RESUMO
Background and study aims Digital single-operator cholangioscopy (DSOC) allows the diagnosis of biliary duct disorders and treatment for complicated stones. However, these technologies have limitations such as the size of the probe and working channel, excessive cost, and low image resolution. Recently, a novel DSOC system (eyeMAX, Micro-Tech, Nanjing, China) was developed to address these limitations. We aimed to evaluate the usefulness and safety of a novel 9F and 11F DSOC system in terms of neoplastic diagnostic accuracy based on visual examination, ability to evaluate tumor extension and to achieve complete biliary stone clearance, and procedure-related adverse events (AEs). Patients and methods Data from ≥ 18-year-old patients who underwent DSOC from July 2021 to April 2022 were retrospectively recovered and divided into a diagnostic and a therapeutic cohort. Results A total of 80 patients were included. In the diagnostic cohort (n = 49/80), neovascularity was identified in 26 of 49 patients (46.9%). Biopsy was performed in 65.3% patients with adequate tissue sample obtained in 96.8% of cases. Biopsy confirmed neoplasia in 23 of 32 cases. DSOC visual impression achieved 91.6% sensitivity and 87.5% specificity in diagnosing neoplasms. In the therapeutic cohort (n = 43/80), 26 of 43 patients required lithotripsy alone. Total stone removal was achieved in 71% patients in the first session. Neither early nor late AEs were documented in either the diagnostic or therapeutic cohort. Conclusions The novel DSOC device has excellent diagnostic accuracy in distinguishing neoplastic biliary lesions as well as therapeutic benefits in the context of total stone removal, with no documented AEs.
RESUMO
BACKGROUND: We aimed to develop a convolutional neural network (CNN) model for detecting neoplastic lesions during real-time digital single-operator cholangioscopy (DSOC) and to clinically validate the model through comparisons with DSOC expert and nonexpert endoscopists. METHODS: In this two-stage study, we first developed and validated CNN1. Then, we performed a multicenter diagnostic trial to compare four DSOC experts and nonexperts against an improved model (CNN2). Lesions were classified into neoplastic and non-neoplastic in accordance with Carlos Robles-Medranda (CRM) and Mendoza disaggregated criteria. The final diagnosis of neoplasia was based on histopathology and 12-month follow-up outcomes. RESULTS: In stage I, CNN2 achieved a mean average precision of 0.88, an intersection over the union value of 83.24â%, and a total loss of 0.0975. For clinical validation, a total of 170 videos from newly included patients were analyzed with the CNN2. Half of cases (50â%) had neoplastic lesions. This model achieved significant accuracy values for neoplastic diagnosis, with a 90.5â% sensitivity, 68.2â% specificity, and 74.0â% and 87.8â% positive and negative predictive values, respectively. The CNN2 model outperformed nonexpert #2 (area under the receiver operating characteristic curve [AUC]-CRM 0.657 vs. AUC-CNN2 0.794, Pâ<â0.05; AUC-Mendoza 0.582 vs. AUC-CNN2 0.794, Pâ<â0.05), nonexpert #4 (AUC-CRM 0.683 vs. AUC-CNN2 0.791, Pâ<â0.05), and expert #4 (AUC-CRM 0.755 vs. AUC-CNN2 0.848, Pâ<â0.05; AUC-Mendoza 0.753 vs. AUC-CNN2 0.848, Pâ<â0.05). CONCLUSIONS: The proposed CNN model distinguished neoplastic bile duct lesions with good accuracy and outperformed two nonexpert and one expert endoscopist.
Assuntos
Inteligência Artificial , Neoplasias , Humanos , Redes Neurais de Computação , Curva ROC , Valor Preditivo dos TestesRESUMO
BACKGROUND: Endoscopy has evolved to become first-line therapy for the treatment of post-bariatric leaks; however, many sessions are often required with variable success rates. Due to these limitations, the use of the cardiac septal defect occluder (CSDO) has recently been reported in this population. METHODS: The study population was a multicenter retrospective series of patients with post-bariatric surgical leaks who underwent treatment with CSDO placement. Data on the type of surgery, previous treatment details, fistula dimensions, success rate, and adverse events were collected. Leaks were grouped according to the International Sleeve Gastrectomy Expert Panel Consensus. Outcomes included technical and clinical success and safety of the CSDO. Regression analysis was performed to determine the predictors of response. RESULTS: Forty-three patients with leaks were included (31 sleeve gastrectomy and 12 Roux-en-Y gastric bypass). They were divided into acute (n = 3), early (n = 5), late (n = 23), and chronic (n = 12). Forty patients had failed previous endoscopic treatment and 3 patients had CSDO as the primary treatment. Median follow-up was 34 weeks. Technical success was achieved in all patients and clinical success in 39 patients (90.7%). All chronic, late, and early leaks were successfully closed, except one undrained late leak. The 5 patients with early leaks had an initial satisfactory response, but within 30 days, drainage recurred. The CSDOs were removed and replaced with larger-diameter devices leading to permanent defect closure. Acute leaks were not successfully closed in all 3 patients. Regression analysis showed that chronicity and previous treatment were associated with fistula closure; success rates for late/chronic leaks versus acute/early leaks were 97.1% and 62.5%, respectively (P = .0023). CONCLUSION: This observational study found that the CSDO had a high efficacy rate in patients with non-acute leaks, with no adverse events. All early, late, and chronic leaks were successfully closed, except for one undrained late leak. However, early leaks required a second placement of a larger CSDO in all cases. These results suggest that the CSDO should be considered for non-acute fistula and that traditional closure methods are likely preferred in the acute and early settings.
