BACKGROUND Splanchnic vein thrombosis(SVT)is a major complication of moderate and severe acute pancreatitis.There is no consensus on whether therapeutic anticoagulation should be started in patients with acute pancrea...BACKGROUND Splanchnic vein thrombosis(SVT)is a major complication of moderate and severe acute pancreatitis.There is no consensus on whether therapeutic anticoagulation should be started in patients with acute pancreatitis and SVT.AIM To gain insight into current opinions and clinical decision making of pancreatologists regarding SVT in acute pancreatitis.METHODS A total of 139 pancreatologists of the Dutch Pancreatitis Study Group and Dutch Pancreatic Cancer Group were approached to complete an online survey and case vignette survey.The threshold to assume group agreement was set at 75%.RESULTS The response rate was 67%(n=93).Seventy-one pancreatologists(77%)regularly prescribed therapeutic anticoagulation in case of SVT,and 12 pancreatologists(13%)for narrowing of splanchnic vein lumen.The most common reason to treat SVT was to avoid complications(87%).Acute thrombosis was the most important factor to prescribe therapeutic anticoagulation(90%).Portal vein thrombosis was chosen as the most preferred location to initiate therapeutic anticoagulation(76%)and splenic vein thrombosis as the least preferred location(86%).The preferred initial agent was low molecular weight heparin(LMWH;87%).In the case vignettes,therapeutic anticoagulation was prescribed for acute portal vein thrombosis,with or without suspected infected necrosis(82%and 90%),and thrombus progression(88%).Agreement was lacking regarding the selection and duration of long-term anticoagulation,the indication for thrombophilia testing and upper endoscopy,and about whether risk of bleeding is a major barrier for therapeutic anticoagulation.CONCLUSION In this national survey,the pancreatologists seemed to agree on the use of therapeutic anticoagulation,using LMWH in the acute phase,for acute portal thrombosis and in the case of thrombus progression,irrespective of the presence of infected necrosis.展开更多
AIM:To assess the characteristics and quality of endoscopic ultrasonography-guided fine needle aspiration(EUS-FNA) in a large panel of endosonographers.METHODS:A survey was conducted during the 13th annual live course...AIM:To assess the characteristics and quality of endoscopic ultrasonography-guided fine needle aspiration(EUS-FNA) in a large panel of endosonographers.METHODS:A survey was conducted during the 13th annual live course of endoscopic ultrasonography(EUS) held in Amsterdam,Netherlands.A 2-page questionnaire was developed for the study.Content validity of the questionnaire was determined based on input by experts in the field and a review of the relevant literature.It contained 30 questions that pertained to demographics and the current practice for EUS-FNA of responders,including sampling technique,sample processing,cytopathological diagnosis and sensitivity of EUS-FNA for the diagnosis of solid mass lesions.One hundred and sixty-one endosonographers who attended the course were asked to answer the survey.This allowed assessing the current practice of EUS-FNA as well as the self-reported sensitivity of EUS-FNA for the diagnosis of solid mass lesions.We also examined which factors were associated with a self-reported sensitivity of EUS-FNA for the diagnosis of solid mass lesions > 80%.RESULTS:Completed surveys were collected from 92(57.1%) of 161 endosonographers who attended the conference.The endosonographers had been practicing endoscopy and EUS for 12.5 ± 7.8 years and 4.8 ± 4.1 years,respectively;one third of them worked in a hospital with an annual caseload > 100 EUS-FNA.Endoscopy practices were located in 29 countries,including 13 countries in Western Europe that totaled 75.3% of the responses.Only one third of endosonographers reported a sensitivity for the diagnosis of solid mass lesions > 80%(interquartile range of sensitivities,25.0%-75.0%).Factors independently associated with a sensitivity > 80% were(1) > 7 needle passes for pancreatic lesions or rapid on-site cytopathological evaluation(ROSE)(P < 0.0001),(2) a high annual hospital caseload(P = 0.024) and(3) routine isolation of microcores from EUS-FNA samples(P = 0.042).ROSE was routinely available to 27.9% of respondents.For lymph nodes and pancreatic masses,a maximum of three needle passes was performed by approximately two thirds of those who did not have ROSE.Microcores were routinely harvested from EUS-FNA samples by approximately one third(37.2%) of survey respondents.CONCLUSION:EUS-FNA sensitivity was considerably lower than reported in the literature.Low EUS-FNA sensitivity was associated with unavailability of ROSE,few needle passes,absence of microcore isolation and low hospital caseload.展开更多
