Carlos Prieto

Endoscopic and anesthetic feasibility of EUS and ERCP combined in a single session versus two different sessions.

AIM To discuss the feasibility of single session endoscopic ultrasonography (EUS) to discuss and endoscopic retrograde cholangiopancreatography (ERCP) execution. METHODS Retrospective endoscopic and anesthetic outcome comparison of performing both EUS and ERCP in a single endoscopic session (Group I) versus performing each procedure in two different sessions (Group II) was made. The following variables were evaluated: epidemiological variables, American Society of Anesthesiologists Physical Status Classification (ASA) level, procedural time, propofol dose, anesthetic complications, endoscopic complications and diagnostic yield, and therapeutic procedures on both groups. T-student, Chi-Square and Fisher test were used for comparison. RESULTS We included 39 patients in Group I (mean age: 69.85 ± 9.25; 27 men) and 46 in Group II (mean age: 67.46 ± 12.57; 25 men). Procedural time did not differ significantly between both groups (Group Ivs Group II: 93 ± 32.78 vs 98.98 ± 38.17; P >0.05) but the dose of propofol differed (Group I vs Group II: 322.28 ± 250.54 mg vs 516.96 ± 289.06 mg; P = 0.001). Three patients had normal findings on both explorations. Three anesthetic complications [O(2) desaturation (2), broncoaspiration (1)] and 9 endoscopic complications [pancreatitis (6), bleeding (1), perforation (1), cholangitis (1)] occurred without significant differences between both groups (P > 0.05). We did not find any significant difference regarding age, sex, ASA scale level, diagnostic yield or therapeutic maneuvers between both groups. CONCLUSION The performance of EUS and ERCP in a single session offers a similar diagnostic and therapeutic yield, does not entail a higher complication risk and requires a significantly smaller dose of propofol for sedation compared with performing each exploration in a different session.

EUS-guided transgastric drainage of a peripancreatic collection containing an arterial bypass graft

A 63-year-old man was admitted with aortic dissection and acute thrombosis of the superior mesenteric artery in May 2013. After urgent surgical arterial bypass, he experienced postoperative mesenteric ischemia, pancreatitis, and bleeding, requiring 2 additional surgical interventions. Subsequently, he experienced pancreaticocutaneous fistula and abdominal sepsis; after a lengthy hospital stay, he was discharged in September. One day after discharge he was readmitted for fever related to Pseudomona and Serratia spp infection of a peribypass collection, which was treated with percutaneous drainage twice, and 4 courses of antibiotics for recurrent bacteriemia until April 2014, when recurrence of the peribypass collection was diagnosed. Because of the patient’s unacceptable surgical risk, EUS-guided transgastric drainage of the collection with the arterial bypass floating inside (Fig. 1) was completed (Video 1, available online at www.giejournal. org). A double pigtail stent was inserted, followed by a nasocystic catheter for continuous lavage during 1 week. After 4 weeks, a CT scan confirmed resolution of the collection, and the transgastric double-pigtail stent was retrieved uneventfully. He has been asymptomatic except for an episode of fever, which resolved with antibiotics without recurrence of fluid collection during 9 months of follow-up.

Síndrome general y diarrea como manifestación de infección por Giardia lamblia

Resumen La Giardia lamblia o Giardia duodenalis es un protozoo cosmopolita, cuya transmision, fecal-oral, se produce por la ingestion de sus quistes, que se desenquistan y se adhieren a los enterocitos. La clinica se caracteriza por la aparicion de diarrea, dolor abdominal y otros sintomas menos frecuentes, como nauseas, anorexia y perdida de peso. Las pruebas de enzimoinmunoanalisis, la inmunofluorescencia directa para buscar antigenos en muestras fecales y la biopsia intestinal son las tecnicas que ofrecen mejor sensibilidad diagnostica. En los casos en que se sospeche esta infeccion debe realizarse una biopsia de duodeno, aunque el aspecto endoscopico sea normal. El metronidazol y el tinidazol son los farmacos con mayor eficacia en el tratamiento. Se presenta el caso de un paciente con infeccion por G. lamblia, que consulto por un cuadro de sindrome general de 4 meses de evolucion, forma no usual de presentacion en el adulto de esta parasitosis, al que se anadio un cuadro diarreico en el ultimo mes, cuyo diagnostico se establecio a partir de la biopsia duodenal. El paciente respondio satisfactoriamente al tratamiento con metronidazol.