Assuntos
Fístula Anastomótica/cirurgia , Fístula Brônquica/cirurgia , Fístula Cutânea/cirurgia , Fístula Gástrica/cirurgia , Dispositivo para Oclusão Septal , Doença Aguda , Adulto , Fístula Anastomótica/etiologia , Fístula Brônquica/etiologia , Doença Crônica , Fístula Cutânea/etiologia , Endoscopia Gastrointestinal/métodos , Feminino , Gastrectomia/efeitos adversos , Derivação Gástrica/efeitos adversos , Fístula Gástrica/etiologia , Humanos , Masculino , Pessoa de Meia-Idade , Reoperação , Estudos Retrospectivos , Dispositivo para Oclusão Septal/efeitos adversos , Fatores de Tempo , Resultado do TratamentoRESUMO
Acute pancreatitis is a constant management challenge, especially with peripancreatic collection that are one of the most common complications; after the first surgical attempts that had high mortality, there had to be a new approach based in decades of acquired knowledge in physiopathology added to the development of endoscopic intervention techniques and the evolution of endoscopic devices help to establish less invasive and conservative management. This review allows us to know the last advances in the management of acute pancreatitis, pancreatic pseudocyst and walled off necrosis, determined the right time for the management to become more invasive, even considering surgery at a final stage. It also reviews the different types of drainage of peripancreatic collections and the accessories currently in use.
Assuntos
Pseudocisto Pancreático/terapia , Pancreatite/terapia , Doença Aguda , Colangiopancreatografia Retrógrada Endoscópica , Terapia Combinada , Tratamento Conservador/métodos , Drenagem/métodos , Endossonografia , HumanosRESUMO
Acute pancreatitis is a constant management challenge, especially with peripancreatic collection that are one of the most common complications; after the first surgical attempts that had high mortality, there had to be a new approach based in decades of acquired knowledge in physiopathology added to the development of endoscopic intervention techniques and the evolution of endoscopic devices help to establish less invasive and conservative management. This review allows us to know the last advances in the management of acute pancreatitis, pancreatic pseudocyst and walled off necrosis, determined the right time for the management to become more invasive, even considering surgery at a final stage. It also reviews the different types of drainage of peripancreatic collections and the accessories currently in use.
La Pancreatitis Aguda nos plantea un reto constante en su manejo teniendo a las colecciones líquidas peri pancreáticas como una de las complicaciones más frecuente ; inicialmente de manejo quirúrgico con una alta mortalidad, fue necesario replantear este enfoque en base a los conocimientos adquiridos durante décadas sobre su fisiopatología, que sumado al desarrollo de las técnicas de intervención endoscópica y evolución de los dispositivos endoscópicos permitió establecer manejos menos invasivos y conservadores. Esta revisión nos permite conocer los últimos avances en el manejo de la pancreatitis aguda, seudoquiste pancreático y necrosis encapsulada; determinando en que momento nuestro manejo debe tornarse más invasivo hasta llegar a la cirugía. Haciendo una revisión en los diferentes tipos de drenaje de las colecciones peri pancreáticas y los diferentes accesorios utilizados hasta el momento.
