Jorge Canena

C-reactive protein prognostic accuracy in acute pancreatitis: timing of measurement and cutoff points.

Objectives C-reactive protein (CRP) has been used widely in the early risk assessment of patients with acute pancreatitis. This study evaluated the prognostic accuracy of CRP for severe acute pancreatitis (SAP), pancreatic necrosis (PNec), and in-hospital mortality (IM) in terms of the best timing for CRP measurement and the optimal CRP cutoff points. Materials and methods This was a single-center retrospective cohort study including 379 patients consecutively admitted with acute pancreatitis. CRP determinations at hospital admission, 24, 48, and 72 h after hospital admission were collected. Discriminative and predictive abilities of CRP for SAP, PNec, and IM were assessed by the area under the receiver-operating characteristic curve and the Hosmer–Lemeshow test, respectively. To determine the optimal CRP cutoff points for SAP, PNec, and IM, the minimum P-value approach was used. Results In total, 11% of patients had SAP, 20% developed PNec, and 4.2% died. The area under the receiver-operating characteristic curves of CRP at 48 h after hospital admission for SAP, PNec, and IM were 0.81 [95% confidence interval (CI) 0.72–0.90], 0.77 (95% CI 0.68–0.87), and 0.79 (95% CI 0.67–0.91), respectively. The Hosmer–Lemeshow test P-values of CRP at 48 h after hospital admission for SAP, PNec, and IM were 0.82, 0.47, and 0.24, respectively. The optimal CRP at 48 h after hospital admission cutoff points for SAP, PNec, and IM derived were 190, 190, and 170 mg/l, respectively. Conclusion CRP at 48 h after hospital admission showed a good prognostic accuracy for SAP, PNec, and IM, better than CRP measured at any other timing. The optimal CRP at 48 h after hospital admission cutoff points for SAP, PNec, and IM varied from 170 to 190 mg/l.

C-Reactive Protein at 24 Hours after Hospital Admission may have Relevant Prognostic Accuracy in Acute Pancreatitis: A Retrospective Cohort Study

Introduction C-reactive protein (CRP) and Bedside Index for Severity in Acute Pancreatitis (BISAP) have been used in early risk assessment of patients with AP. Objectives We evaluated prognostic accuracy of CRP at 24 hours after hospital admission (CRP24) for in-hospital mortality (IM) in AP individually and with BISAP. Materials and Methods This retrospective cohort study included 134 patients with AP from a Portuguese hospital in 2009–2010. Prognostic accuracy assessment used area under receiver–operating characteristic curve (AUC), continuous net reclassification improvement (NRI), and integrated discrimination improvement (IDI). Results Thirteen percent of patients had severe AP, 26% developed pancreatic necrosis, and 7% died during index hospital stay. AUCs for CRP24 and BISAP individually were 0.80 (95% confidence interval (CI) 0.65–0.95) and 0.77 (95% CI 0.59–0.95), respectively. No patients with CRP24 <60 mg/l died (P = 0.027; negative predictive value 100% (95% CI 92.3–100%)). AUC for BISAP plus CRP24 was 0.81 (95% CI 0.65–0.97). Change in NRInonevents (42.4%; 95% CI, 24.9–59.9%) resulted in positive overall NRI (31.3%; 95% CI, −36.4% to 98.9%), but IDInonevents was negligible (0.004; 95% CI, −0.007 to 0.014). Conclusions CRP24 revealed good prognostic accuracy for IM in AP; its main role may be the selection of lowest risk patients.

Predictive value of cholangioscopy after endoscopic management of early postcholecystectomy bile duct strictures with an increasing number of plastic stents: a prospective study (with videos)

