European Journal of Gastroenterology & Hepatology, 2016
Background and study aims Endoscopic ultrasonography (EUS) and EUS-guided fine-needle aspiration ... more Background and study aims Endoscopic ultrasonography (EUS) and EUS-guided fine-needle aspiration (EUS-FNA) are wellrecognized techniques for the study of pancreatic cystic lesions (PCLs). However, little evidence exists on their impact on clinical care. The aim of this study is to determine how often EUS and EUS-FNA alter the diagnosis and management of patients with PCLs. Patients and methods Eight physicians expert in pancreatic diseases were asked to report their diagnoses and management recommendations for 49 different PCLs. Clinical information was sequentially disclosed in a stepwise mannerprogressively from clinical data plus computed tomography or MRI (level 1), to EUS (level 2) and EUS-FNA results including cytology, carcinoembryonic antigen, and amylase levels (level 3). Results EUS led to a change in the diagnosis and management in 30% [95% confidence interval (CI): 26-35%] and 19% (95% CI: 16-23%) of cases, respectively, usually to a more intensive approach (14%; 95% CI: 11-18%). EUS-FNA altered the diagnosis and management in an additional 39% (95% CI: 34-44%) and 21% (95% CI: 17-25%) of the evaluations, respectively. EUS-FNA also increased the consensus in the diagnosis among the specialists that ranged from fair with computed tomography/ MRI (κ-index = 0.32) to substantial with EUS-FNA (κ-index = 0.43). Conclusion EUS and EUS-FNA impact the diagnosis and management of patients with PCLs; therefore, both are necessary in the workup of these patients. EUS-FNA markedly improves the agreement between physicians in terms of diagnosis, but not management. This study highlights the need for more research and standardization in the field.
Initial reports suggest that fully covered self expandable metal stents (FCSEMS) may be better su... more Initial reports suggest that fully covered self expandable metal stents (FCSEMS) may be better suited for drainage of dense pancreatic fluid collections (PFCs) like walled-off pancreatic necrosis (WOPN). The primary aim was to analyze the effectiveness and safety of FCSEMS for drainage of different types of PFCs in a large cohort. The secondary aim was to investigate which type of FCSEMS is superior. This was a retrospective, noncomparative review of a nationwide database involving all hospitals of Spain performing EUS-guided PFC drainage. From April 2008 to August 2013, all patients undergoing drainage of a PFC with an FCSEMS were included in a database. Main outcome measurements were technical success, short (2 weeks) and long-term (6 months) effectiveness, adverse events (AEs), and need for surgery. The study included 211 patients (pseudocyst/WOPN 53/47%). FCSEMSs used were straight biliary (66%) or lumen-apposing metal stent (LAMS, 34%). Technical success was achieved in 97% of ...
Endoscopic ultrasound (EUS) and endoscopic retrograde cholangiopancreatography (ERCP) have much i... more Endoscopic ultrasound (EUS) and endoscopic retrograde cholangiopancreatography (ERCP) have much in common, including their main indications (biliopancreatic disorders), powerful therapeutic capacities and a steep learning curve. Over the years they have evolved from novel diagnostic procedures to interventional therapeutic techniques, but along different paths (different scopes or devices and endoscopists specializing exclusively in one or the other technique). However, EUS has gradually developed into a therapeutic technique that requires skills in the use of ERCP devices and stents, leading some ERCP specialists to explore the therapeutic potential of EUS. The corresponding literature, which has grown exponentially, includes recent experiments on combining the two techniques, which have gradually come to be used in routine care in a number of centers, with positive technical, clinical and financial outcomes. We review EUS and ERCP as individual or combined procedures for managing biliopancreatic disorders.