Chronic Pancreatitis-Like Changes Detected by Endoscopic Ultrasound in Type 1 Diabetics Are Not Associated With Gastrointestinal Symptoms or Nutritional Deficiencies.

Objectives Previous studies have shown changes in the pancreas of type 1 diabetic (T1-DM) patients, similar to those present in patients with chronic pancreatitis. Our aim was to analyze the prevalence of endoscopic ultrasound (EUS) criteria for chronic pancreatitis in T1-DM, to determine the association with factors related to the diabetes and to define its clinical significance. Methods Eighty-six T1-DM patients were prospectively included. All of them underwent EUS. Standard criteria were used. Patients were divided into 3 groups according to the number of EUS criteria they met: group A, 0 to 2 criteria; group B, 3 to 4; and group C, more than 4. Association between EUS findings and demographic or clinical factors was studied as well as the relationship between EUS abnormalities and the presence of gastrointestinal symptoms or nutritional deficiencies. Results Fifty-three patients (61.6%) showed at least 1 morphologic abnormality. Fifty-eight patients were included in group A, 21 in group B, and 7 in Group C. No significant differences were found when comparing the 3 groups. Conclusions Chronic pancreatitis-like changes are frequent in the pancreas of T1-DM patients. These changes are not associated with demographic or clinical data. Therefore, the clinical relevance seems to be scarce.

Challenging combined EUS-and-ERCP–endoscopic retrieval of proximally migrated pancreatic stent

A 29-year-old woman with an internally migrated pancreatic stent was sent to our unit for a final ERCP attempt to retrieve the stent. After removing a previously placed transpapillary prophylactic stent, wirsungraphy showed the migrated stent located in the body of the pancreas, with its distal end situated in a 12-mm intrapancreatic collection. The collection was connected to the cephalic duct through a stenosis perpendicularly aligned with the cephalic duct of the pancreas (Fig. 1). Because retrograde progression of a guidewire was precluded by duct morphology, an EUS-guided pancreatic rendezvous was attempted unsuccessfully because of repeated looping of the guidewire in the collection. Drainage of the collection was performed to induce changes in duct disposition, which were confirmed after subsequent papillary cannulation. The guidewire was then advanced through the stenosis into the collection, and by means of simultaneous manipulation of 2 guidewires, the migrated stent was removed using the lasso technique (Video 1, available online at www.giejournal. org). A combination of EUS and ERCP was the key to achieving stent retrieval in our case. Despite a failed EUS-guided rendezvous attempt, the drainage of the collection allowed stent removal. In our experience, the

Low Serum Levels of Prealbumin, Retinol Binding Protein, and Retinol Are Frequent in Adult Type 1 Diabetic Patients

Aim. To determine the serum prealbumin (PA), retinol binding protein (RBP), and retinol levels in adult patients with type 1 diabetes (T1D) and to analyze some factors related to those levels. Methods. A total of 93 patients (47 women) were studied. Age, gender, BMI, duration of diabetes, chronic complications, HbA1c, lipid profile, creatinine, albumin, PA, RBP, and retinol were recorded. High and low parameter groups were compared by Mann–Whitney U and χ 2 tests. Correlation between parameters was analyzed by Spearmans test. Odds of low levels were analyzed by univariate logistic regression and included in the multivariate analysis when significant. Results. 49.5%, 48.4%, and 30.1% of patients displayed serum PA, RBP, and retinol levels below normal values, respectively. A high correlation (Rho > 0.8) between PA, RBP, and retinol serum levels was found. Patients presenting low levels of any of them were predominantly women, normal-weighted, and with lower levels of triglycerides and serum creatinine. No differences in age, macrovascular complications, duration of diabetes, or HbA1c values were observed when comparing low and normal parameter groups. Conclusion. Low serum levels of PA, RBP, and retinol are frequent in T1D adult patients. This alteration is influenced by female sex and serum creatinine and triglyceride levels.

