Malignant biliary obstruction is a challenging condition, requiring a multimodal approach for both diagnosis and treatment. Pancreatic adenocarcinoma and cholangiocarcinoma are the leading causes of ...malignant distal biliary obstruction. Early diagnosis is difficult to establish as biliary obstruction can be the first presentation of the underlying disease, which can already be at an advanced stage. Consequently, the majority of patients (70%) with malignant distal biliary obstruction are unresectable at the time of diagnosis. The association of clinical findings, laboratory tests, imaging, and endoscopic modalities may help in identifying the underlying cause. Novel endoscopic techniques such as cholangioscopy, intraductal ultrasonography, or confocal laser endomicroscopy have been developed with promising results, but are not used in routine clinical practice. As the number of patients with malignant distal biliary obstruction who will undergo curative surgery is limited, endoscopy has a crucial role in palliation, to relieve biliary obstruction. According to the last European guidelines published in the management of biliary obstruction, self-expandable metal stents have a central place in biliary drainage compared to plastic stents. Endoscopic ultrasound has evolved impressively in the last decades. When standard techniques of biliary cannulation by endoscopic retrograde cholangiopancreatography fail, endoscopic ultrasound-guided biliary drainage is a good option compared to percutaneous drainage.
Nutrition in acute pancreatitis Arvanitakis, Marianna; Gkolfakis, Paraskevas; Fernandez Y. Viesca, Michael
Current opinion in clinical nutrition and metabolic care,
09/2021, Letnik:
24, Številka:
5
Journal Article
Recenzirano
Purpose of review
This review aims to discuss recent developments in different topics regarding nutrition and acute pancreatitis (AP), including oral refeeding, nutritional therapy, and implications ...of gut microbiota.
Recent findings
Obesity increases the risk for severe AP and mortality. Considering the worldwide obesity rates, this finding could have major implications in the global outcomes of patients admitted with AP. Recent research confirms that early oral feeding leads to shorter length of stay, fewer complications, and lower costs. In case of intolerance to oral feeding or severe disease, nutritional therapy should be offered within 24–72 h, whereas enteral nutrition (EN) has been shown superior to parenteral nutrition. EN can be administered through gastric or jejunal feeding, depending on digestive tolerance and the presence of ileus. Nevertheless, modalities of EN in patients undergoing endoscopic drainage of pancreatitis-related collections are still undetermined. Weight-loss after discharge occurs frequently and could reflect post-AP pancreatic exocrine failure. Finally, novel research regarding gut microbiota could open new therapeutic opportunities to prevent bacterial translocation and pancreatic necrosis’ infection.
Summary
Despite available evidence many questions regarding nutritional management in patients with AP remain open. Modulation of gut microbiota could play an important role in further therapeutic management.
Pancreatic cancer and cholangiocarcinoma are life threatening oncological conditions with poor prognosis and outcome. Pancreatic cystic lesions are considered precursors of pancreatic cancer as some ...of them have the potential to progress to malignancy. Therefore, accurate identification and classification of these lesions is important to prevent the development of invasive cancer. In the biliary tract, the accurate characterization of biliary strictures is essential for providing appropriate management and avoiding unnecessary surgery. Techniques have been developed to improve the diagnosis, risk stratification, and management of pancreato-biliary lesions. Endoscopic ultrasound (EUS) and associated techniques, such as elastography, contrasted-enhanced EUS, and EUS-guided needle confocal laser endomicroscopy, may improve diagnostic accuracy. In addition, intraductal techniques applied during endoscopic retrograde cholangiopancreatography (ERCP), such as new generation cholangioscopy and in vivo cellular evaluation through probe-based confocal laser endomicroscopy, can increase the diagnostic yield in characterizing indeterminate biliary strictures. Both EUS-guided and intraductal approaches can provide the possibility for tissue sampling with new tools, such as needles, biopsies forceps, and brushes. At the molecular level, novel biomarkers have been explored that provide new insights into diagnosis, risk stratification, and management of these lesions.
Background
Vascular complications of severe acute pancreatitis are well known and largely described unlike non-occlusive mesenteric ischemia, which is a rare and potentially fatal complication. ...Non-occlusive mesenteric ischemia is an acute mesenteric ischemia without thrombotic occlusion of blood vessels, poorly described as a complication of acute pancreatitis.