BACKGROUNDnEndotherapy of postcholecystectomy bile duct stricture (PCBS) has been established as an alternative treatment to surgery. Several studies have reported conflicting results regarding the predictors of success or failure of endotherapy.nnnOBJECTIVEnTo evaluate the different cholangioscopic appearances of PCBS after endotherapy with an increasing number of plastic stents and the predictive values of these appearances for the outcome.nnnDESIGNnProspective study with a long-term follow-up.nnnSETTINGnTwo academic tertiary referral centers.nnnPATIENTSnTwenty consecutive patients with major bile duct injury, with a bile leak, and a PCBS who underwent therapeutic ERCP.nnnINTERVENTIONSnClosure of the leak followed by temporary placement of multiple plastic stents for the treatment of PCBS, followed by cholangioscopy at the end of endotherapy.nnnMAIN OUTCOME MEASUREMENTSnTo analyze the predictive value of cholangioscopy, other predictors of stricture recurrence after endotherapy, and long-term clinical success.nnnRESULTSnClosure of the leak was achieved in all patients. The median duration of endotherapy was 12 months (range 7-18 months). After endoscopic stenting, the PCBS was considered to be appropriately dilated in all patients. After endotherapy, 3 different findings were noted on cholangioscopy: (1) no lesion or minor defect (n = 10), (2) minor stricture with a fibrous ring (n = 6), and (3) presence of tissue hyperplasia (n = 4). During follow-up, stricture recurrence developed in 4 of 20 patients. All 4 patients were successfully retreated by an additional period of stenting and remained free of cholestasis after a median follow-up period of 44 months. By Kaplan-Meier (log-rank) and univariate analyses, the cholangioscopic pattern of tissue hyperplasia was significantly associated with stricture recurrence (P < .01).nnnLIMITATIONSnSmall sample size.nnnCONCLUSIONSnEndoscopic stenting should be regarded as the primary treatment of choice because of the successful long-term outcome after 1 or more additional periods of treatment. However, the cholangioscopic pattern of tissue hyperplasia at the time of stent removal is a strong predictor of stricture recurrence, and this observation may lead to an additional period of endotherapy or other treatment modalities.

A non-randomized study in consecutive patients with postcholecystectomy refractory biliary leaks who were managed endoscopically with the use of multiple plastic stents or fully covered self-expandable metal stents (with videos).

BACKGROUNDnEndoscopic management of postcholecystectomy biliary leaks is widely accepted as the treatment of choice. However, refractory biliary leaks after a combination of biliary sphincterotomy and the placement of axa0large-bore (10F) plastic stent can occur, and the optimal rescue endotherapy for this situation is unclear.nnnOBJECTIVEnTo compare the clinical effectiveness of the use of a fully covered self-expandable metal stentxa0(FCSEMS) with the placement of multiple plastic stents (MPS) for the treatment of postcholecystectomy refractory biliary leaks.nnnDESIGNnProspective study.nnnSETTINGnTwo tertiary-care referral academic centers and one general district hospital.nnnPATIENTSnForty consecutive patients with refractory biliary leaks who underwent endoscopic management.nnnINTERVENTIONSnTemporary placement of MPS (nxa0= 20) or FCSEMSs (nxa0= 20).nnnMAIN OUTCOME MEASUREMENTSnClinical outcomes of endotherapy as well as the technical success, adverse events, need for reinterventions, and prognostic factors for clinical success.nnnRESULTSnEndotherapy was possible in all patients. After endotherapy, closure of the leak was accomplished in 13xa0patients (65%) who received MPS and in 20 patients (100%) who received FCSEMSs (Pxa0= .004). Thexa0Kaplan-Meier (log-rank) leak-free survival analysis showed a statistically significant difference between the 2 patient populations (χ(2) [1]xa0= 8.30; Pxa0< .01) in favor of the FCSEMS group. Use ofxa0<3 plastic stents (Pxa0= .024), a plastic stent diameterxa0<20F (Pxa0= .006), and a high-grade biliary leak (Pxa0= .015) were shown to be significant predictors ofxa0treatment failure with MPS. The 7 patients in whom placement of MPS failed were retreated with FCSEMSs, resulting in closure of the leaks in all cases.nnnLIMITATIONSnNon-randomized design.nnnCONCLUSIONnIn our series, the results of the temporary placement of FCSEMSs for postcholecystectomy refractory biliary leaks were superior to those from the use of MPS. A randomized study is needed to confirm our results before further recommendations.

Esophageal Anastomotic Stricturotomy: Electroincision Therapy with a Needle Knife

a Gastroenterology Department, Hospital Santa Luzia, Viana do Castelo, Portugal; b Gastroenterology Department, Centro Hospitalar Cova da Beira EPE, Covilhã, Portugal; c Gastroenterology Department, Instituto Português de Oncologia do Porto Francisco Gentil, Porto, Portugal; d Gastroenterology Department, Hospital Cuf Infante Santo, Lisbon, Portugal; e Life and Health Sciences Research Institute (ICVS), School of Medicine, University of Minho, Braga, Portugal; f ICVS/3B’s – PT Government Associate Laboratory, Braga/Guimarães, Portugal Received: February 11, 2018 Accepted after revision: April 23, 2018 Published online: June 12, 2018

