RESUMO
BACKGROUND AND STUDY AIMS: Post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis (PEP) is a complication associated with important morbidity, occasional mortality and high costs. Preventive strategies are suboptimal as PEP continues to affect 4% to 9% of patients. Spraying epinephrine on the papilla may decrease oedema and prevent PEP. This study aimed to compare rectal indomethacin plus epinephrine (EI) versus rectal indomethacin plus sterile water (WI) for the prevention of PEP. PATIENTS AND METHODS: This multicentre randomised controlled trial included patients aged >18 years with an indication for ERCP and naive major papilla. All patients received 100 mg of rectal indomethacin and 10 mL of sterile water or a 1:10 000 epinephrine dilution. Patients were asked about PEP symptoms via telephone 24 hours and 7 days after the procedure. The trial was stopped half way through after a new publication reported an increased incidence of PEP among patients receiving epinephrine. RESULTS: Of the 3602 patients deemed eligible, 3054 were excluded after screening. The remaining 548 patients were randomised to EI group (n=275) or WI group (n=273). The EI and WI groups had similar baseline characteristics. Patients in the EI group had a similar incidence of PEP to those in the WI group (3.6% (10/275) vs 5.12% (14/273), p=0.41). Pancreatic duct guidewire insertion was identified as a risk factor for PEP (OR 4.38, 95% CI (1.44 to 13.29), p=0.009). CONCLUSION: Spraying epinephrine on the papilla was no more effective than rectal indomethacin alone for the prevention of PEP. TRIAL REGISTRATION NUMBER: This study was registered with ClinicalTrials.gov (NCT02959112).
Assuntos
Colangiopancreatografia Retrógrada Endoscópica , Pancreatite , Administração Retal , Anti-Inflamatórios não Esteroides/uso terapêutico , Colangiopancreatografia Retrógrada Endoscópica/efeitos adversos , Epinefrina , Humanos , Pancreatite/etiologiaRESUMO
Idiopathic acute recurrent pancreatitis (IARP) is defined as at least two episodes of acute pancreatitis with the complete or near-complete resolution of symptoms and signs of pancreatitis between episodes, without an identified cause. There is a paucity of information about the usefulness of endoscopic ultrasound (EUS) in IARP. OBJECTIVES: To determine the diagnostic yield of EUS in IARP. DESIGN: A retrospective study was performed in patients with IARP evaluated by EUS between January 2009 and December 2016. Follow-up assessments of acute pancreatitis recurrence were carried out. RESULTS: Seventy-three patients with 102 EUS procedures were included. EUS was able to identify the cause of IARP in 55 patients (75.3%). The most common findings were chronic pancreatitis in 27 patients (49.1%), followed by lithiasic pathology in 24 patients (43.6%), and intraductal papillary mucinous neoplasm in four patients (7.3%). A directed treatment against EUS findings had a protective tendency associated with the final resolution of recurrence. There were no complications reported. CONCLUSION: EUS performed in patients with IARP helped to identify a possible cause in 2/3 of the cases. The majority of patients have a treatable disease.
Assuntos
Endossonografia , Pancreatite Crônica , Doença Aguda , Humanos , Estudos RetrospectivosRESUMO
BACKGROUND AND OBJECTIVES: There is no consensus about the ideal method for diagnosis in patients who have already undergone endoscopic ultrasound fine needle aspiration (EUS-FNA), and the inconclusive material is often obtained. The aim was to evaluate the diagnostic yield of the second EUS-FNA of pancreatic lesions. MATERIALS AND METHODS: A retrospective analysis of prospectively collected data of patients with EUS-FNA of pancreatic lesions is performed. All patients who underwent more than one EUS-FNA for the evaluation of suspected pancreatic cancer over a 7-year period were included in the analysis. RESULTS: A total of 296 EUS-FNAs of the pancreas were performed in 257 patients. The diagnostic yield with the first EUS-FNA was 78.6% (202/257). Thirty-nine (13.3%) FNAs were repeated in 34 patients; 17 (50%) patients were women. The mean ± standard deviation (SD) age was 58.8 ± 16.1 years. The location of the lesions in the pancreatic gland, from which the second biopsies were taken, was head of the pancreas, n = 28 (82.4%), body of the pancreas, n = 3 (8.8%), and tail, n = 3 (8.8%). The mean ± SD of the size of the lesion was 36.3 ± 14.6 mm. The second EUS-FNA was more likely to be positive for diagnosis in patients with an "atypical" histological result in the first EUS-FNA (odds ratio [OR]: 4.04; 95% confidence interval [CI]: 0.9-18.3), in contrast to patients with a first EUS-FNA reported as "normal" (OR: 0.21; 95% CI: 0.06-0.71). Overall, the diagnostic yield of the second EUS-FNA was 58.8% (20/34) with an increase to 86.3% overall (222/257). CONCLUSION: Repeat EUS-FNA in pancreatic lesions is necessary in patients with a negative first EUS-FNA because it improves the diagnostic yield.
