Diagnostic Efficacy of Endoscopic Ultrasound Elastography in Differentiating Solid Pancreatic Lesions: A Single-Center Experience

Background/Aims Endoscopic ultrasound (EUS) has a limited ability to determine the nature of solid pancreatic lesions (SPLs). Most recent ultrasound processors are provided with elastography software, which allows quantification of the tissue hardness. The aim of this study is to evaluate the effectiveness of the elasticity score (ES) and strain ratio (SR) in the differentiation of benign pancreatic lesions from malignant pancreatic lesions. Methods The study had a retrospective design; it included 97 patients with SPLs and 19 patients with inflammatory lesions. The ES and SR were determined during the examination; finally, EUS-guided fine needle aspiration was performed. Results In this 2-year study, 116 patients were enrolled (97 with malignant lesions and 19 with benign lesions). There were 69 men and 47 women. Their median age was 55.9 years. A cut-off point was detected at SR of 7.75 with a specificity of 99.9%, sensitivity of 90.7%, positive predictive value (PPV) of 99.9%, negative predictive value (NPV) of 67.9%, and accuracy of 92.2%. After adding the ES to the SR, the cut-off point at 7.75 resulted in a specificity of 94.6%, sensitivity of 99%, PPV of 98%, NPV of 98.5%, and accuracy of 97%. Conclusions The use of the ES combined with the SR increases the accuracy of differentiation between benign and malignant SPLs and is an effective method for the evaluation of pancreatic masses

Effect of early versus delayed feeding following emergency endoscopic therapy for acute esophageal variceal bleeding on short-term outcomes

Background/aim It is generally assumed that systematic fasting is obligatory in the context of acute variceal bleeding owing to the fear of increasing the risk of rebleeding if patients instituted feeding early after endoscopy. However, this assumption is generally built on experts’ beliefs instead of being based on large clinical trials. Such lack of clinical trials was the reason why we conducted this controlled study. Patients and methods Patients were selected from those with acute esophageal variceal bleeding admitted at the Hematemesis Unit at Mansoura Emergency Hospital. The study involved 90 patients who divided into two equal groups: group I included 45 patients as the early-feeding group and group II included 45 patients as the late-feeding group. Results There was no statistically significant difference regarding treatment complications distribution between the studied groups. The successful hemostatic rate was 100% in both groups. Neither rebleeding incidents nor deaths were encountered in the first 5 days in either group. Conclusion Early feeding with a liquid diet after successful endoscopic therapy of bleeding esophageal varices did not enhance rebleeding or increase mortality in the first 5 days following endoscopic intervention

EUS-guided cyanoacrylate injection into the perforating vein versus direct endoscopic injection in the treatment of gastric varices

Background and study aims Endoscopic injection of gastric varices (GVs) using cyanoacrylate (CYA) is associated with significant adverse events (AEs). We aimed to compare the efficacy and safety of endoscopic ultrasound (EUS)-guided CYA injection into the perforating vein versus direct endoscopic injection (DEI) of CYA in treatment of high-risk GVs. Patients and methods This was a randomized controlled trial that included 52 patients with high-risk GVs. Group A underwent EUS-guided injection into the perforator vein and Group B underwent DEI of 1 mL CYA. Endoscopic examination and Doppler EUS were repeated after 3 months to confirm eradication. Obliteration by Doppler EUS was considered by absence of Doppler flow within the varix. Repeated injection was performed in the absence of obliteration. Doppler EUS examination was repeated at 3 and 6 months after each injection. Results Forty-three patients including 27 males and 16 females with mean age 57 years completed the study. Variceal obliteration was achieved during the index session after 3 months in eight of 21 (38.1 %) in group B compared to 17 of 22 (77.2 %) in group A (P = 0.014). There was a significant difference in the amount of CYA needed to achieve obliteration in group B compared to group A (2 vs.1 mL, P = 0.027). There was no statistically significant difference in the overall AE rate between group A and group B (4.5 % vs. 14.3 %, P = 0.345). Conclusions EUS-guided CYA injection into the perforating veins achieved less amount of CYA, fewer number of sessions to obliteration, and similar overall AE rates in the treatment of high-risk GVs compared to DEI

Acute kidney injury network criteria as a prognostic factor in cirrhotic patients with spontaneous bacterial peritonitis

Background and Aim One of the most common complications of spontaneous bacterial peritonitis (SBP) is renal injury. The aim of the study was to detect the frequency of AKI as a problem in end stage liver disease patients with SBP, evaluate the role of acute kidney injury network criteria (AKIN) as a prognostic factor for kidney insult in cirrhotic patients complicated by SBP and lastly. Settings and Design A single center, observational, prospective study. Patients and methods The study was conducted on 150 cirrhotic patients complicated by SBP who were admitted in hepatology unit, Mansoura Specialized Medical Hospital, Mansoura University. After that, all patients were followed up for three months duration. Statistical analysis used Data analysis was performed using SPSS version 16.0 (SPSS, Inc, USA). Chi-square test (crosstabs) was used to compare the distribution of different clinical finding according to AKI stage. Results The obtained results were showed a significant change in the number of patients among the three groups at the end of the study versus at admission indicating progressive deterioration of kidney functions. Moreover, the mortality was high (70.42%), most of them were AKIN stage 2 and 3. There was a significant increase of hospital acquired complication especially (hepatic encephalopathy, ICU admission) more commonly in advanced AKIN stages (stage 3). Conclusion AKI, as defined by AKIN diagnostic criteria, is associated with a high mortality rate in cirrhotic patients presented with SBP, especially patients with advanced liver disease (Child B and C, high MELD score) in a stage-dependent pattern