Data Revues 00165107 V75i4ss S0016510712012989, Apr 1, 2012
then asked to score the same forty pCLE video clips which were randomized and renumbered. The cli... more then asked to score the same forty pCLE video clips which were randomized and renumbered. The clips were graded as malignant or benign based on Miami Classification criteria. K statistics were interpreted based on the convention by Landis and Koch: poor agreement 0; slight agreement: 0 to 0.20; fair agreement: 0.21 to 0.40; moderate agreement: 0.41 to 0.60; substantial agreement: 0.61 to 0.80; almost perfect agreement: 0.81 to 1.0. Results: Four nonexpert confocal observers were included in the study ( 20 confocal cases). One observer was considered expert ( 20 cases). Pre-training session interobserver agreement for all observers was ‘Fair’ (k: 0.31, pvalue: .0001). The overall diagnostic accuracy for the pre-training session scoring was 72%, with 55% being the lowest and 80% being the highest (Table 1). Post training session interobserver agreement for all observers was ‘Substantial’(k: 0.74, pvalue: .0001). The overall diagnostic accuracy for the post-training session scoring was 89%, with 80% being the lowest and 95% being the highest. Using a paired t-test, we observed an increase of 17% (95% CI 7.6 26.4) in the post training session diagnostic accuracy (t 5.01, df 4, P-value 0.007). Conclusion: The overall interobserver agreement as well as diagnostic accuracy improved after the observers were subjected to a training session with a specific sequence set. Given the significant increase in accuracy, users of pCLE should participate in such training programs in order to maximize diagnostic value of pCLE exam.
The diagnosis of gastrointestinal stromal tumors (GISTs) has important prognostic and therapeutic... more The diagnosis of gastrointestinal stromal tumors (GISTs) has important prognostic and therapeutic implications. The specific diagnosis of GIST has to be based on immunocytochemistry. This study aimed to prospectively compare in a crossover manner the accuracy of endoscopic ultrasound (EUS)-guided fine-needle aspiration (EUS-FNA) and EUS-guided trucut biopsy (EUS-TCB) in the specific diagnosis of gastric GISTs. We hypothesized that EUS-TCB is superior to EUS-FNA in this respect. Forty patients with gastric subepithelial tumors suspected on the basis of EUS of being a GIST underwent both EUS-FNA and EUS-TCB. The sequence in which the techniques were employed was randomly assigned to avoid bias. Forty tumors were sampled (mean number of passes: 2.1 +/- 0.9 with EUS-TNB and 1.9 +/- 0.8 with EUS-FNA; P = not significant, NS). Final diagnoses were: GIST (n = 27), carcinoma (n = 2), leiomyoma (n = 1), schwannoma (n = 1), and no diagnosis possible (n = 9). Device failure occurred in 6 patie...
pancreatic cysts and solid lesions are routinely examined by EUS-guided fine-needle aspiration (E... more pancreatic cysts and solid lesions are routinely examined by EUS-guided fine-needle aspiration (EUS-FNA). The aim of this study was to compare the incidence of adverse events (AEs) of this procedure using the lexicon recommended by the ASGE. This is a prospective and comparative study of patients that underwent EUS-FNA with a 22G needle. In the pancreatic cyst group (Group I), complete fluid evacuation in a single needle pass was attempted and ciprofloxacin was given during the procedure and 3 days after. In the solid lesion group (Group II) the number of passes was determined by the on-site evaluation of the sample. AEs were defined and graded according to the lexicon recommended by the American Society for Gastrointestinal Endoscopy (ASGE). Patients were followed for 48 hours, 1 week, and 1 month after the procedure. a total of 146 patients were included, 73 in Group I and 73 in Group II. Potential factors influencing the incidence of AE (ie, access route for FNA), were similar in both groups. AE occurred in 5 of 146 patients (3.4%; 95% CI, 1.3%-8%); 4 in Group I (5.5%; 95% CI, 1.7%-13.7%), and 1 in Group II (1.4%; 95% CI,-0.5%-8.1%) (P=0.03). Severity was mild in 1 of 5 (20%) and moderate in 3 of 5 (60%). One patient with a solid mass in the head of the pancreas had a duodenal perforation after EUS with a fatal outcome after surgery. All other AEs occurred in the first 48 hours and resolved with medical therapy. There were 3 incidents of transient hypoxia and self-limited abdominal pain in 1 and 2 patients, respectively. No patients were lost for follow-up. EUS-FNA of pancreatic cysts has an AE rate similar to that of solid pancreatic masses, which is small enough to consider this procedure a safe and effective method for managing patients with both type of lesions. AEs occurred early after EUS-FNA and should be closely followed during the first two days after the procedure.