ERCP in Portugal: A Wide Survey on the Prevention of Post-ERCP Pancreatitis and Papillary Cannulation Techniques

Background/Aims: Recently the European Society of Gastrointestinal Endoscopy delivered guidelines on the prevention of post-endoscopic retrograde cholangiopancreatography pancreatitis (PEP) and on the papillary cannulation and sphincterotomy techniques at endoscopic retrograde cholangiopancreatography (ERCP). There are no data concerning current practices in Portugal. The aim of this study was to capture practice patterns of Portuguese pancreaticobiliary endoscopists with special interest in the prevention of PEP and cannulation techniques. Methods: A written survey was distributed to all pancreaticobiliary endoscopists attending the first Portuguese meeting dedicated to ERCP in November 2016. The main outcome measures were: technique used for standard biliary cannulation, use of nonsteroidal anti-inflammatory drugs (NSAIDs) in PEP, attempting prophylactic pancreatic stenting after using pancreatic guidewire (PGW)-assisted biliary cannulation in patients where biliary cannulation was difficult, and use of precut as the first rescue technique when biliary cannulation was difficult. Results: Completed surveys were collected from 28 of the 32 pancreatobiliary endoscopists attending the meeting (answer rate 87.5%). Biliary cannulation was performed using a guidewire access technique by the majority (77%), usually with a sphincterotome. When cannulation was unsuccessful, precut was the first choice for 70%. NSAIDs were administered routinely for PEP by only 54%; PGW-assisted biliary cannulation was the first choice after failed standard cannulation for a minority of them, and only 27% reported to routinely attempt insertion of a pancreatic stent. High-volume endoscopists (> 150/year) tended to use NSAIDs and to insert a stent in PGW-assisted cannulation less often than low-volume-endoscopists (50 vs. 83.3%, p < 0.01, and 40 vs. 100%, p < 0.01, respectively). Precut was started without prior formal training by more than half of the endoscopists. Conclusions: There is a pronounced discrepancy between evidence-based guidelines and current clinical practice. This discrepancy is more pronounced in PEP prophylaxis, especially among high-volume endoscopists. Some advanced techniques in ERCP are initiated unsupervised, without any previous formal training. Key Message: There is a significant gap between guidelines and routine clinical practice.

Outcomes of Single-Operator Cholangioscopy-Guided Lithotripsy in Patients with Difficult Biliary and Pancreatic Stones

Background and Aims: Endoscopic retrograde cholangiopancreatography is the preferred strategy for the management of biliary and pancreatic duct stones. However, difficult stones occur, and electrohydraulic (EHL) and laser lithotripsy (LL) have emerged as treatment modalities for ductal clearance. Recently, single-operator cholangioscopy was introduced, permitting the routine use of these techniques. We aimed to evaluate the clinical effectiveness of cholangioscopy-guided lithotripsy using LL or EHL in patients with difficult biliary or pancreatic stones. Methods: This is a prospective clinical study – conducted at two affiliated university hospitals – of 17 consecutive patients with difficult biliary and pancreatic stones who underwent single-operator cholangioscopy-guided lithotripsy using two techniques: holmium laser lithotripsy (HL) or bipolar EHL. We analyzed complete ductal clearance as well as the impact of the location and number of stones on clinical success and evaluated the efficacy of the two techniques used for cholangioscopy-guided lithotripsy and procedural complications. Results: Twelve patients (70.6%) had stones in the common bile duct/common hepatic duct, 2 patients (17.6%) had a stone in the cystic stump, and 3 patients (17.6%) had stones in the pancreas. Sixteen patients (94.1%) were successfully managed in 1 session, and 1 patient (5.9%) achieved ductal clearance after 3 sessions including EHL, LL, and mechanical lithotripsy. Eleven patients were successfully submitted to HL in 1 session using a single laser fiber. Six patients were treated with EHL: 4 patients achieved ductal clearance in 1 session with a single fiber, 1 patient obtained successful fragmentation in 1 session using two fibers, and 1 patient did not achieve ductal clearance after using two fibers and was successfully treated with a single laser fiber in a subsequent session. Complications were mild and were encountered in 6/17 patients (35.2%), including fever (n = 3), pain (n = 1), and mild pancreatitis (n = 1). Conclusions: Cholangioscopy-guided lithotripsy using LL or EHL in patients with difficult biliary or pancreatic stones is highly effective with transient and minimal complications. There is a clear need to further compare EHL and HL in order to assess their role in the success of cholangioscopy-guided lithotripsy.

