Pedro Moutinho-Ribeiro

Risk factors associated with refractoriness to esophageal dilatation for benign dysphagia.

Background Benign esophageal strictures need repeated dilatations to relieve dysphagia. Literature is scarce on the risk factors for refractoriness of these strictures. Aim This study aimed to assess the risk factors associated with refractory strictures. Materials and methods This is a retrospective study of patients with benign esophageal strictures who were referred for esophageal dilatation over a period of 3 years. Results A total of 327 esophageal dilatations were performed in 103 patients; 53% of the patients reported dysphagia for liquids. Clinical success was achieved in 77% of the patients. There was a need for further dilatations in 54% of patients, being more frequent in patients with dysphagia for liquids [78 vs. 64%, P=0.008, odds ratio (OR) 1.930], in those with caustic strictures (89 vs. 70%, P=0.007, OR 3.487), and in those with complex strictures (83 vs. 70%, P=0.047, OR 2.132). Caustic strictures, peptic strictures, and complex strictures showed statistical significance in the multivariate analysis. Time until subsequent dilatations was less in patients with dysphagia for liquids (49 vs. 182 days, P<0.001), in those with peptic strictures (49 vs. 98 days, P=0.004), in those with caustic strictures (49 vs. 78 days, P=0.005), and in patients with complex strictures (47 vs. 80 days P=0.009). In multivariate analysis, further dilatations occurred earlier in patients with dysphagia for liquids [hazard ratio (HR) 1.506, P=0.004], in those with peptic strictures (HR 1.644, P=0.002), in those with caustic strictures (HR 1.581, P=0.016), and in patients with complex strictures (HR 1.408, P=0.046). Conclusion Caustic, peptic, and complex strictures were associated with a greater need for subsequent dilatations. Time until subsequent dilatations was less in patients with dysphagia for liquids and in those with caustic, peptic, and complex strictures.

Endoscopic Retrograde Cholangiopancreatography and Endoscopic Ultrasound: To Be One Traveler in Converging Roads

Background: Endoscopic retrograde cholangiopancreatography (ERCP) and endoscopic ultrasound (EUS) were initially introduced into the world of gastroenterology as purely diagnostic procedures. With progressive evolution of intervention, both these techniques conquered fields in the treatment of many conditions that had once been exclusively surgical domains. Nowadays, more and more clinical situations have an indication to perform both EUS and ERCP, and these two techniques are frequently required at the same time for the same patient. More than competitors, ERCP and EUS are truly complementary, with great ability for mutual aid. They share their main indications, equipment, accessories, and main technical gestures. Objectives and Methods: We review the major indications to perform both techniques, sequentially or complementarily, describe the common things that these two techniques essentially share, and discuss the ERCP-EUS single session. Also, the issues of learning curves and education of upcoming biliopancreatic endoscopists are highlighted. Conclusion: In recent years the complementation between ECRP and EUS has been growing both from a diagnostic and a therapeutic point of view, allowing optimization of the use of these techniques and the creation of a more systematized approach of patients with biliopancreatic pathology. Endoscopists with experience in both techniques will be increasingly important, suggesting a parallel formation in the training plans of future endoscopists with interest in the area.

Self-expanding metal stents in postoperative esophageal leaks

BACKGROUND Postoperative esophageal leaks have a high morbidity and mortality. Self-expanding metal stents (SEMS) have been used as an alternative to re-operation. AIM Evaluating predictors of success of SEMS in postoperative esophageal leaks. METHODS Retrospective study of patients with postoperative esophageal leaks referred for SEMS placement in a reference center during a period of 3 years. Technical success was defined as closure of the leak in barium swallow at 15 days. Clinical success was considered as endoscopic and/or radiographic confirmation of closure after stent removal. RESULTS Thirteen patients placed SEMS. Median follow-up was 58 days. Leaks had a median size of 20 mm. Time between surgery and SEMS placement was 20 days. One patient died 2 days after SEMS placement and one had worsening of the fistula after SEMS expansion. Time till stent migration was 9 days. Technical success was achieved in 9 of 11 patients, with clinical success without recurrence in 5 patients. All leaks with less than 20 mm were solved endoscopically. Technical and clinical success was higher when time between surgery and SEMS placement was lower, even though without statistical significance (respectively, p = 0.228 and 0.374). In the 8 patients who died during follow-up, median survival was 59 days. CONCLUSIONS Technical success of SEMS was higher than 80%; however, due to high morbidity and mortality, only 45% of patients had their stent removed. Lower time from diagnosis to SEMS placement and leak size less than 20 mm may be associated with better results.