RESUMO
BACKGROUND AND AIM: Pancreatic pseudocysts (PPC) are a complication that occurs in acute and chronic pancreatitis. They comprise 75% of cystic lesions of the pancreas. There are scarce data about surgical versus endoscopic treatment on PPC. The aim of this study was to compare both treatment modalities regarding clinical success, complication rate, recurrence, hospital stay and cost. METHODS: Retrospectively, data obtained prospectively from 2000 to 2012 were analyzed. A PPC was defined as a fluid collection in the pancreatic or peripancreatic area that had a well-defined wall and contained no solid debris or recognizable parenchymal necrosis. Clinical success was defined as complete resolution or a decrease in size of the PPC to 2 cm or smaller. RESULTS: Overall, 64 procedures in 61 patients were included: 21 (33%) cases were drained endoscopically guided by EUS and 43 (67%) cases were drained surgically. The clinical success of the endoscopic group was 90.5 versus 90.7% for the surgical group (P = 0.7), with a complication rate of 23.8 and 25.6%, respectively (P = 0.8), and a mortality rate of 0 and 2.3% for each group, respectively (P = 0.4). The hospital stay was lower for the endoscopic group: 0 (0-10) days compared with 7 (2-42) days in the surgical group (P < 0.0001). Likewise, the cost was lower in the endoscopic group (P < 0.001). The recurrence rate was similar in both groups: 9.5 and 4.5% respectively (P = 0.59). The two recurrences found in the endoscopic group were associated with stent migration, and the recurrence in the surgical group was due to the type of surgery performed (open drainage). CONCLUSION: Endoscopic treatment of PPC offers the same clinical success, recurrence, complication and mortality rate as surgical treatment but with a shorter hospital stay and lower costs.
Assuntos
Drenagem/métodos , Endoscopia/métodos , Endossonografia/métodos , Pseudocisto Pancreático/cirurgia , Complicações Pós-Operatórias/epidemiologia , Cirurgia Assistida por Computador/métodos , Adulto , Análise Custo-Benefício , Drenagem/economia , Endoscopia/economia , Endossonografia/economia , Feminino , Humanos , Incidência , Masculino , México/epidemiologia , Pseudocisto Pancreático/diagnóstico por imagem , Pseudocisto Pancreático/economia , Estudos Retrospectivos , Cirurgia Assistida por Computador/economia , Resultado do TratamentoRESUMO
BACKGROUND AND AIM: Postoperative fluid collections (POFC) have high mortality. Percutaneous drainage (PD) is the preferred treatment modality. Drainage guided by endoscopic ultrasound (EUS-GD) represents a good alternative. The aim of the present study was to compare clinical success and complication rates of EUS-GD versus PD. METHODS: Data collected prospectively were analyzed in a retrospective manner. Patients with POFC from October 2008 to November 2013 were included. All collections were drained percutaneously or by EUS-GD. RESULTS: Sixty-three procedures in 43 patients with POFC were analyzed; 13 patients were drained using EUS-GD and 32 patients with PD. Two patients assigned initially to the PD group were reassigned to EUS-GD. Surgery procedures most often related to the collections were intestinal reconnection, distal pancreatectomy, biliary-digestive bypass, and exploratory laparotomy. Technical success (100% vs 91%; P = 0.25), clinical success (100% vs 84%; P = 0.13), recurrence (31% vs 25%; P = 0.69), hospital stay days (median 22 vs 27; P = 0.35), total costs (8328 ± 1600 USD vs 11 047 ± 1206 USD; P = 0.21), complications (0% vs 6%; P = 0.3), and mortality (8% vs 6%; P = 0.9) were each evaluated in the EUS-GD and PD groups, respectively. In the PD group one death was related to the procedure. CONCLUSIONS: EUS-GD is as effective and safe as PD in patients with POFC. The advantage of not requiring external drainage and a trend to higher clinical success and lower total costs must be considered.