Assuntos
Humanos , Pseudocisto Pancreático/terapia , Pancreatite/terapia , Drenagem/métodos , Doença Aguda , Colangiopancreatografia Retrógrada Endoscópica , Terapia Combinada , Endossonografia , Tratamento Conservador/métodosRESUMO
BACKGROUND AND AIMS: Endoscopic ultrasound-guided biliary drainage (EUS-BD) has emerged as an alternative in cases of endoscopic retrograde cholangiopancreatography (ERCP) failure. Two types of EUS-BD methods for achieving biliary drainage when ERCP fails are choledochoduodenostomy (CDS) or hepaticogastrostomy (HGS). However, there is no consensus if one approach is better than the other. Therefore, we conducted a systematic review and meta-analysis to evaluate these 2 main EUS-BD methods. METHODS: We searched MEDLINE, Embase, Scopus, Cochrane database, LILACS from inception through April 8, 2017, using the following search terms in various combinations: biliary drainage, biliary stent, transluminal biliary drainage, choledochoduodenostomy, hepaticogastrostomy, endoscopic ultrasound-guided biliary drainage. We selected studies comparing CDS and HGS in patients with malignant biliary obstruction with ERCP failure. Pooled odds ratio (OR) were calculated for technical success, clinical success, and adverse events and difference of means calculated for duration of procedure and survival after procedure. RESULTS: A total of 10 studies with 434 patients were included in the meta-analysis: 208 underwent biliary drainage via HGS and the remaining 226 via CDS. The technical success for CDS and HGS was 94.1% and 93.7%, respectively, pooled OR=0.96 [95% confidence interval (CI)=0.39-2.33, I=0%]. Clinical success was 88.5% in CDS and 84.5% in HGS, pooled OR=0.76 (95% CI=0.42-1.35, I=17%). There was no difference for adverse events OR=0.97 (95% CI=0.60-1.56), I=37%. CDS was about 2 minutes faster with a pooled difference in means of was -2.69 (95% CI=-4.44 to -0.95). CONCLUSION: EUS-CDS and EUS-HGS have equal efficacy and safety, and are both associated with a very high technical and clinical success. The choice of approach may be selected based on patient anatomy.
Assuntos
Coledocostomia/métodos , Endossonografia/métodos , Gastrostomia/métodos , Colangiopancreatografia Retrógrada Endoscópica/métodos , Coledocostomia/efeitos adversos , Drenagem/métodos , Gastrostomia/efeitos adversos , Humanos , Fígado/cirurgia , Stents , Ultrassonografia de Intervenção/métodosRESUMO
BACKGROUND AND OBJECTIVES: Endoscopic retrograde cholangiopancreatography (ERCP) is the method of choice for drainage in patients with distal malignant biliary obstruction, but it fails in up to 10% of cases. Percutaneous transhepatic cholangiography (PTC) and surgical bypass are the traditional drainage alternatives. This study aimed to compare technical and clinical success, quality of life, and survival of surgical biliary bypass or hepaticojejunostomy (HJT) and endoscopic ultrasound (EUS)-guided choledochoduodenostomy (CDT) in patients with distal malignant bile duct obstruction and failed ERCP. PATIENTS AND METHODS: A prospective, randomized trial was conducted. From March 2011 to September 2013, 32 patients with malignant distal biliary obstruction and failed ERCP were studied. The HJT group consisted of 15 patients and the CDT group consisted of 14 patients. Technical and clinical success, quality of life, and survival were assessed prospectively. RESULTS: Technical success was 94% (15/16) in the HJT group and 88% (14/16) in the CDT group (P = 0.598). Clinical success occurred in 14 (93%) patients in the HJT group and in 10 (71%) patients in the CDT group (P = 0.169). During follow-up, a statistically significant difference was seen in mean functional capacity scores, physical health, pain, social functioning, and emotional and mental health aspects in both techniques (P < 0.05). The median survival time in both groups was the same (82 days). CONCLUSION: Data relating to technical and clinical success, quality of life, and survival were similar in patients who underwent HJT and CDT drainage after failed ERCP for malignant distal biliary obstruction.
RESUMO
La endomicroscopia confocal láser basada en probes (Cellvizio de Mauna Kea Technologies, París) es una nueva tecnología que permite, durante cualquier procedimiento endoscópico, realizar análisis histológicos en tiempo real (biopsia óptica), mejorando el diagnóstico y ayudando a definir el tratamiento de múltiples patologías digestivas. Es de resaltar, para nuestro medio, su utilidad en patologías de difícil diagnóstico como son las estenosis biliares indeterminadas y las neoplasias quísticas pancreáticas, cuyo diagnóstico temprano y exacto es muy difícil con las técnicas actualmente disponibles, y que es necesario para definir la realización o la exclusión de tratamientos quirúrgicos de alta morbimortalidad y alto costo, como por ejemplo, la cirugía de Whipple. En esta revisión se muestran los aportes actuales de esta tecnología, ya disponible en nuestro medio, para el diagnóstico y estudio de las patologías digestivas.
