EUS-guided transrectal drainage of pelvic fluid collections using electrocautery-enhanced lumen-apposing metal stents: a case series

Background and Aims: Pelvic fluid collections (PFCs) are frequent adverse events of abdominal surgery or inflammatory conditions. A percutaneous approach to deep PFCs could be challenging and result in a longer, painful recovery. The transvaginal approach has been considered easy but is limited by the difficulty of leaving a stent in place. The transrectal approach has been described, but issues related to fecal contamination were hypothesized. Data on EUS-guided transrectal drainage (EUS-TRD) with lumen-apposing metal stents (LAMSs) are few and suggest unsatisfactory outcomes. The aim of this study was to evaluate the safety and efficacy of EUS-TRD with LAMSs in patients with PFCs. Methods: A retrospective analysis of a prospectively maintained database on therapeutic EUS was conducted. All EUS-TRD procedures were included. Results: Five patients (2 male, age 44-89 years) were included. Four patients had postoperative PFCs, and 1 presented with a pelvic abscess complicating acute diverticulitis. Two of 5 had fecal diversion; the remaining 3 had unaltered large-bowel anatomy. One case had a concomitant abdominal collection, treated with percutaneous drainage in the same session. An electrocautery-enhanced LAMS delivery system (15 7 10 mm) was used in all cases. EUS-TRD was performed with the direct-puncture technique and lasted less than 10 minutes in 4 cases; in the remaining case, needle puncture and LAMS placement over a guidewire was required, and the procedure length was 14 minutes. The clinical success rate was 100%. LAMSs were removed after a median of 14 (range, 12-24) days. One patient reported partial proximal LAMS migration after 24 days (mild adverse event). No PFC recurrence was observed. Conclusion: EUS-TRD with LAMSs is a safe and effective technique for treatment of PFCs. The use of 15- 7 10-mm LAMSs allows rapid PFC resolution. EUS-TRD could be performed not only in patients with fecal diversion but also in cases of unaltered anatomy

EUS-guided gallbladder drainage in high-risk surgical patients with acute cholecystitis—procedure outcomes and evaluation of mortality predictors

Background: Recent evidences suggest that gallbladder drainage is the treatment of choice in elderly or high-risk surgical patients with acute cholecystitis (AC). Despite better outcomes compared to other approaches, endoscopic ultrasound-guided gallbladder drainage (EUS-GBD) is burdened by high mortality. The aim of the study was to evaluate predictive factors for mortality in high-risk surgical patients who underwent EUS-GBD for AC. Methods: A retrospective analysis of a prospectively maintained database was performed. Electrocautery-enhanced lumen-apposing metal stents were used; all recorded variables were evaluated as potential predictive factors for mortality. Results: Thirty-four patients underwent EUS for suspected AC and 25 (44% male, age 78) were finally included. Technical, clinical success rate and adverse events rate were 92%, 88%, and 16%, respectively. 30-day and 1-year mortality were 12% and 32%. On univariate analysis, age-adjusted Charlson Comorbidity Index (CCI) (OR 20.8[4–68.2]), acute kidney injury (AKI) (OR 21.4[2.6–52.1]) and clinical success (OR 8.9[1.2–11.6]) were related to 30-day mortality. On multivariate analysis, CCI and AKI were independently related to long-term mortality. Kaplan–Meier curves showed an increased long-term mortality in patients with CCI > 6 (hazard ratio 7.6[1.7–34.6]) and AKI (hazard ratio 11.3[1.4–91.5]). Conclusions: Severe comorbidities and AKI were independent predictive factors confirming of long-term mortality after EUS-GBD. Outcomes of EUS-GBD appear more influenced by patients’ conditions rather than by procedure success

Patch test reactions to 0.1% thimerosal: Allergic or irritant?

The remarkable rise in incidence rates of delayed reactions to 0.1% thimerosal in petrolatum, the sometimes difficult evaluation and the poor clinical relevance of many of these reactions and their preponderance in young-age classes prompted us to investigate the frequency of positive patch tests to 0.05% and 0.01% thimerosal in a group of 155 subjects who had previously reacted positively to 0.1% concentration. The incidence of positive reactions to other mercury compounds was evaluated also in 124 of our subjects, to thiosalicylic acid in 32 and to intradermal testing with 0.0001% thimerosal in saline in 102. The results of the investigation indicate that the optimal eliciting patch test concentration for studing thimerosal sensitivity is 0.05% because it allows for a reduction in irritant reactions. Moreover, in subjects sensitive to 0.05% thimerosal the intradermal testing was more often positive and crossreactions with other mercurials more frequent

Computer-aided Diagnosis of Melanocytic Lesions

Background The clinical diagnosis of melanoma could be difficult for a general practitioner and in some cases for dermatologists. To enhance and support the clinical evaluation of pigmented skin lesions a computer-aided diagnosis has been introduced. Objective The purposes of this study were 1) to provide dermatologists as well as general practitioners with a computer aided device in order to produce an objective risk level of the melanocytic lesions helping the clinician during the diagnostic pathway and 2) to compare the discrimination capacity of dermatologists and general practitioners, with the system of automated analysis. Methods 477 images of melanocytic lesions (42 melanomas and 435 melanocytic) evaluated in epiluminescence microscopy and recorded with x16 magnification were selected. A training set of 22 melanomas and 218 nevi has been randomized from the dataset. The test set has been formed by the complement (the remaining 20 melanomas and 217 nevi). Furthermore a set of images consisting in 31 melanomas and 103 nevi has been selected to compare the discrimination capacity of three general practitioners and three dermatologists with experience in dermoscopy (2 years), with the system of automated analysis ADAM. Sensitivity and specificity were estimated for observer assessments and computer diagnosis