AIM: To analyze the outcomes of self-expandable stent placement for benign esophageal strictures and benign esophageal leaks in the literature.METHODS: The Pub Med, Embase and Cochrane databases were searched for rele...AIM: To analyze the outcomes of self-expandable stent placement for benign esophageal strictures and benign esophageal leaks in the literature.METHODS: The Pub Med, Embase and Cochrane databases were searched for relevant articles published between January 2000 and July 2014. Eight prospective studies were identified that analyzed the outcomes of stent placement for refractory benign esophageal strictures. The outcomes of stent placement for benign esophageal leaks, perforations and fistulae were extracted from 20 retrospective studies that were published after the inclusion period of a recent systematic review. Data were pooled and analyzed using descriptive statistics.RESULTS: Fully covered self-expandable metal stents(FC SEMS)(n = 85), biodegradable(BD) stents(n = 77) and self-expandable plastic stents(SEPS)(n = 70) were inserted in 232 patients with refractory benign esophageal strictures. The overall clinical success rate was 24.2% and according to stent type 14.1% for FC SEMS, 32.9% for BD stents and 27.1% for SEPS. Stent migration occurred in 24.6% of cases. The overall complication rate was 31.0%, including major(17.7%) and minor(13.4%) complications. A total of 643 patients were treated with self-expandable stents mainly for postsurgical leaks(64.5%), iatrogenic perforations(19.6%), Boerhaave's syndrome(7.8%) and fistulae(3.7%). FC SEMS and partially covered SEMS were used in the majority of patients. Successful closure of the defect was achieved in 76.8% of patients and according to etiology in 81.4% for postsurgical leaks, 86.0% for perforations and 64.7% for fistulae. The pooled stent migration rate was 16.5%. Stent-related complications occurred in 13.4% of patients, including major(7.8%) and minor(5.5%) complications.CONCLUSION: The outcomes of stent placement for refractory benign esophageal strictures were poor. However, randomized trials are needed to put this into perspective. The evidence on successful stent placement for benign esophageal leaks, perforationsand fistulae is promising.展开更多
AIM: To provide an overview of the clinical outcomes of self-expandable metal stent(SEMS) placement for malignant gastric outlet obstruction(MGOO).METHODS: A systematic literature search was performed in Pub Med of th...AIM: To provide an overview of the clinical outcomes of self-expandable metal stent(SEMS) placement for malignant gastric outlet obstruction(MGOO).METHODS: A systematic literature search was performed in Pub Med of the literature published between January 2009 and March 2015. Only prospective studies that reported on the clinical success of stent placement for MGOO were included. The primary endpoint was clinical success,defined according to the definition used in the original article. Data were pooled and analyzed using descriptive statistics. Subgroup analyses were performed for partially covered SEMSs(PCSEMSs) and uncovered SEMSs(UCSEMSs) using Fisher's exact test.RESULTS: A total of 19 studies,including 1281 patients,were included in the final analysis. Gastric(42%) and pancreatic(37%) cancer were the main causes of MGOO. UCSEMSs were used in 76% of patients and PCSEMSs in 24%. The overall pooled technical success rate was 97.3% and the clinical success rate was 85.7%. Stent dysfunction occurred in 19.6% of patients,mainly caused by re-obstruction(12.6%) and stent migration(4.3%),and was comparable between PCSEMSs and UCSEMSs(21.2% vs 19.1%,respectively,P = 0.412). Re-obstruction was more common with UCSEMSs(14.9% vs 5.1%,P < 0.001) and stent migration was more frequent after PCSEMS placement(10.9% vs 2.2%,P < 0.001). The overall perforation rate was 1.2%. Bleeding was reported in 4.1% of patients,including major bleeding in 0.8%. The median stent patency ranged from 68 to 307 d in five studies. The median overall survival ranged from 49 to 183 d in 13 studies.CONCLUSION: The clinical outcomes in this large population showed that enteral stent placement was feasible,effective and safe. Therefore,stent placement is a valid treatment option for the palliation of MGOO.展开更多