Probe based confocal laser endomicroscopy (Cellvizio Mauna Kea, Paris) is a new technology that allows performance of histological analysis (optical biopsy) during any endoscopic procedure. This improves diagnosis and helps define the treatment needed for multiple digestive diseases. Its utility for diseases that are difficult to diagnose such as indeterminate biliary strictures and pancreatic cystic neoplasms is noteworthy. Early and accurate diagnoses can be very difficult with currently available techniques, but they are exactly what are needed to determine whether or not expensive surgical treatments with great potential morbidity, for example the Whipple procedure, need to be performed. This review looks at the contribution that this technology can make in our country where it is now available for the diagnosis and study of digestive diseases.
Assuntos
Humanos , Neoplasias Gastrointestinais , Programas de Rastreamento , Microscopia ConfocalRESUMO
AIM: To review results of endoscopic treatment for anastomotic biliary strictures after orthotopic liver transplantation (OLT) during an 8-year period. METHODS: This is a retrospective review of all endoscopic retrograde cholangiopancreatographys (ERCPs) performed between May 2006 and June 2014 in deceased OLT recipients with anastomotic stricture at a tertiary care hospital. Patients were divided into 2 groups, according to the type of stent used (multiple plastic or covered self-expandable metal stents), which was chose on a case-by-case basis and their characteristics. The primary outcome was anastomotic stricture resolution rate determined if there was no more than a minimum waist at cholangiography and a 10 mm balloon could easily pass through the anastomosis with no need for further intervention after final stent removal. Secondary outcomes were technical success rate, number or ERCPs required per patient, number of stents placed, stent indwelling, stricture recurrence rate and therapy for recurrent anastomotic biliary stricture (AS). Stricture recurrence was defined as clinical laboratorial and/or imaging evidence of obstruction at the anastomosis level, after it was considered completely treated, requiring subsequent interventional procedure. RESULTS: A total of 195 post-OLT patients were assessed for eligibility. One hundred and sixty-four (164) patients were diagnosed with anastomotic biliary stricture. ERCP was successfully performed in 157/164 (95.7%) patients with AS, that were treated with either multiple plastic (n = 109) or metallic billiary stents (n = 48). Mean treatment duration, number of procedures and stents required were lower in the metal stent group. Acute pancreatitis was the most common procedure related complication, occurring in 17.1% in the covered self-expandable metal stents (cSEMS) and 4.1% in the multiple plastic stent (MPS) group. Migration was the most frequent stent related complication, observed in 4.3% and 5.5% (cSEMS and MPS respectively). Stricture resolution was achieved in 86.8% in the cSEMS group and in 91% in MPS group. Stricture recurrence after a median follow up of 20 mo was observed in 10 (30.3%) patients in the cSEMS and 7 (7.7%) in the plastic stent group, a statistically significant difference (P = 0.0017). Successful stricture resolution after secondary treatment was achieved in 66.6% and 62.5% of patients respectively in the cSEMS and plastic stents groups. CONCLUSION: Multiple plastic stents are currently the first treatment option for AS in patients with duct-to-duct anastomosis. cSEMS was associated with increased pancreatitis risk and higher recurrence rate.
RESUMO
BACKGROUND: EUS-guided biliary drainage (BD) is an evolving alternative technique for patients with malignant biliary obstruction for which ERCP failed. OBJECTIVE: To compare the outcomes of 2 nonanatomic EUS-guided BD routes: hepaticogastrostomy (HPG) and choledochoduodenostomy (CD). DESIGN: Prospective, randomized trial. SETTING: Tertiary endoscopic referral center. PATIENTS: Forty-nine patients with unresectable distal malignant biliary obstruction and failed ERCP were included. The HPG group had 25 patients and the CD group had 24 patients. INTERVENTIONS: EUS-guided HPG or CD. In all procedures, a biliary puncture with a 19-gauge needle followed by cholangiography, wire advancement, track dilation, and self-expandable metal stent deployment were performed. MAIN OUTCOME MEASUREMENTS: Technical and clinical success, quality of life, adverse events, and survival. RESULTS: The technical success rate was 96% for HPG and 91% for CD. The clinical success rate was 91% for HPG and 77% for CD. The mean procedural time was 47.8 minutes for HPG and 48.8 minutes for CD. The mean scores of quality of life were similar during follow-up. The overall adverse event rate was 16.3% (20% for the HPG group and 12.5% for the CD group). One patient with a bile leak required percutaneous biloma drainage. There was no statistical difference between the 2 techniques and no difference with regard to survival time between the 2 groups. LIMITATIONS: Single-center study. CONCLUSION: HPG and CD techniques are similar in efficacy and safety. Both HPG and CD seem valid alternative options for BD in patients with distal malignant biliary obstruction after failed ERCP.