Methods
We retrospectively reviewed a prospectively maintained registry of all pancreatic diseases referred to our center from 2013 to 2018, in order to determine the causes of early death. We identified three patients who died within 48 h after hospital admission from severe acute pancreatitis complicated by irreversible non-occlusive mesenteric ischemia. Their clinical presentation, management, and outcomes were herein reported.
Results
Three consecutive patients with severe acute pancreatitis developed non-occlusive mesenteric ischemia within the first 5 days after onset of symptoms and died 48 h after non-occlusive mesenteric ischemia diagnosis despite optimal intensive care management and surgery, giving a prevalence of 3/609 (0.5%). Symptoms were unspecific with consequently potential delayed diagnosis and management. High doses of norepinephrine required for hemodynamic support (
n
= 3) potentially leading to splanchnic vessels vasoconstriction, transient hypotension (
n
= 3), and previous severe ischemic cardiomyopathy (
n
= 1) could be involved as precipitating factors of non-occlusive mesenteric ischemia.
Conclusion
Non-occlusive mesenteric ischemia can be a fatal complication of acute pancreatitis but is also challenging to diagnose. Priority is to reestablish a splanchno-mesenteric perfusion flow. Surgery should be offered in case of treatment failure or deterioration but is still under debate in early stage, to interrupt the vicious circle of intestinal hypoperfusion and ischemia.
Acute necrotizing pancreatitis is a common gastrointestinal disease requiring hospitalization and multiple interventions resulting in higher morbidity and mortality. Development of infection in such ...necrotic tissue is one of the sentinel events in natural history of necrotizing pancreatitis. Infected necrosis develops in around 1/3rd of patients with necrotizing pancreatitis resulting in higher mortality. So, timely diagnosis of infected necrosis using clinical, laboratory and radiological parameters is of utmost importance. Though initial conservative management with antibiotics and organ support system is effective in some patients, a majority of patients still requires drainage of the collection by various modalities. Mode of drainage of infected pancreatic necrosis depends on various factors such as the clinical status of the patient, location and characteristics of collection and availability of the expertise and includes endoscopic, percutaneous and minimally invasive or open surgical approaches. Endoscopic drainage has proved to be a game changer in the management of infected pancreatic necrosis in the last decade with rapid evolution in procedure techniques, development of novel metal stent and dedicated necrosectomy devices for better clinical outcome. Despite widespread adoption of endoscopic transluminal drainage of pancreatic necrosis with excellent clinical outcomes, peripheral collections are still not amenable for endoscopic drainage and in such scenario, the role of percutaneous catheter drainage or minimally invasive surgical necrosectomy cannot be understated. In a nutshell, the management of patients with infected pancreatic necrosis involves a multi-disciplinary team including a gastroenterologist, an intensivist, an interventional radiologist and a surgeon for optimum clinical outcomes.
The introduction of motorized spiral enteroscopy (mSE) into clinical practice holds diagnostic and therapeutic potential for small-bowel investigations. This systematic review and meta-analysis aims ...to evaluate the performance of this modality in diagnosing and treating small-bowel lesions.
A systematic search of MEDLINE, Cochrane, and ClinicalTrials.gov databases were performed through September 2022. The primary outcome was diagnostic success, defined as the identification of a lesion relative to the indication. Secondary outcomes were successful therapeutic manipulation, total enteroscopy rate (examination from the duodenojejunal flexion to the cecum), technical success (passage from the ligament of Treitz or ileocecal valve for anterograde and retrograde approach, respectively), and adverse event rates. We performed meta-analyses using a random-effects model, and the results are reported as percentages with 95% confidence intervals (CIs).
From 2016 to 2022, 9 studies (959 patients; 42% women; mean age >45 years; 474 patients 49.4% investigated for mid-GI bleeding/anemia) were considered eligible and included in analysis. The diagnostic success rate of mSE was 78% (95% CI, 72-84; I2 = 78.3%). Considering secondary outcomes, total enteroscopy was attempted in 460 cases and completed with a rate of 51% (95% CI, 30-72; I2 = 96.2%), whereas therapeutic interventions were successful in 98% of cases (95% CI, 96-100; I2 = 79.8%) where attempted. Technical success rates were 96% (95% CI, 94-97; I2 = 1.5%) for anterograde and 97% (95% CI, 94-100; I2 = 38.6%) for retrograde approaches, respectively. Finally, the incidence of adverse events was 17% (95% CI, 13-21; I2 = 65.1%), albeit most were minor adverse events (16%; 95% CI, 11-20; I2 = 67.2%) versus major adverse events (1%; 95% CI, 0-1; I2 = 0%).
mSE provides high rates of diagnostic and therapeutic success with a low prevalence of severe adverse events.
