Pull vs. Wet:Diagnostic performance and sample quality of eus-guided fna in solid lesions of pancreas

Differential diagnosis of pancreatic masses is challenging. The endoscopic ultrasound-guided fine-needle aspiration method with the highest diagnostic yield has not been esta-blished. It was realized a prospective, randomized, double-blind study of the endoscopic ultrasound-guided fine-needle aspiration in solid lesions of the pancreas to compare and evaluate diagnostic yield and aspirate quality between wet and pull technique. Forty-one patients were enrolled. The wet technique presented a sensitivity, a specificity, a positive and negative predictive value, and a diagnostic accuracy of 58.3%, 100%, 100%, 25% and 63.4%, respectively. In the capillary technique they were: 75%, 100%, 100%, 35.7% and 78.1%, respectively. Comparing the diagnostic yield between both techniques, there was no statistically significant difference (McNemar's test p = 0.388). Regarding the cellularity of the specimen, both in cytology and the cell block samples, no significant difference was observed between the techniques (p = 0.84 and 0.61, respectively). With res-pect to contaminating blood in the specimen, there was no difference in cytology samples (p = 0.89) and no difference in cell block samples (p = 0.08). The suitability of cytology samples for diagnosis was similar in both techniques (wet = 57.5% and capillary = 56.7%, p = 0.94) and there was no difference in cell block samples (wet = 75% and capillary = 66.1%, p = 0.38). In this study we did not observe differences in diagnostic yield or sample quality. Since both techniques are effective, we suggest the simultaneous and alternate use of both methods.</p

Post-ERCP pancreatitis: early precut or pancreatic duct stent?: a multicenter, randomized-controlled trial and cost-effectiveness analysis

Background: Pancreatitis is the most frequent complication due to ERCP. Pancreatic duct stent placement has been described as a preventive measure. There is also evidence pointing towards the preventive effect that early precut may provide. Aim: To determine and compare the cost-effectiveness of an early precut approach versus pancreatic duct stent placement for the prevention of post-ERCP pancreatitis. Methods: This was a multicenter, randomized-controlled pilot study with a cost-effectiveness analysis performed between early precut (group A) and pancreatic duct stent (group B) for the prevention of pancreatitis in high-risk patients. Patients with a difficult biliary cannulation and at least one other risk factor for post-ERCP pancreatitis were enrolled and randomized to one of the treatment arms. Both effectiveness and costs of the procedures and their complications were analyzed and compared. Results: From November 2011 to November 2013, 101 patients were enrolled; 50 subjects were assigned to group A and 51 to group B. There were no significant differences in terms of baseline characteristics of patients between groups. Two cases of mild pancreatitis were observed in each group. The overall costs were U$1,242.6 per patient in group A and U$ 1,606.5 per patient in group B. The cost in group B was 29.3% higher (p < 0.0001). Conclusion: Early precut showed a better cost-effectiveness profile when compared to pancreatic duct stent placement

Inserción de prótesis metálicas autoexpandibles totalmente recubiertas en patología biliar benigna

RESUMEN Introducción: las enfermedades biliares benignas se han tratado, tradicionalmente, mediante la colocación de prótesis plásticas. Sin embargo, en la actualidad, las prótesis metálicas autoexpandibles totalmente recubiertas están ganando aceptación para el tratamiento de dichas patologías. Objetivo: evaluar la eficacia y las complicaciones de la inserción endoscópica temporal de prótesis metálicas totalmente recubiertas para el tratamiento de patologías biliares benignas. Materiales y métodos: estudio retrospectivo y observacional realizado a partir de una base de datos prospectiva en un centro de tercer nivel entre marzo de 2012 y mayo de 2016. Se incluyeron pacientes a los que se les colocó una prótesis metálica totalmente recubierta por patología benigna de la vía biliar. Se documentaron las indicaciones, las tasas de resolución, las de éxito técnico y los eventos adversos. Resultados: se incluyeron 31 pacientes a los que se insertaron 34 prótesis. Las indicaciones fueron las siguientes: 8 (25%) estenosis biliares poscolecistectomía, 11 (31%) coledocolitiasis de gran tamaño o múltiple, 3 (8,3%) fístulas biliares, 2 (6%) estenosis postrasplante hepático, 3 (8,3%) estenosis papilares, 2 (6%) perforaciones y 2 (6%) sangrados. La tasa de éxito global de resolución de la patológica fue del 88%: 87,5% (7/8) en estenosis poscolecistectomía, 73% (8/11) en litiasis gigante, y 100% en el resto de las indicaciones. Se retiraron mediante endoscopia 33 de las 34 tras un promedio de 133 días (rango 10-180 días). No se registraron complicaciones. Conclusión: las prótesis metálicas autoexpandibles totalmente recubiertas son una alternativa efectiva y segura en la resolución de patologías biliares benignas

