods. In some cases, the diagnosis represents a challenge to establish the treatment, as it can range from inflammatory pseudocysts to primary or metastatic cystic neoplasms. In order to choose the treatment, it is necessary to determine if the lesion is benign, borderline, or malignant. Currently, echoendoscopy is considered the gold standard procedure for pancreatic evaluation as it clearly shows the morphology of the lesion, and also allows the acquisition of pancreatic material for cytological and tumor markers studies using fine needle aspiration biopsy. This procedure is considered safe and efficient with high rates of sensibility and specificity and low rates of complications and morbidity. The presence of septa, mural nodules and irregularities in the parenchyma are the most significant predictive factors for the differential diagnosis of mucinous pancreatic-cystic lesions for which sensibility, specificity and accuracy rates are 94%, 85% and 88%, respectively. The aim of the authors in this study is to review the major primary-cystic-pancreatic neoplasms with emphasis in the application of echoendoscopy for the definite diagnosis of these lesions.

Un homme de 75 ans a ete examine par echoendoscopie gastrique suite a une douleur abdominale et a un ictere. A la fin de l’examen endoscopique, le patient presentait une intense douleur epigastrique. Le CTscanner amis en evidence une plage de 7 cm, contenant un liquide dense, en arriere de la paroi posterieure de l’estomac et un aspect d’ischemie de la rate. Le drainage de la collection hematique, la cholecystectomie et la splenectomie ont ete realises sept jours apres l’examen diagnostique. L’hypothese est qu’un passage difficile de l’echoendoscope a travers le pylore, secondaire a un phlegmon perivesiculaire, pourrait avoir cause la lesion d’un vaisseau splenique et donc un saignement extraluminal. Cette complication durant l’endoscopie conventionnelle n’a jamais ete decrite auparavant.