The development of artificial intelligence(AI)has increased dramatically in the last 20 years,with clinical applications progressively being explored for most of the medical specialties.The field of gastroenterology a...The development of artificial intelligence(AI)has increased dramatically in the last 20 years,with clinical applications progressively being explored for most of the medical specialties.The field of gastroenterology and hepatology,substantially reliant on vast amounts of imaging studies,is not an exception.The clinical applications of AI systems in this field include the identification of premalignant or malignant lesions(e.g.,identification of dysplasia or esophageal adenocarcinoma in Barrett’s esophagus,pancreatic malignancies),detection of lesions(e.g.,polyp identification and classification,small-bowel bleeding lesion on capsule endoscopy,pancreatic cystic lesions),development of objective scoring systems for risk stratification,predicting disease prognosis or treatment response[e.g.,determining survival in patients post-resection of hepatocellular carcinoma),determining which patients with inflammatory bowel disease(IBD)will benefit from biologic therapy],or evaluation of metrics such as bowel preparation score or quality of endoscopic examination.The objective of this comprehensive review is to analyze the available AI-related studies pertaining to the entirety of the gastrointestinal tract,including the upper,middle and lower tracts;IBD;the hepatobiliary system;and the pancreas,discussing the findings and clinical applications,as well as outlining the current limitations and future directions in this field.展开更多
Acute pancreatitis(AP),chronic pancreatitis(CP)and pancreatic cancer are three distinct pancreatic diseases with different prognoses and treatment options.However,it may be difficult to differentiate between benign an...Acute pancreatitis(AP),chronic pancreatitis(CP)and pancreatic cancer are three distinct pancreatic diseases with different prognoses and treatment options.However,it may be difficult to differentiate between benign and malignant disease.AP may be a first symptom of pancreatic cancer,particularly in patients between the ages of 56 and 75 with presumed idiopathic AP who had a concomitant diagnosis of new-onset diabetes mellitus or patients who present with CP at diagnosis of AP.In these patients,additional imaging is warranted,preferably by endoscopic ultrasonography.CP may lead to pancreatic cancer through oncogenic mutations,mostly in patients with hereditary CP,and in patients in whom risk factors for pancreatic cancer(e.g.,nicotine and alcohol abuse)are also present.Patients with PRSS1-mediated CP and patients with a history of autosomal dominant hereditary CP without known genetic mutations may be considered for surveillance for pancreatic cancer.Pancreatic inflammation may mimic pancreatic cancer by appearing as a focal mass-forming lesion on imaging.Differentiation between the above mentioned benign and malignant disease may be facilitated by specific features like the duct-penetrating sign and the duct-to-parenchyma ratio.Research efforts are aimed towards developing a superior discriminant between pancreatitis and pancreatic cancer in the form of imaging modalities or biomarkers.This may aid clinicians in timely diagnosing pancreatic cancer in a potentially curable stage.展开更多
BACKGROUND Preoperative biliary drainage in patients with presumed resectable perihilar cholangiocarcinoma(PHC)is hypothesized to promote the occurrence of seeding metastases.Seeding metastases can occur at the surgic...BACKGROUND Preoperative biliary drainage in patients with presumed resectable perihilar cholangiocarcinoma(PHC)is hypothesized to promote the occurrence of seeding metastases.Seeding metastases can occur at the surgical scars or at the site of postoperative drains,and in case of percutaneous biliary drainage,at the catheter port-site.To prevent seeding metastases after resection,we routinely treated PHC patients with preoperative radiotherapy(RT)for over 25 years until January 2018.AIM To investigate the incidence of seeding metastases following resection of PHC.METHODS All patients who underwent resection for pathology proven PHC between January 2000 and March 2019 were included in this retrospective study.Between 2000-January 2018,patients received preoperative RT(3×3.5 Gray).RT was omitted in patients treated after January 2018.RESULTS A total of 171 patients underwent resection for PHC between January 2000 and March 2019.Of 171 patients undergoing resection,111 patients(65%)were treated with preoperative RT.Intraoperative bile cytology showed no difference in the presence of viable tumor cells in bile of patients undergoing preoperative RT or not.Overall,two patients(1.2%)with seeding metastases were identified,both in the laparotomy scar and both after preoperative RT(one patient with endoscopic and the other with percutaneous and endoscopic biliary drainage).CONCLUSION The incidence of seeding metastases in patients with resected PHC in our series was low(1.2%).This low incidence and the inability of providing evidence that preoperative low-dose RT prevents seeding metastases,has led us to discontinue preoperative RT in patients with resectable PHC in our center.展开更多