Gastrointestinal stromal tumors in the imatinib era: 15 years’ experience of a tertiary center

Gastrointestinal stromal tumors (GISTs) were associated with a disease free survival rate of disease of 50% at 5 years, but the actual natural history since the advent of imatinib is poorly described. Our objective was to evaluate the evolution in the treatment and prognosis of patients with GISTs since the start of imatinib. Retrospective analysis of GISTs diagnosed between January 2000 and June 2015 in a Portuguese large volume center. We included 131 patients, 55% female, with a mean age of 64±14 years, followed for a median of 30 months; 64% of cases had gastric involvement; 92% of the tumors were c-Kit positive; 95% of patients were operated. Imatinib was initiated in 25% of patients, as adjuvant therapy in 69%; 75% reported adverse effects, and 16% developed resistance. The recurrence rate was 4%, and was associated with age at diagnosis (P=0.037), tumor size (P=0.028), presence of metastases (P=0.019) and high-risk lesions (P=0.036). Survival at 1, 3 and 5 years was 87%, 71% and 61%, respectively. One years mortality was significantly associated with tumor size (P=0.021), stage IV at diagnosis (P=0.003), non-complete resection (P=0.002) and palliation with imatinib (P=0.035). Similar associations were observed at the 3 and 5 years. In the imatinib era there is an increased long-term survival in comparison with previous epidemiological data, and reduced recurrence rates. In more advanced cases survival remains limited in the short term.

Rectovaginal Septum Nodule: The Key for an Unexpected Diagnosis

We report the case of a 54-year-old female with a 2-year history of hypertrophic cranial pachymeningitis (medicated with prednisolone 5 mg and pregabalin), a cranioencephalic traumatic accident in childhood (with a period in coma), and no other relevant medical history including immunosuppressive pathology as HIV. A Gallium-67 scintigraphy was performed for etiological evaluation, which revealed a vaginal uptake. With the exception of neurological symptoms, she had no other complaints and denied all risk factors for anal cancer. On digital rectal examination, a smooth, irregular nodule measuring 15 mm was palpated. An endovaginal ultrasonography revealed a solid mass of the rectovaginal septum in close contact with the anterior wall of the rectum, suggesting the possibility of a nodule of endometriosis. Flexible rectosigmoidoscopy was then performed and a bulging of the lower rectal wall covered by normal mucosa 15 mm in diameter was found, corresponding to the described lesion. Furthermore, during the retroflexion maneuver for complete observation of the distal rectum and anal canal, an irregular sessile polypoid lesion was found, extending from the anal verge (Fig. 1). Biopsies were taken and were consistent with a squamous cell anal carcinoma. Radial endoscopic ultrasound (EUS) was first performed to evaluate the extraluminal nodule. It corresponded to a rounded, homogenous, hypoechogenic lesion, with regular contours and well-defined borders, located in the recto-vaginal septum (extrinsic to the rectal wall) (Fig. 2, 3). No perilesional lymph nodes were detected. EUS fine-needle aspiration (22-G needle) through linear EUS was then performed and the cytological diagnosis was a metastasis of the squamous cell anal carcinoma. The patient was discussed in a multidisciplinary oncological meeting and proposed for radiochemotherapy. Follow-up at 3 months revealed a good tolerance except for limited oral mucositis, pending radiological evaluation of therapy response.

Glypican-1 circulating exosomes: a promising clue to individualize surveillance of pancreatic cysts?