1.92-8.22; p < 0.001; PPV = 0.75), whereas high values of SOFA and mSOFA did not provide any sign... more 1.92-8.22; p < 0.001; PPV = 0.75), whereas high values of SOFA and mSOFA did not provide any significant prediction. Conclusions: In critically ill cirrhotic patients, the CLIF-SOFA is able to predict both in-ICU mortality and 6-month mortality in ICU survivors, conversely to the SOFA and mSOFA. High values of CLIF-SOFA better predict in-ICU mortality than high values of SOFA or increase in SOFA on day three, and better predict 6-month mortality in ICU survivors than the MELD score. The CLIF-SOFA thus appears as the prognostic score of choice for the critically ill cirrhotic patients.
The purpose of this study was to identify optimal target propofol and remifentanil concentrations... more The purpose of this study was to identify optimal target propofol and remifentanil concentrations to avoid a gag reflex in response to insertion of an upper gastrointestinal endoscope. Patients presenting for endoscopy received target-controlled infusions (TCI) of both propofol and remifentanil for sedation-analgesia. Patients were randomized to 4 groups of fixed target effect-site concentrations: remifentanil 1 ng•mL (REMI 1) or 2 ng•mL (REMI 2) and propofol 2 μg•mL (PROP 2) or 3 μg•mL (PROP 3). For each group, the other drug (propofol for the REMI groups and vice versa) was increased or decreased using the "up-down" method based on the presence or absence of…
Background: Patients with suspected pancreatic cancer are increasingly referred for EUS for stagi... more Background: Patients with suspected pancreatic cancer are increasingly referred for EUS for staging and tissue diagnosis. Although most referring physicians are highly suspicious of an underlying diagnosis of pancreatic cancer, patients are often unaware of this likelihood. Due to poor communication in such cases, the endosonographer bears the unenviable burden of informing patients of their diagnosis. Aim: Evaluate the determinants of poor communication between referring physicians and patients with suspected pancreatic cancer. Methods: This is a cross-sectional study of outpatients with high clinical suspicion for pancreatic cancer undergoing EUS at a tertiary referral center over a 6-month period. Prior to undergoing EUS, all patients were administered a standard questionnaire that elicited their level of understanding and communication with their referring doctor on their clinical presentation. In our practice, referring doctors request EUS by completion of datasheet that queries specifically on suspected diagnosis. Patient responses were compared with diagnosis on their referral datasheet and patients were grouped as being aware or unaware (indicating poor communication) of their underlying illness. Results: Of the 89 study patients, 25 (28%) were unaware of the nature of their underlying illness. Mean age of patients was 64.7 years, 52% were men and 28% were African-Americans. Clinical presentation included jaundice (82%), weight loss (79%), abdominal pain (67%), and abnormal finding on CT of the abdomen (82%). On an average, patients had 2 visits with their referring doctors prior to undergoing EUS. Majority of the cases were referred by gastroenterologists (67%) followed by surgeons (18%). Pancreatic cancer was diagnosed in 86% at EUSguided FNA. In multivariable analysis, African-Americans (Adjusted OR Z 4.84; pZ0.017) and those with less than high-school education (Adjusted OR Z 13.87; pZ0.001) were significantly more likely to be unaware of the nature of their underlying illness when adjusted for age, gender, and type of referring doctor. Conclusions: This study demonstrates racial disparity in communication between referring physicians and patients with high clinical suspicion for pancreatic cancer. African-Americans are more likely to be unaware of the nature of their underlying illness and the diagnosis is often conveyed by the endosonographer. Underlying reasons for this disparity need to be identified and addressed. Background: Multimodal therapy is the standard of care for NSCLC in stages IIIa and some IIIb. Survival of patients with residual lymph node (LN) disease after neoadjuvant therapy plus surgery does not differ from that of patients not submitted to surgery. Therefore, it is crucial to identify the patients with complete LN response before surgery. Few data in the literature suggest that EUS-FNA could be useful for mediastinal restaging in these group of patients.