Myocardial adaptation as assessed by speckle tracking echocardiography after isolated mitral valve surgery for primary mitral regurgitation

The risk of left ventricular (LV) and right ventricular (RV) maladaptation after surgery for isolated primary mitral regurgitation (PMR) is poorly defined. We aimed to evaluate LV and RV contractile function using speckle-tracking analysis alongside with quantification of exercise tolerance in patients with PMR after mitral valve surgery. All consecutive patients with symptomatic PMR undergoing mitral valve surgery between July 2015 and May 2017 were prospectively enrolled. Sequential echocardiographic studies along with clinical assessment were performed before and three months after surgery. Mean age in 138 patients was 65.8 ± 12.7 years, 48.2% (66) of whom were female. Mean LV ejection fraction decreased from 57 ± 12% to 50 ± 11% (p < 0.001), LV global longitudinal strain deteriorated from -19.2 ± 4.1% to -15.7 ± 3.8% (p < 0.001), and mechanical strain dispersion increased from 88 ± 12 to 117 ± 115 ms (p = 0.004). There was a reduction in tricuspid annulus plane systolic excursion from 22 ± 5 mm to 18 ± 4 mm (p < 0.001), as well as a slight deterioration of RV free wall mean longitudinal strain from -16.9 ± 5.6% to -15.7 ± 4.1% (p = 0.05). The rate of moderate to severe tricuspid regurgitation significantly decreased (p < 0.005). Regarding exercise tolerance, the New York Heart Association class improved (p < 0.001) and the walking distance increased (p < 0.001). During mid-term follow up after surgery for PMR, a deterioration of LV and RV contractile function measures could be observed. However, the clinical status, LV dimensions, and concomitant tricuspid regurgitation improved which in particular imply more effective RV contractile pattern

Prevalence of sleep disordered breathing in patients with primary mitral regurgitation undergoing mitral valve surgery

Sleep disordered breathing (SDB) is a frequent comorbidity in cardiac disease patients. Nevertheless, the prevalence and relationship between SDB and severe primary mitral regurgitation (PMR) has not been well investigated to date. Methods: A cohort of 121 patients with significant PMR undergoing mitral valve surgery were prospectively enrolled and received a cardiorespiratory single night polygraphy screening using ApneaLink before surgery. Eighty-two of them underwent a follow-up examination including a follow-up single-night sleep study 3 months after surgery. Results: The mean age of patients was 65.3 ± 12.0 years. Sixty patients (49.6%) were female. The mean EuroSCORE II was 2.5 ± 2.4%. Initially, 91 (75.2%) patients presented with SDB, among whom 50.4% (46 patients, 38.0% of total cohort) were classified as moderate to severe. These patients tended to require significantly longer postoperative intensive care and mechanical ventilation. Among the 82 patients who completed follow-up exams, mitral valve surgery led to a significant reduction in relevant SDB (20.7%). The apnea-hypopnea index (from 11/h [4;18] to 4/h [3;14] (p = 0.04)), the oxygenation-desaturation index (from 8/h [3;18] to 5/h [3;12] (p = 0.008)) as well as the saturation time below 90% (from 32 min [13;86] to 18 min [5;36] (p = 0.005)), were all shown to be improved significantly. Conclusion: The prevalence of SDB is very high in patients with severe primary mitral regurgitation and may contribute to postoperative complications and prolonged intensive care. A significantly reduced but still high prevalence of SDB was observed 3 months after mitral valve surgery, highlighting the bidirectional relationship between SDB and heart failure

Myocardial adaptation as assessed by speckle tracking echocardiography after isolated mitral valve surgery for primary mitral regurgitation

The risk of left ventricular (LV) and right ventricular (RV) maladaptation after surgery for isolated primary mitral regurgitation (PMR) is poorly defined. We aimed to evaluate LV and RV contractile function using speckle-tracking analysis alongside with quantification of exercise tolerance in patients with PMR after mitral valve surgery. All consecutive patients with symptomatic PMR undergoing mitral valve surgery between July 2015 and May 2017 were prospectively enrolled. Sequential echocardiographic studies along with clinical assessment were performed before and three months after surgery. Mean age in 138 patients was 65.8 $\pm$ 12.7 years, 48.2% (66) of whom were female. Mean LV ejection fraction decreased from 57 $\pm$ 12% to 50 $\pm$ 11% (p < 0.001), LV global longitudinal strain deteriorated from −19.2 $\pm$ 4.1% to −15.7 $\pm$ 3.8% (p < 0.001), and mechanical strain dispersion increased from 88 $\pm$ 12 to 117 $\pm$ 115 ms (p = 0.004). There was a reduction in tricuspid annulus plane systolic excursion from 22 $\pm$ 5 mm to 18 $\pm$ 4 mm (p < 0.001), as well as a slight deterioration of RV free wall mean longitudinal strain from −16.9 $\pm$ 5.6% to −15.7 $\pm$ 4.1% (p = 0.05). The rate of moderate to severe tricuspid regurgitation significantly decreased (p < 0.005). Regarding exercise tolerance, the New York Heart Association class improved (p < 0.001) and the walking distance increased (p < 0.001). During mid-term follow up after surgery for PMR, a deterioration of LV and RV contractile function measures could be observed. However, the clinical status, LV dimensions, and concomitant tricuspid regurgitation improved which in particular imply more effective RV contractile pattern