Assuntos
Cavidade Abdominal/cirurgia , Procedimentos Cirúrgicos do Sistema Digestório/efeitos adversos , Drenagem/métodos , Endossonografia/métodos , Cuidados Pós-Operatórios/métodos , Complicações Pós-Operatórias/cirurgia , Cirurgia Assistida por Computador/métodos , Adulto , Idoso , Idoso de 80 Anos ou mais , Feminino , Seguimentos , Humanos , Masculino , Pessoa de Meia-Idade , Complicações Pós-Operatórias/etiologia , Estudos Retrospectivos , Adulto JovemAssuntos
Neoplasias dos Ductos Biliares/patologia , Ductos Biliares Intra-Hepáticos/patologia , Colangiocarcinoma/patologia , Endossonografia , Ultrassonografia de Intervenção , Adulto , Idoso , Idoso de 80 Anos ou mais , Neoplasias dos Ductos Biliares/diagnóstico por imagem , Ductos Biliares Intra-Hepáticos/diagnóstico por imagem , Biópsia por Agulha Fina , Colangiocarcinoma/diagnóstico por imagem , Humanos , Pessoa de Meia-Idade , Sensibilidade e EspecificidadeRESUMO
OBJECTIVES: To evaluate the accuracy of endoscopic ultrasound (EUS) to determine vascular invasion in patients with pancreatic cancer. METHODS: Data were obtained prospectively from patients with a pancreatic lesion who underwent EUS, computed tomographic (CT) imaging, and surgery from March 2005 to March 2010. RESULTS: Fifty patients were included with a mean ± SD age 61 ± 11.5 years; 27 (54%) were women. The sensitivity, specificity, positive predictive value, and negative predictive value for EUS were the following: 61.1 (95% CI, 38.6-79.7), 90.3 (95% CI, 75.1-96.7), 78.6 (95% CI, 52.4-92.4), and 80 (95% CI, 64.1-90), respectively. The area under the curve for EUS and that for CT were 0.80 (95% CI, 0.68-0.92) and 0.74 (95% CI, 0.61-0.86), respectively. The positive predictive value for arterial invasion was 100% (95% CI, 61-100) for EUS and 60% (95% CI, 31.3-83.2) for CT. There were no complications associated with the EUS or the CT. CONCLUSION: Endoscopic US is a very good option to detect vascular invasion in patients with pancreatic cancer and is especially sensitive for arterial invasion. When it is available, we recommend that it be performed in addition to CT staging.