European Journal of Gastroenterology & Hepatology, 2016
Background and study aims Endoscopic ultrasonography (EUS) and EUS-guided fine-needle aspiration ... more Background and study aims Endoscopic ultrasonography (EUS) and EUS-guided fine-needle aspiration (EUS-FNA) are wellrecognized techniques for the study of pancreatic cystic lesions (PCLs). However, little evidence exists on their impact on clinical care. The aim of this study is to determine how often EUS and EUS-FNA alter the diagnosis and management of patients with PCLs. Patients and methods Eight physicians expert in pancreatic diseases were asked to report their diagnoses and management recommendations for 49 different PCLs. Clinical information was sequentially disclosed in a stepwise mannerprogressively from clinical data plus computed tomography or MRI (level 1), to EUS (level 2) and EUS-FNA results including cytology, carcinoembryonic antigen, and amylase levels (level 3). Results EUS led to a change in the diagnosis and management in 30% [95% confidence interval (CI): 26-35%] and 19% (95% CI: 16-23%) of cases, respectively, usually to a more intensive approach (14%; 95% CI: 11-18%). EUS-FNA altered the diagnosis and management in an additional 39% (95% CI: 34-44%) and 21% (95% CI: 17-25%) of the evaluations, respectively. EUS-FNA also increased the consensus in the diagnosis among the specialists that ranged from fair with computed tomography/ MRI (κ-index = 0.32) to substantial with EUS-FNA (κ-index = 0.43). Conclusion EUS and EUS-FNA impact the diagnosis and management of patients with PCLs; therefore, both are necessary in the workup of these patients. EUS-FNA markedly improves the agreement between physicians in terms of diagnosis, but not management. This study highlights the need for more research and standardization in the field.
Initial reports suggest that fully covered self expandable metal stents (FCSEMS) may be better su... more Initial reports suggest that fully covered self expandable metal stents (FCSEMS) may be better suited for drainage of dense pancreatic fluid collections (PFCs) like walled-off pancreatic necrosis (WOPN). The primary aim was to analyze the effectiveness and safety of FCSEMS for drainage of different types of PFCs in a large cohort. The secondary aim was to investigate which type of FCSEMS is superior. This was a retrospective, noncomparative review of a nationwide database involving all hospitals of Spain performing EUS-guided PFC drainage. From April 2008 to August 2013, all patients undergoing drainage of a PFC with an FCSEMS were included in a database. Main outcome measurements were technical success, short (2 weeks) and long-term (6 months) effectiveness, adverse events (AEs), and need for surgery. The study included 211 patients (pseudocyst/WOPN 53/47%). FCSEMSs used were straight biliary (66%) or lumen-apposing metal stent (LAMS, 34%). Technical success was achieved in 97% of ...
Endoscopic ultrasound (EUS) and endoscopic retrograde cholangiopancreatography (ERCP) have much i... more Endoscopic ultrasound (EUS) and endoscopic retrograde cholangiopancreatography (ERCP) have much in common, including their main indications (biliopancreatic disorders), powerful therapeutic capacities and a steep learning curve. Over the years they have evolved from novel diagnostic procedures to interventional therapeutic techniques, but along different paths (different scopes or devices and endoscopists specializing exclusively in one or the other technique). However, EUS has gradually developed into a therapeutic technique that requires skills in the use of ERCP devices and stents, leading some ERCP specialists to explore the therapeutic potential of EUS. The corresponding literature, which has grown exponentially, includes recent experiments on combining the two techniques, which have gradually come to be used in routine care in a number of centers, with positive technical, clinical and financial outcomes. We review EUS and ERCP as individual or combined procedures for managing biliopancreatic disorders.