The Editor We read with great interest the article published by Imbe et al. [1] in European Radiology (Jan 2018) titled ‘Validation of the American Gastroenterological Association (AGA) guidelines on management of intraductal papillary mucinous neoplasms: more than 5 years of follow-up’. In this paper, the authors discuss a ‘hot’ topic in pancreatic diseases related to the best approach for managing cystic lesions, which are being diagnosed more frequently since the increasing use of sectional imaging modalities. In this validation study, data were analysed for 392 patients with intraductal papillary mucinous neoplasms (IPMNs) and at most one high-risk feature who were periodically followed up for more than 1 year with imaging tests (group 1) and for 159 IPMN patients without worsening highrisk features after 5 years (group 2: stop surveillance group). In the first group, pancreatic cancer (PC) was identified in 12 patients (27.3 %) when endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) was indicated and none in the nonEUS-FNA indication group (p < 0.01). On the other hand, in the ‘stop surveillance group’, PCwas identified in three patients (1.9 %) at 84, 103 and 145 months, respectively. These observations led the authors to conclude that PC risk and mortality for IPMNs not showing significant change for 5 years is likely to be low, and the non-EUS-FNA indication can provide reasonable decisions; however, three patients without worsening high-risk features for 5 years developed PC, so the ‘stop surveillance strategy’ supported by AGA guidelines [2] should be reconsidered. In fact, controversy exists about the best algorithm to manage these apparently low-risk lesions. Older guidelines such as the ones proposed by the International Consensus [3] and the European Consensus [4] suggest a life-long closer follow-up. On the other hand, the more recent guidelines by the American Gastroenterology Association [2] recommend discontinuation of surveillance at 5 years in the absence of significant changes. In the same line of investigation, in a recent study published by Crippa et al. [5] in the American Journal of Gastroenterology, the authors support the idea that active surveillance beyond 5 years is required for presumed branch-duct intraductal papillary mucinous neoplasms (BD-IPMN) with no high-risk stigmata (HRS) or worrisome features (WF) undergoing non-operative management. In the Crippa et al. study [5], 144 patients with BD-IPMNwere followed for a median of 84 months, with at least annual magnetic resonance imaging and/or magnetic resonance cholangiopancreatography, and changes during follow-up were observed in 48 % of the patients. Remarkably, new-onset WF/HRS was observed in 26 patients (18 %) after a median follow-up period of 71 and 77.5 months from diagnosis, respectively, and without previous changes in 19 (73 %) of them. Although considering the study limitations, these observations led the authors to conclude that discontinuation of surveillance of these apparently ‘inoffensive’ lesions cannot be recommended and, instead, an algorithmwith intensification of follow-up is proposed after 5 years of follow-up. Nevertheless, the authors recognize that discontinuation of surveillance should be considered in patients who are unfit for surgery because of age and/or relevant comorbidities. In the same issue of the American Journal of Gastroenterology, the Editorial by James Farrell [6] titled ‘Stopping pancreatic cyst surveillance’, critically discusses the pros and cons of different approaches to BD-IPMN management. In James Farrell’s opinion, sufficient data (especially * Pedro Moutinho-Ribeiro pmoutinhoribeiro@gmail.com

Early pancreatic cancer — The role of endoscopic ultrasound with or without tissue acquisition in diagnosis and staging

Pancreatic cancer (PC) is one of the deadliest cancers with a 5-year overall survival of less than 6%. Due to its insidious clinical course and unspecific symptoms, the diagnosis is usually late, with only 15-20% patients presenting with potentially curable disease. It is, therefore, extremely important to identify patients with PC at early stages of the disease when tumors may be amenable to surgical resection. For unresectable and borderline resectable PC it is consensual to perform a biopsy to have a cyto/histological confirmation of malignancy before treatment. However, for patients presenting with promptly resectable disease, the role of biopsy is more debatable. There are, in the literature, arguments both for and against the usefulness of a preoperative biopsy. Endoscopic ultrasound (EUS) is an important technique assisting in the diagnosis and staging of PC. EUS-guided tissue acquisition is a well-established tool to demonstrate the malignant nature of a pancreatic lesion. This review focuses on the role of EUS in the diagnosis and staging of PC, and highlights the controversy related to the role of EUS-guided tissue acquisition in the preoperative assessment of patients presenting with promptly resectable tumors (early PC).