Main Recommendations
The European Society of Gastrointestinal Endoscopy (ESGE) has recognized the need to formalize and enhance training in endoscopic retrograde cholangiopancreatography (ERCP) and ...endoscopic ultrasound (EUS). This manuscript represents the outcome of a formal Delphi process resulting in an official Position Statement of the ESGE and provides a framework to develop and maintain skills in ERCP and EUS. This curriculum is set out in terms of the prerequisites prior to training; recommended steps of training to a defined syllabus; the quality of training; and how competence should be defined and evidenced before independent practice.
1
Trainees should be competent in gastroscopy prior to commencing training. Formal training courses and the use of simulation in training are recommended.
2
Trainees should keep a contemporaneous logbook of their procedures, including key performance indicators and the degree of independence. Structured formative assessment is encouraged to enhance feedback. There should be a summative assessment process prior to commencing independent practice to ensure there is robust evidence of competence. This evidence should include a review of a trainee’s procedure volume and current performance measures. A period of mentoring is strongly recommended in the early stages of independent practice.
3
Specifically for ERCP, all trainees should be competent up to Schutz level 2 complexity (management of distal biliary strictures and stones > 10 mm), with advanced ERCP requiring a further period of training. Prior to independent practice, ESGE recommends that a trainee can evidence a procedure volume of > 300 cases, a native papilla cannulation rate of ≥ 80 % (90 % after a period of mentored independent practice), complete stones clearance of ≥ 85 %, and successful stenting of distal biliary strictures of ≥ 90 % (90 % and 95 % respectively after a mentored period of independent practice).
4
The progression of EUS training and competence attainment should start from diagnostic EUS and then proceed to basic therapeutic EUS, and finally to advanced therapeutic EUS. Before independent practice, ESGE recommends that a trainee can evidence a procedure volume of > 250 cases (75 fine-needle aspirations/biopsies FNA/FNBs), satisfactory visualization of key anatomical landmarks in ≥ 90 % of cases, and an FNA/FNB accuracy rate of ≥ 85 %.
ESGE recognizes the often inadequate quality of the evidence and the need for further studies pertaining to training in advanced endoscopy, particularly in relation to therapeutic EUS.
Introduction
We evaluated the efficacy of pharmacologic treatments for patients with overt or occult bleeding due to gastrointestinal angiodysplasias (GIADs).
Methods
A systematic computer-aided ...literature search across
Medline, Cochrane, Scopus
and
Embase
databases was performed. Studies evaluating pharmacologic treatments for patients presenting with GIADs-related overt or occult bleeding were included. Post-treatment rebleeding was the primary outcome. Need for red blood cells (RBC) transfusion, post-treatment hemoglobin levels and adverse events rate comprised secondary outcomes. Results are presented as odds ratio (OR), mean difference (MD) or pooled rates (%) with 95% confidence intervals (95%CI).
Results
Four types of pharmacologic treatment were identified (25 studies): somatostatin analogs, hormonal therapy, thalidomide and angiogenesis inhibitors. Pharmacologic treatment of any kind led to significantly reduced bleeding episodes OR (95% CI), 0.08 (0.04–0.18). No pharmacologic treatment was superior to others (
P
= 0.46). Overall, pooled rebleeding rate post-treatment was 34% (26–43%). Similarly, significantly fewer patients required RBC transfusion during the post-treatment period 0.03 (0.03–0.07), with no differences among various treatments (
P
= 0.83), yielding an overall pooled transfusion rate of 33% (19–46%). Administration of pharmacological treatment led to significant improvement in terms of hemoglobin levels MD (95% CI), 3.21 g/dL (2.42–3.99). The pooled rate of adverse events was 32% (22–42%).
Conclusion
In patients with GIADs administration of any pharmacologic treatment significantly decreases rebleeding episodes and transfusions leading to higher hemoglobin values. One-third of them experience at least one adverse event related to the treatment.
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