EUS-guided wirsung-gastrostomy: Outcomes and long-term management

Introduction: Technical success for endoscopic wirsung-gastrostomy (EWG) is about 40% with a complication rate >20%. Long-term results are scarce. Case: A 46 year old patient with alcoholic liver and pancreatic chronic disease with active consumption referred recurrent pancreatic like type pain requiring intensive analgesic therapy. CT scan showed pancreatic duct dilation proximal to the head of the pancreas with distal pancreatic duct stenosis and severe perigastric collateral vessels related to portal hypertension. The patient was considered as high surgical risk so in October 2011 pancreatic stent placement was attempted but failed because of impossibility of pancreatic duct cannulation. EUS-guided transgastric pancreatic duct access was performed. Wirsungraphy was accomplished through the transgastric EUS guided needle showing a severe pancreatic duct stenosis in the pancreatic isthmus hindering guidewirenavigation and the EWGwas completed by insertion of a 5F pancreatic stent connecting the pancreatic duct and the gastric lumen. The patient had a favourable outcome and could stop taking analgesics. In may 2012 a second transgastric 7F stent placement was scheduled uneventfully to ensure pancreatic drainage. The patient remained asymptomatic thereafter despite keeping toxic habits, until august 2013 when he was admitted for a septic clinical picture with abdominal pain. A CT scan showed two abdominal collections with transgastric pancreatic stents correctly placed. The patient was diagnosed of acute relapse over chronic pancreatitis and percutaneous drainage of both collections was performed. In order to rule out origin of those collections from the EWG, the transgastric fistula was cannulated showing no leakage and improvement of the pancreatic head stenosis. Three plastic pancreatic stents were placed through the gastric wall into the pancreatic duct. The patient remains asymptomatic 40 months after initial EWG. Conclusion: In our experience, the EWG offers good clinical long-term outcomes in patients with high surgical risk.

T1091 Synchronous Neoplastic Lesions in Colorectal Cancer. Analysis of Possible Risk Factors Favouring Presentation

Aim: few data have been published regardingthe causes of synchronous lesionsinpatientswith colorectal cancer.The aim of our study was to identifypotentialfactors that mightbe implicated in the development of multicentric lesions, since this knowledge could be useful for tailored follow-up once initial synchronousle sions havebeenremoved. Methods: we retrospectively reviewed 382 colorectal cancer cases diagnosedby total colonoscopy and histological study of surgical specimens. We divided our population into 2 groups, based on whether they had synchronous lesions or otherwise. Several data related to personal and family history, habits, symp toms, and tumor characteristics were assessed. Univariateand multivariate statistical analyses were performed. Results: 208 (54.5%) patients had synchronous adenomas and 28 (7.3%) had synchronouscancer. A multivariate analysis showed that the followingparameters were consistently related to the presence of multicentriclesions –male gender:OR = 1.97; CI = 1.13-3.45; p = 0.017; age ≥ 59 years: OR = 2.57; CI = 1.54-4.29; p < 0.001; personal history of colonic adeno mas: OR = 3.04; CI = 1.04-8.85; p = 0.042; and obstructivetu mors: OR = 0.48; CI = 0.27-0.85; p = 0.012. Conclusion: our results show that severalparameters that are easy to measure could be considered risk factors for the develop ment of multicentric lesions. These factors need to be confirmed with follow-up studies analyzingtheir role in patients with and without metachronic lesions once all synchronous lesions have beenremoved.