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Liver and biliary tract diseases are common causes of morbidity and mortality worldwide. Invasive procedures are usually performed in those patients with hepatobiliary diseases for both diagnostic and therapeutic purposes. Defining proper indications and restraints of commonly used techniques is crucial for proper patient selection, maximizing positive results and limiting complications. In 2018, the Brazilian Society of Hepato-logy (SBH) in cooperation with the Brazilian Society of Interventional Radiology and Endovascular surgery (SOBRICE) and the Brazilian Society of Digestive Endoscopy (SOBED) sponsored a joint single-topic meeting on invasive procedures in patients with hepatobiliary diseases. This paper summarizes the proceedings of the aforementioned meeting. It is intended to guide clinicians, gastroenterologists, hepatologists, radiologists, and endoscopists for the proper use of invasive procedures for management of patients with hepatobiliary diseases.

Background and Objectives: At the time of its introduction in the early 80s, endoscopic ultrasonography (EUS) was indicated for diagnostic purposes. Recently, EUS has been employed to assist or to be the main platform of complex therapeutic interventions., Methods: From a series of relevant new topics in the literature and based on the need to complement the I Brazilian consensus on EUS, twenty experienced endosonographers identified and reviewed the pertinent literature in databases. The quality of evidence, strength of recommendations, and level of consensus were graded and voted on., Results: Consensus was reached for eight relevant topics: treatment of gastric varices, staging of nonsmall cell lung cancer, biliary drainage, tissue sampling of subepithelial lesions (SELs), treatment of pancreatic fluid collections, tissue sampling of pancreatic solid lesions, celiac neurolysis, and evaluation of the incidental pancreatic cysts., Conclusions: There is a high level of evidence for staging of nonsmall cell lung cancer; biopsy of SELs as the safest method; unilateral and bilateral injection techniques are equivalent for EUS-guided celiac neurolysis, and in patients with visible ganglia, celiac ganglia neurolysis appears to lead to better results. There is a moderate level of evidence for: yield of tissue sampling of pancreatic solid lesions is not influenced by the needle shape, gauge, or employed aspiration technique; EUS-guided and percutaneous biliary drainage present similar clinical success and adverse event rates; plastic and metallic stents are equivalent in the EUS-guided treatment of pancreatic pseudocyst. There is a low level of evidence in the routine use of EUS-guided treatment of gastric varices.

Apples and apple products are excellent substrates for Penicillium expansum to produce patulin. In an attempt to avoid excessive levels of patulin, limiting or reducing P. expansum contamination levels on apples designated for storage in packinghouses and/or during apple juice processing is critical. The aim of this work was (i) to determine the thermal resistance of P. expansum spores in apple juice, comparing the abilities of the Bigelow and Weibull models to describe the survival curves and (ii) to determine the inactivation of P. expansum spores in aqueous chlorine solutions at varying concentrations of chlorine solutions, comparing the abilities of the biphasic and Weibull models to fit the survival curves. The results showed that the Bigelow and Weibull models were similar for describing the heat inactivation data, because the survival curves were almost linear. In this case, the concept of D- and z-values could be used, and the D-values obtained were 10.68, 6.64, 3.32, 1.14, and 0.61 min at 50, 52, 54, 56, and 60 degrees C, respectively, while the z-value was determined to be 7.57 degrees C. For the chlorine treatments, although the biphasic model gave a slightly superior performance, the Weibull model was selected, considering the parsimony principle, because it has fewer parameters than the biphasic model has. In conclusion, the typical pasteurization regimen used for refrigerated apple juice (71 degrees C for 6 s) is capable of achieving a 6-log reduction of P. expansum spores.

This study examined the potential for patulin production in six different varieties of apples (Red Delicious, Golden Supreme, Gala, Fuji, Empire, and McIntosh) inoculated with Penicillium expansum spores and stored at two different temperatures (11 and 20.5 degrees C). Samples for patulin analysis were randomly taken from apples stored at different times, ranging from 21 to 93 days. While patulin was produced at both storage temperatures, apples incubated at 20.5 degrees C yielded significantly higher patulin concentrations than did those incubated at 11 degrees C. All apple varieties showed mold spoilage at both temperatures, except Red Delicious and Empire. A total of 44% of the samples analyzed showed patulin concentrations above the U.S. Food and Drug Administration regulatory limit (50 ppb). The highest patulin productions occurred in Golden Supreme (54,221 ppb) and McIntosh (52,131 and 48,457 ppb) varieties. Our results showed that careful culling of apples is essential for high juice quality, since high patulin levels in some apples varieties could result in a level greater than 50 ppb of this mycotoxin in the finished juice or cider, even when only one contaminated apple occurs in 1,000 apples.

The effectiveness of several wash treatments was evaluated against spores of Penicillium expansum inoculated on six varieties of apples (Red Delicious, Golden Supreme, Empire, Macintosh, Fuji, and Gala). The wash treatments were water, acidified water (pH 6.5), acidified sodium hypochlorite (pH 6.5), nonacidified sodium hypochlorite (pH 8.8, 9.3, and 9.7; 50, 100, and 200 ppm, respectively), and peracetic acid (50 and 80 ppm). Spores of P. expansum were dried on the surface of the apples for 2 h before exposure to the different sanitizer solutions. Each apple was submerged in 100 ml of each treatment solution for 30 s, and the number of spores remaining were recovered and enumerated. The efficacy of chlorine solutions was enhanced by decreasing the pH to 6.5 (up to 5-log reduction, depending on apple variety). Peracetic acid solutions (50 and 80 ppm) resulted in a reduction of less than 2 log spores per g and had the same efficacy (P < or = 0.05) as nonacidified chlorine solutions (50, 100, and 200 ppm). Control water solutions produced a reduction of 1.34 log spores per g. Chlorine solutions at pH 6.5 resulted in the largest reduction of P. expansum spores for all apple varieties tested.

Heterotopic gastric mucosa in the gallbladder is extremely unusual. In this study, we aimed to report a case of gastric heterotopia together with squamous metaplasia in the gallbladder of a 47-year-old female patient who experienced an intensive abdominal pain. He was admitted to the hospital for clinical treatment without any improvement. Ultrasonography showed a stone located in the gallbladder neck and dilatation of intrahepatic bile ducts, both hepatic ducts and common hepatic duct. Laparoscopic cholecystectomy was performed. In the microscopical examination, the epithelium of the gallbladder revealed an unspecified chronic cholecystitis. Besides, at the level of the gallbladder body, a heterotopic gastric mucosa contain chief, parietal and mucosal cells with cystic glands and squamous metaplasia was found. Actually the patient is in long-time follow-up, asymptomatic. We also review 96 other reports of HGM in the gallbladder in the international medical literature from 1934. As heterotopic tissue may promote carcinogenesis of the gallbladder, close attention should be paid to any occurrence of such lesions in this anatomical region. It appears that laparoscopic cholecystectomy may be unavoidable for patients affected by heterotopic gastric mucosa at the present time and care must be taken when a diagnosis is made based on intraoperative frozen sections.