Data Revues 00165107 V75i4ss S0016510712012989, Apr 1, 2012
then asked to score the same forty pCLE video clips which were randomized and renumbered. The cli... more then asked to score the same forty pCLE video clips which were randomized and renumbered. The clips were graded as malignant or benign based on Miami Classification criteria. K statistics were interpreted based on the convention by Landis and Koch: poor agreement 0; slight agreement: 0 to 0.20; fair agreement: 0.21 to 0.40; moderate agreement: 0.41 to 0.60; substantial agreement: 0.61 to 0.80; almost perfect agreement: 0.81 to 1.0. Results: Four nonexpert confocal observers were included in the study ( 20 confocal cases). One observer was considered expert ( 20 cases). Pre-training session interobserver agreement for all observers was ‘Fair’ (k: 0.31, pvalue: .0001). The overall diagnostic accuracy for the pre-training session scoring was 72%, with 55% being the lowest and 80% being the highest (Table 1). Post training session interobserver agreement for all observers was ‘Substantial’(k: 0.74, pvalue: .0001). The overall diagnostic accuracy for the post-training session scoring was 89%, with 80% being the lowest and 95% being the highest. Using a paired t-test, we observed an increase of 17% (95% CI 7.6 26.4) in the post training session diagnostic accuracy (t 5.01, df 4, P-value 0.007). Conclusion: The overall interobserver agreement as well as diagnostic accuracy improved after the observers were subjected to a training session with a specific sequence set. Given the significant increase in accuracy, users of pCLE should participate in such training programs in order to maximize diagnostic value of pCLE exam.
The diagnosis of gastrointestinal stromal tumors (GISTs) has important prognostic and therapeutic... more The diagnosis of gastrointestinal stromal tumors (GISTs) has important prognostic and therapeutic implications. The specific diagnosis of GIST has to be based on immunocytochemistry. This study aimed to prospectively compare in a crossover manner the accuracy of endoscopic ultrasound (EUS)-guided fine-needle aspiration (EUS-FNA) and EUS-guided trucut biopsy (EUS-TCB) in the specific diagnosis of gastric GISTs. We hypothesized that EUS-TCB is superior to EUS-FNA in this respect. Forty patients with gastric subepithelial tumors suspected on the basis of EUS of being a GIST underwent both EUS-FNA and EUS-TCB. The sequence in which the techniques were employed was randomly assigned to avoid bias. Forty tumors were sampled (mean number of passes: 2.1 +/- 0.9 with EUS-TNB and 1.9 +/- 0.8 with EUS-FNA; P = not significant, NS). Final diagnoses were: GIST (n = 27), carcinoma (n = 2), leiomyoma (n = 1), schwannoma (n = 1), and no diagnosis possible (n = 9). Device failure occurred in 6 patie...
pancreatic cysts and solid lesions are routinely examined by EUS-guided fine-needle aspiration (E... more pancreatic cysts and solid lesions are routinely examined by EUS-guided fine-needle aspiration (EUS-FNA). The aim of this study was to compare the incidence of adverse events (AEs) of this procedure using the lexicon recommended by the ASGE. This is a prospective and comparative study of patients that underwent EUS-FNA with a 22G needle. In the pancreatic cyst group (Group I), complete fluid evacuation in a single needle pass was attempted and ciprofloxacin was given during the procedure and 3 days after. In the solid lesion group (Group II) the number of passes was determined by the on-site evaluation of the sample. AEs were defined and graded according to the lexicon recommended by the American Society for Gastrointestinal Endoscopy (ASGE). Patients were followed for 48 hours, 1 week, and 1 month after the procedure. a total of 146 patients were included, 73 in Group I and 73 in Group II. Potential factors influencing the incidence of AE (ie, access route for FNA), were similar in both groups. AE occurred in 5 of 146 patients (3.4%; 95% CI, 1.3%-8%); 4 in Group I (5.5%; 95% CI, 1.7%-13.7%), and 1 in Group II (1.4%; 95% CI,-0.5%-8.1%) (P=0.03). Severity was mild in 1 of 5 (20%) and moderate in 3 of 5 (60%). One patient with a solid mass in the head of the pancreas had a duodenal perforation after EUS with a fatal outcome after surgery. All other AEs occurred in the first 48 hours and resolved with medical therapy. There were 3 incidents of transient hypoxia and self-limited abdominal pain in 1 and 2 patients, respectively. No patients were lost for follow-up. EUS-FNA of pancreatic cysts has an AE rate similar to that of solid pancreatic masses, which is small enough to consider this procedure a safe and effective method for managing patients with both type of lesions. AEs occurred early after EUS-FNA and should be closely followed during the first two days after the procedure.