Assuntos
Adenocarcinoma/patologia , Endossonografia , Tomografia Computadorizada Multidetectores , Neoplasias Pancreáticas/patologia , Neoplasias Vasculares/secundário , Adenocarcinoma/diagnóstico por imagem , Idoso , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Invasividade Neoplásica , Neoplasias Pancreáticas/diagnóstico por imagem , Estudos Retrospectivos , Sensibilidade e Especificidade , Neoplasias Vasculares/diagnóstico por imagemRESUMO
BACKGROUND: Reports of incidental gastrointestinal luminal wall thickening (IGILWT) on computed tomography (CT) in patients without gastrointestinal complaints are not rare. Currently there is no consensus about what to do in those cases. The aim of this study was to evaluate the utility of endoscopic study in asymptomatic patients with IGILWT. MATERIAL AND METHODS: Retrospective analysis of data obtained prospectively between September 2004 and March 2007 was carried out. Patients without gastrointestinal symptoms/signs with IGILWT and assessed by endoscopy were included. The endoscopic findings were classified as follows: normal, abnormal or nonspecific. RESULTS: A total of 10,161 abdominal/pelvic CT scans were performed. Thirty-one patients were included (14 women and 17 men). Median age was 59 years (19-84 years). Distribution of IGILWT along the gastrointestinal (GI) tract was as follows: 1 esophagus, 19 stomach, 1 small-bowel, and 10 colon. Endoscopy was normal in 19 cases (61.2%) and abnormal/nonspecific in 12 cases (38.8%). Nine (29%) patients had cancer as a final diagnosis (gastric cancer in six, colon cancer in two, and non-Hodgkin's lymphoma in one). On multivariate analysis hemoglobin <12 g/dl was the only significant variable to predict an abnormal result by endoscopy. CONCLUSION: Endoscopic study is useful in patients with IGILWT. More than one-third of patients with IGILWT have a significant finding by endoscopic evaluation, mainly cancer. Absence of GI symptoms/signs, age or gender are not valid criteria to decide about further endoscopic evaluation.
Assuntos
Colonoscopia , Gastroscopia , Intestinos/patologia , Tomografia Computadorizada por Raios X , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Meios de Contraste , Feminino , Neoplasias Gastrointestinais/patologia , Humanos , Achados Incidentais , Intestinos/diagnóstico por imagem , Modelos Logísticos , Masculino , Pessoa de Meia-Idade , Radiografia Abdominal , Estudos Retrospectivos , Estatísticas não ParamétricasRESUMO
BACKGROUND AND AIM: The correct approach and treatment in a patient with a pancreatic lesion detected by imaging is not easy. Recently, the endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) biopsy is becoming a useful tool. The aim of the study is to evaluate the diagnostic yield and therapeutic impact of EUS-FNA in pancreatic lesions. METHODS: Fifty-three patients with focal pancreatic lesions underwent EUS-FNA from March 2005 to March 2006. The final diagnosis was confirmed by the histological analysis from the surgical specimen and/or clinical follow-up for at least 6 months. RESULTS: . Fifty-two patients were evaluated. Forty-seven useful samples for histological evaluation were obtained. Adequate samples were obtained in 83.3% (5/6) for lesions < 20 mm, 100% (19/19) for lesions from 20 to < 40 mm and 85.1% (23/ 27) for those > or = 40 mm. To differentiate between benign/malignant disease the sensitivity, specificity, positive predictive value, negative predictive value and diagnostic accuracy of EUS-FNA were 97.3% (95% CI: 84.9-99.1), 100% (95% CI: 66-100), 100% (95% CI: 88-100), 90% (95% CI: 57-96) and 97.8%, respectively. There was a change in the initial diagnosis in seven patients (14.8%). No complications were reported. CONCLUSIONS: EUS-FNA is a useful and safe method with high predictive values to differentiate between malignant and benign pancreatic lesions.
Assuntos
Biópsia por Agulha Fina/métodos , Endossonografia , Neoplasias Pancreáticas/diagnóstico por imagem , Neoplasias Pancreáticas/patologia , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estudos RetrospectivosRESUMO
INTRODUCTION AND AIMS: Endoscopic treatment of peptic ulcers with high-risk stigmata has been probed. The rates of recurrent bleeding, need for emergent surgery and death are related to Forrest Classification, Blatchford's modified risk score and the kind of endoscopic treatment used (monotherapy vs. dual). The aims of the present study were to report the success of endoscopic therapy in the reduction of the rate of initial success, recurrent bleeding, the need for surgery, and the mortality rate for patients with bleeding peptic ulcer and high-risk stigmata. PATIENTS AND METHODS: From a retrospective view, patients seen from September 2004 to March 2007 who had peptic ulcers Forrest Ia, Ib, IIa and/or IIb were included. RESULTS: Fifty-six patients were included (mean [SD] age 57.3 +/-16.6 years). The success rate was 91%, whilst the rest of the patients required immediate surgery. Recurrent bleeding was presented in 14 (27%) patients and eight (14.2%) required emergency surgery. The mortality rate was 3.6%. No factors were associated with the risk of failure to initial treatment, recurrent bleeding or need for surgery. The use of monotherapy by endoscopy was associated with the mortality. The variable "performed by a fellow alone" was not associated with any kind of outcome. CONCLUSION: Complication rate is similar to previous reports of general hospitals, but is higher than those of referral centers. Endoscopic monotherapy is associated with a major mortality risk.