文摘BACKGROUND Splanchnic vein thrombosis(SVT)is a major complication of moderate and severe acute pancreatitis.There is no consensus on whether therapeutic anticoagulation should be started in patients with acute pancreatitis and SVT.AIM To gain insight into current opinions and clinical decision making of pancreatologists regarding SVT in acute pancreatitis.METHODS A total of 139 pancreatologists of the Dutch Pancreatitis Study Group and Dutch Pancreatic Cancer Group were approached to complete an online survey and case vignette survey.The threshold to assume group agreement was set at 75%.RESULTS The response rate was 67%(n=93).Seventy-one pancreatologists(77%)regularly prescribed therapeutic anticoagulation in case of SVT,and 12 pancreatologists(13%)for narrowing of splanchnic vein lumen.The most common reason to treat SVT was to avoid complications(87%).Acute thrombosis was the most important factor to prescribe therapeutic anticoagulation(90%).Portal vein thrombosis was chosen as the most preferred location to initiate therapeutic anticoagulation(76%)and splenic vein thrombosis as the least preferred location(86%).The preferred initial agent was low molecular weight heparin(LMWH;87%).In the case vignettes,therapeutic anticoagulation was prescribed for acute portal vein thrombosis,with or without suspected infected necrosis(82%and 90%),and thrombus progression(88%).Agreement was lacking regarding the selection and duration of long-term anticoagulation,the indication for thrombophilia testing and upper endoscopy,and about whether risk of bleeding is a major barrier for therapeutic anticoagulation.CONCLUSION In this national survey,the pancreatologists seemed to agree on the use of therapeutic anticoagulation,using LMWH in the acute phase,for acute portal thrombosis and in the case of thrombus progression,irrespective of the presence of infected necrosis.
文摘AIM:To assess the characteristics and quality of endoscopic ultrasonography-guided fine needle aspiration(EUS-FNA) in a large panel of endosonographers.METHODS:A survey was conducted during the 13th annual live course of endoscopic ultrasonography(EUS) held in Amsterdam,Netherlands.A 2-page questionnaire was developed for the study.Content validity of the questionnaire was determined based on input by experts in the field and a review of the relevant literature.It contained 30 questions that pertained to demographics and the current practice for EUS-FNA of responders,including sampling technique,sample processing,cytopathological diagnosis and sensitivity of EUS-FNA for the diagnosis of solid mass lesions.One hundred and sixty-one endosonographers who attended the course were asked to answer the survey.This allowed assessing the current practice of EUS-FNA as well as the self-reported sensitivity of EUS-FNA for the diagnosis of solid mass lesions.We also examined which factors were associated with a self-reported sensitivity of EUS-FNA for the diagnosis of solid mass lesions > 80%.RESULTS:Completed surveys were collected from 92(57.1%) of 161 endosonographers who attended the conference.The endosonographers had been practicing endoscopy and EUS for 12.5 ± 7.8 years and 4.8 ± 4.1 years,respectively;one third of them worked in a hospital with an annual caseload > 100 EUS-FNA.Endoscopy practices were located in 29 countries,including 13 countries in Western Europe that totaled 75.3% of the responses.Only one third of endosonographers reported a sensitivity for the diagnosis of solid mass lesions > 80%(interquartile range of sensitivities,25.0%-75.0%).Factors independently associated with a sensitivity > 80% were(1) > 7 needle passes for pancreatic lesions or rapid on-site cytopathological evaluation(ROSE)(P < 0.0001),(2) a high annual hospital caseload(P = 0.024) and(3) routine isolation of microcores from EUS-FNA samples(P = 0.042).ROSE was routinely available to 27.9% of respondents.For lymph nodes and pancreatic masses,a maximum of three needle passes was performed by approximately two thirds of those who did not have ROSE.Microcores were routinely harvested from EUS-FNA samples by approximately one third(37.2%) of survey respondents.CONCLUSION:EUS-FNA sensitivity was considerably lower than reported in the literature.Low EUS-FNA sensitivity was associated with unavailability of ROSE,few needle passes,absence of microcore isolation and low hospital caseload.