1.92-8.22; p < 0.001; PPV = 0.75), whereas high values of SOFA and mSOFA did not provide any sign... more 1.92-8.22; p < 0.001; PPV = 0.75), whereas high values of SOFA and mSOFA did not provide any significant prediction. Conclusions: In critically ill cirrhotic patients, the CLIF-SOFA is able to predict both in-ICU mortality and 6-month mortality in ICU survivors, conversely to the SOFA and mSOFA. High values of CLIF-SOFA better predict in-ICU mortality than high values of SOFA or increase in SOFA on day three, and better predict 6-month mortality in ICU survivors than the MELD score. The CLIF-SOFA thus appears as the prognostic score of choice for the critically ill cirrhotic patients.
The purpose of this study was to identify optimal target propofol and remifentanil concentrations... more The purpose of this study was to identify optimal target propofol and remifentanil concentrations to avoid a gag reflex in response to insertion of an upper gastrointestinal endoscope. Patients presenting for endoscopy received target-controlled infusions (TCI) of both propofol and remifentanil for sedation-analgesia. Patients were randomized to 4 groups of fixed target effect-site concentrations: remifentanil 1 ng•mL (REMI 1) or 2 ng•mL (REMI 2) and propofol 2 μg•mL (PROP 2) or 3 μg•mL (PROP 3). For each group, the other drug (propofol for the REMI groups and vice versa) was increased or decreased using the "up-down" method based on the presence or absence of…
Background: Patients with suspected pancreatic cancer are increasingly referred for EUS for stagi... more Background: Patients with suspected pancreatic cancer are increasingly referred for EUS for staging and tissue diagnosis. Although most referring physicians are highly suspicious of an underlying diagnosis of pancreatic cancer, patients are often unaware of this likelihood. Due to poor communication in such cases, the endosonographer bears the unenviable burden of informing patients of their diagnosis. Aim: Evaluate the determinants of poor communication between referring physicians and patients with suspected pancreatic cancer. Methods: This is a cross-sectional study of outpatients with high clinical suspicion for pancreatic cancer undergoing EUS at a tertiary referral center over a 6-month period. Prior to undergoing EUS, all patients were administered a standard questionnaire that elicited their level of understanding and communication with their referring doctor on their clinical presentation. In our practice, referring doctors request EUS by completion of datasheet that queries specifically on suspected diagnosis. Patient responses were compared with diagnosis on their referral datasheet and patients were grouped as being aware or unaware (indicating poor communication) of their underlying illness. Results: Of the 89 study patients, 25 (28%) were unaware of the nature of their underlying illness. Mean age of patients was 64.7 years, 52% were men and 28% were African-Americans. Clinical presentation included jaundice (82%), weight loss (79%), abdominal pain (67%), and abnormal finding on CT of the abdomen (82%). On an average, patients had 2 visits with their referring doctors prior to undergoing EUS. Majority of the cases were referred by gastroenterologists (67%) followed by surgeons (18%). Pancreatic cancer was diagnosed in 86% at EUSguided FNA. In multivariable analysis, African-Americans (Adjusted OR Z 4.84; pZ0.017) and those with less than high-school education (Adjusted OR Z 13.87; pZ0.001) were significantly more likely to be unaware of the nature of their underlying illness when adjusted for age, gender, and type of referring doctor. Conclusions: This study demonstrates racial disparity in communication between referring physicians and patients with high clinical suspicion for pancreatic cancer. African-Americans are more likely to be unaware of the nature of their underlying illness and the diagnosis is often conveyed by the endosonographer. Underlying reasons for this disparity need to be identified and addressed. Background: Multimodal therapy is the standard of care for NSCLC in stages IIIa and some IIIb. Survival of patients with residual lymph node (LN) disease after neoadjuvant therapy plus surgery does not differ from that of patients not submitted to surgery. Therefore, it is crucial to identify the patients with complete LN response before surgery. Few data in the literature suggest that EUS-FNA could be useful for mediastinal restaging in these group of patients.
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Papers by Oriol Sendino Garcia