Calidad y competencia en colangiografía endoscópica. Rumbo a lo seguro

Introducción. La Sociedad Americana de Gastroenterología (ASGE) y el Colegio Americano de Gastroenterología (ACG) han establecido indicadores para el reconocimiento de estudios de colangiopancreatografía retrógrada endoscópica (CPRE) de alta calidad. Los indicadores fueron los siguientes. a) Preprocedimiento: indicación adecuada, consentimiento informado firmado, evaluación del grado de dificultad del procedimiento y profilaxis antibiótica. b) Intraprocedimiento: éxito en la canulación, extracción de coledocolitiasis y colocación de prótesis. c) Postprocedimiento: documentación completa y cifra de complicaciones. Métodos. Análisis retrospectivo, descriptivo, observacional y autoevaluativo del cumplimiento de los indicadores de calidad en CPRE propuestas por la ASGE en un centro de tercer nivel entre octubre de 2010 y octubre de 2012. Resultados. En los 734 estudios realizados fueron evaluados todos los indicadores preprocedimiento. El éxito en la canulación, extracción de coledocolitiasis y colocación de prótesis debajo de la bifurcación hiliar fue de 96,2%, 95,4% y 100%, respectivamente. La frecuencia de complicaciones fue del 5,6% y la mortalidad del 0,27%. La severidad de las complicaciones fue evaluada según la clasificación de Masci (30 leves, 7 moderadas y 4 severas). Conclusiones. La calidad es una herramienta básica que permite que nuestro accionar sea comparado con otros ya predeterminados como adecuados. La indicación adecuada es un indicador a mejorar. Consideramos que el 12% de los estudios normales registrados podría deberse a un problema de accesibilidad en nuestro medio a la colangiorresonancia. El cumplimiento de los restantes indicadores validados internacionalmente nos posiciona como un servicio de alta calidad en colangiografía endoscópica y como un centro de entrenamiento con competencia adecuada en el desarrollo de la actividad

Early precut is as efficient as pancreatic stent in preventing post-ERCP pancreatitis in high-risk subjects: a randomized study

Background: The most common adverse event of endoscopic retrograde cholangiopancreatography is pancreatitis. Precut sphincterotomy has been regarded as a risk factor. Some authors have stated that early precut may actually reduce post-ERCP pancreatitis risk. However, early precut as a preventive measure has not been compared to other preventive measures, such as pancreatic duct stent placement. Aim: To compare the efficacy of early precut sphincterotomy versus pancreatic duct stent placement in high-risk subjects undergoing endoscopic retrograde cholangiopancreatography for the prevention of post-endoscopic cholangiopancreatography. Materials and Methods: This was a single-blinded, randomized trial that took place in two tertiary referral centers in Buenos Aires, from November 2011 to December 2013. ERCP subjects presented at least one of the following risk factors: female sex, age less than 40 years, clinical suspicion of sphincter of Oddi dysfunction, previous pancreatitis, and/or common bile duct diameter of less than 8 mm. Only those who presented a difficult biliary cannulation were randomized into two groups: those who received early precut sphincterotomy and those in whom persistency of biliary cannulation was intended, with subsequent pancreatic duct stent placement after cholangiography was achieved. The incidence of post-ERCP pancreatitis, as well as other adverse events incidence, was compared. Results: Overall, 101 patients were enrolled, 51 in the pancreatic duct stent group and 50 in the early precut group. Pancreatitis rate was similar in both groups (3.92% vs. 4%, p NS). In all cases, pancreatitis was classified as mild. There were no deaths registered. Conclusion: Early precut was associated with an incidence of adverse events similar to pancreatic duct stent placement