Pancreatic cancer screening: Still a delusion?

Pancreatic adenocarcinoma represents the fourth most common cause of cancer mortality and death due to pancreatic cancer (PC) have increased since 2003. Its incidence has also raised about 30% in the past decade and it is expected to become the second cause of cancer mortality by 2020 in the USA. Most PC present with metastatic disease and improvements in treatment outcomes for this group have been disappointing. These observations support the idea that screening to identify patients at an earlier stage might be an important strategy in improving overall PC outcomes. Many protocols have been tested, nevertheless, by now there is no effective screening program. Given the overall low incidence of disease and the current lack of accurate, inexpensive and noninvasive screening tests, the consensus is that widespread population-based screening for PC in the general population or in patients with only one affected first-degree relative is neither practicable nor indicated in most countries. However, a different scenario is screening patients with higher risk for PC, most of them with hereditary conditions predisposing the development of this neoplasia. In fact, some guidelines are now available helping to select these individuals at risk and to screen them, in order to achieve early detection of PC.

Elastography and Contrast-Enhanced Endoscopic Ultrasound Findings in a Pseudo-Solid Variant of a Pancreatic Serous Cystadenoma

mediate-high signal intensity on T2-weighted images, suggesting a complex solid microcystic lesion ( Fig. 1 ). Endoscopic ultrasound (EUS) showed a well-circumscribed, 45-mm, predominantly hypoechogenic complex mass in the pancreatic isthmus, with scattered cystic areas. EUS-guided fine-needle aspiration with a 25-gauge needle was performed (3 passes) and cytology was suspicious, although not definitive, for malignancy. In a multidisciplinary team meeting, surveillance was decided based on MRCP/EUS morphologic findings, compatible with a pseudo-solid variant of a serous cystadenoma (SCA) and equivocal findings for malignancy on cytology, besides the location of the lesion (pancreatic isthmus) and the patient’s age and comorbidities. EUS was repeated 12 months later, with stable morphologic findings. Additional evaluation with Doppler-EUS showed increased color-Doppler signal ( Fig. 2 a), real-time elastography presented a soft pattern (strain ratio 3.1) ( Fig. 2 b) and, in the dynamic study with contrast (Sonovue ® ), the pseudosolid areas presented intense enhancement with slow washout ( Fig. 2 c). No suspicious lymph nodes were found. The differential diagnosis of complex pancreatic lesions is often challenging, and EUS morphology alone cannot provide a diagnosis in the majority of cases. EUS

Endoscopic Ultrasound Images of a Choledochal Cyst Mimicking a Pregnant Uterus

A 31-year-old man with a first episode of acute cholangitis underwent an endoscopic ultrasound following a normal abdominal ultrasound that showed neither choledocholithiasis nor biliary dilation. The endoscopic ultrasound revealed a thickening and stratification of the bile duct wall, which maintained its normal caliber. However, adjacent to the extrapancreatic portion of the common bile duct, and apparently communicating with it (arrow), was a 2-cm saccular, mainly anechoic, area containing polymorphic, sonolucent, and mobile material without posterior acoustic shadowing (a,b), resembling a fetus in a uterus (arrowhead). To clarify the etiology, endoscopic retrograde cholangiopancreatography was performed. It revealed, in the middle third of the common bile duct, a large diverticulum with a narrowed neck, leading to the diagnosis of a type II choledochal cyst, according to the Todani classification (c). After sphincterotomy, exploration with a triple-lumen balloon catheter confirmed that the sonolucent content of the cyst was composed of cellular debris mixed with mucopurulent material, secondary to the cholangitic process. (Informed consent was obtained from the patient to publish these images.)