Assuntos
Endoscopia Gastrointestinal , Epinefrina/uso terapêutico , Técnicas Hemostáticas , Úlcera Péptica Hemorrágica/terapia , Úlcera Péptica/terapia , Adulto , Idoso , Antiulcerosos/uso terapêutico , Transfusão de Sangue , Terapia Combinada , Eletrocoagulação , Emergências , Endoscopia Gastrointestinal/efeitos adversos , Endoscopia Gastrointestinal/estatística & dados numéricos , Epinefrina/administração & dosagem , Feminino , Técnicas Hemostáticas/efeitos adversos , Técnicas Hemostáticas/instrumentação , Humanos , Injeções , Fotocoagulação a Laser , Masculino , Pessoa de Meia-Idade , Úlcera Péptica Hemorrágica/mortalidade , Recidiva , Estudos Retrospectivos , Risco , Instrumentos CirúrgicosRESUMO
BACKGROUND: With the popularity of laparoscopic cholecystectomy (LC), the algorithm of endoscopic retrograde cholangiography (ERC) with biliary sphincterotomy followed by laparoscopic cholecystectomy has proven to be an effective treatment in choledocholithiasis in symptomatic gallstone disease. However, its use as a standard approach remains controversial. OBJECTIVES: 1. To determine the diagnostic and therapeutic usefulness of ERC with biliary sphincterotomy in patients with LC. 2. To evaluate clinical, biochemical and ultrasonographic factors which can be used as predictors of choledocholithiasis in symptomatic gallstone disease. MATERIAL AND METHODS: It is a retrospective study which included patients with: 1. symptomatic cholelithiasis with presurgical clinical, biochemical and ultrasonographic suspicion of choledocholithiasis; 2. patients with acute biliary pancreatitis subjected to ERC before LC; 3. patients subjected to ERC under suspicion of residual choledocholitiasis or complicated LC. The clinical laboratorial, ultrasonographic, ERC and surgical variables were analyzed. RESULTS: From January 1997 to December 2001, 805 LC were performed, 91 patients were included in the final analysis. Jaundice was found at arrival in 54 patients (59%), 15 (16%) had cholangitis and 32 (35%) had pancreatitis. The ultrasonographic features found common bile duct dilation in 34 patients (38%) and choledocholithiasis in seven (7.8%). Presurgical ERC was performed in 73 patients (80.2%) and post surgically in 18 (19.8%), no intraoperative cholangiogram was performed during surgery. In the presurgical ERC, choledocholithiasis was found in 37 patients (51%) and post surgically in 8 (44%). Five biliary leaks were diagnosed during post surgical ERC, or which the cystic duct fistula was the most common. The duration of hospital stay ranged between 1 to 53 days (medium 4.8 days) after LC. The multivariate analysis showed that the best predictors of choledocholithiasis were cholangitis (OR 15.9, IC 95% 1.8-135.1 and p = 9.01) and elevated alanine aminotransferase (OR 4.7, IC 95% 1.5-15.3 and p = 0.009). CONCLUSIONS: The ERC with biliary sphincterotomy and stones extraction is a useful and safe treatment of choledocholithiasis associated with symptomatic gallstone disease before or after LC. The best predictors of choledocholithiasis in ERC were cholangitis and elevation of alanine aminotransferase at arrival. It is convenient to perform ERC with biliary sphincterotomy before LC in patients with evidence of choledocholithiasis.