Precut fistulotomy – widening its limits

Selective cannulation of the common bile duct (CBD) is the most important and challenging step in a biliary endoscopic retrograde cholangiopancreatography (ERCP) [1, 2]. However, in the first ERCP, even in experienced hands, biliary cannulation may fail in up to 15%–35% of cases when using standard methods alone [3]. In this subset of patients, additional cannulation techniques are needed to access the CBD in order to continue with the ERCP. Precut is the most common strategy used by experienced endoscopists, when conventional methods have failed [2]. Needle-knife fistulotomy (NKF) and conventional precut are the two most common variants. Recently published guidelines recommend opting for NKF, as evidence suggests a lower risk of adverse events, especially pancreatitis, when used early in the biliary cannulation algorithm [2, 4]. This video report aims to demonstrate basic and advanced NKF maneuvers in challenging and hazardous settings, with an emphasis on the need to adapt to the patients’ individual anatomy (▶Fig. 1, ▶Video1). Consequently, even some of the most difficult biliary cannulation cases can have their problems managed by ERCP alone (in the same session), instead of being referred for endoscopic ultrasound or percutaneous biliary drainage. In each case, the NKF procedure was performed using a needle-knife, in a freehand fashion, making a puncture in the papilla above the orifice, and then cutting on the CBD axis, while maintaining a free distance from the papillary orifice [5]. All procedures were performed by an experienced endoscopist (L. L.). NKF is probably an obligatory technique to be included in the toolbox of every future advanced ERCP endoscopist. However, given its potential complications and the skills required to be proficient, it should probably be reserved for skilled endoscopists in high-volume ERCP centers.

Palliative Stenting for Malignant Large Bowel Obstruction: Stents for All?

used as a bridge to surgery?” [1–5] . It is clear that 8 years ago, the use of a stent preoperatively was considered the standard of care and highly recommended in every tertiary center [6, 7] . Furthermore, the use of a stent as a definitive palliative treatment for the remaining life of a patient was still a matter of debate. However, today, in December 2016, everything is reversed. In 2014, the European Society of Gastrointestinal Endoscopy (ESGE) presented guidelines for the use of metallic stents in obstructive colorectal cancer [8] . The special focus is on 2 items: (a) SEMS placement as a bridge to elective surgery is not recommended as a standard treatment of symptomatic left-sided malignant colonic obstruction. For patients with potentially curable but obstructing left-sided colonic cancer, stent placement may be considered as an alternative to emergency surgery in those who have an increased risk of postoperative mortality, i.e., American Society of Anesthesiologists (ASA) physical status ≥ III and/or age >70 years. In addition, to create the perfect scenario for a huge debate, the so-called poor son returned in glory: (b) SEMS placement is recommended as the preferred treatment for palliation of malignant colonic obstruction, except in patients treated or considered for treatment with antiangiogenic drugs (e.g., bevacizumab). How did we arrive at this conclusion?

Once upon a Time a Guideline Was Used for the Evaluation of Suspected Choledocholithiasis: A Fairy Tale or a Nightmare

ent in up to 20% of the patients [2, 3] . The approach used in these patients is most important because CBD stones are a common cause of hospitalization due to recurrent symptoms, cholangitis, and pancreatitis [5] . Once the diagnosis of choledocholithiasis is made, stones should be removed by a therapeutic procedure, namely endoscopic retrograde cholangiopancreatography (ERCP), which is the gold standard for the treatment of CBD stones [3–5] . However, although ERCP is highly effective for the extraction of CBD stones, it is associated with a reasonable rate of adverse events, some of them life-threatening [6, 7] . For many clinicians, the initial evaluation of patients with suspected choledocholithiasis includes serum liver biochemical tests (aspartate aminotransferase, alanine aminotransferase, alkaline phosphatase, and total bilirubin) and a transabdominal ultrasonography (US) [8–10] to select patients for other procedures, such as magnetic resonance cholangiopancreatography (MRCP) [11] or endoscopic ultrasound (EUS) [12] , before they recommend ERCP to the patient; thus, they are trying to avoid the overuse of ERCP, which should not be a diagnostic procedure because it is associated with complications [6, 7] . In 2010, the American Society for Gastrointestinal Endoscopy (ASGE) published guidelines for the prediction of risk stratification for patients being evaluated for CBD