文摘AIM: To analyze the outcomes of self-expandable stent placement for benign esophageal strictures and benign esophageal leaks in the literature.METHODS: The Pub Med, Embase and Cochrane databases were searched for relevant articles published between January 2000 and July 2014. Eight prospective studies were identified that analyzed the outcomes of stent placement for refractory benign esophageal strictures. The outcomes of stent placement for benign esophageal leaks, perforations and fistulae were extracted from 20 retrospective studies that were published after the inclusion period of a recent systematic review. Data were pooled and analyzed using descriptive statistics.RESULTS: Fully covered self-expandable metal stents(FC SEMS)(n = 85), biodegradable(BD) stents(n = 77) and self-expandable plastic stents(SEPS)(n = 70) were inserted in 232 patients with refractory benign esophageal strictures. The overall clinical success rate was 24.2% and according to stent type 14.1% for FC SEMS, 32.9% for BD stents and 27.1% for SEPS. Stent migration occurred in 24.6% of cases. The overall complication rate was 31.0%, including major(17.7%) and minor(13.4%) complications. A total of 643 patients were treated with self-expandable stents mainly for postsurgical leaks(64.5%), iatrogenic perforations(19.6%), Boerhaave's syndrome(7.8%) and fistulae(3.7%). FC SEMS and partially covered SEMS were used in the majority of patients. Successful closure of the defect was achieved in 76.8% of patients and according to etiology in 81.4% for postsurgical leaks, 86.0% for perforations and 64.7% for fistulae. The pooled stent migration rate was 16.5%. Stent-related complications occurred in 13.4% of patients, including major(7.8%) and minor(5.5%) complications.CONCLUSION: The outcomes of stent placement for refractory benign esophageal strictures were poor. However, randomized trials are needed to put this into perspective. The evidence on successful stent placement for benign esophageal leaks, perforationsand fistulae is promising.
文摘AIM: To provide an overview of the clinical outcomes of self-expandable metal stent(SEMS) placement for malignant gastric outlet obstruction(MGOO).METHODS: A systematic literature search was performed in Pub Med of the literature published between January 2009 and March 2015. Only prospective studies that reported on the clinical success of stent placement for MGOO were included. The primary endpoint was clinical success,defined according to the definition used in the original article. Data were pooled and analyzed using descriptive statistics. Subgroup analyses were performed for partially covered SEMSs(PCSEMSs) and uncovered SEMSs(UCSEMSs) using Fisher's exact test.RESULTS: A total of 19 studies,including 1281 patients,were included in the final analysis. Gastric(42%) and pancreatic(37%) cancer were the main causes of MGOO. UCSEMSs were used in 76% of patients and PCSEMSs in 24%. The overall pooled technical success rate was 97.3% and the clinical success rate was 85.7%. Stent dysfunction occurred in 19.6% of patients,mainly caused by re-obstruction(12.6%) and stent migration(4.3%),and was comparable between PCSEMSs and UCSEMSs(21.2% vs 19.1%,respectively,P = 0.412). Re-obstruction was more common with UCSEMSs(14.9% vs 5.1%,P < 0.001) and stent migration was more frequent after PCSEMS placement(10.9% vs 2.2%,P < 0.001). The overall perforation rate was 1.2%. Bleeding was reported in 4.1% of patients,including major bleeding in 0.8%. The median stent patency ranged from 68 to 307 d in five studies. The median overall survival ranged from 49 to 183 d in 13 studies.CONCLUSION: The clinical outcomes in this large population showed that enteral stent placement was feasible,effective and safe. Therefore,stent placement is a valid treatment option for the palliation of MGOO.
文摘The development of artificial intelligence(AI)has increased dramatically in the last 20 years,with clinical applications progressively being explored for most of the medical specialties.The field of gastroenterology and hepatology,substantially reliant on vast amounts of imaging studies,is not an exception.The clinical applications of AI systems in this field include the identification of premalignant or malignant lesions(e.g.,identification of dysplasia or esophageal adenocarcinoma in Barrett’s esophagus,pancreatic malignancies),detection of lesions(e.g.,polyp identification and classification,small-bowel bleeding lesion on capsule endoscopy,pancreatic cystic lesions),development of objective scoring systems for risk stratification,predicting disease prognosis or treatment response[e.g.,determining survival in patients post-resection of hepatocellular carcinoma),determining which patients with inflammatory bowel disease(IBD)will benefit from biologic therapy],or evaluation of metrics such as bowel preparation score or quality of endoscopic examination.The objective of this comprehensive review is to analyze the available AI-related studies pertaining to the entirety of the gastrointestinal tract,including the upper,middle and lower tracts;IBD;the hepatobiliary system;and the pancreas,discussing the findings and clinical applications,as well as outlining the current limitations and future directions in this field.
文摘Acute pancreatitis(AP),chronic pancreatitis(CP)and pancreatic cancer are three distinct pancreatic diseases with different prognoses and treatment options.However,it may be difficult to differentiate between benign and malignant disease.AP may be a first symptom of pancreatic cancer,particularly in patients between the ages of 56 and 75 with presumed idiopathic AP who had a concomitant diagnosis of new-onset diabetes mellitus or patients who present with CP at diagnosis of AP.In these patients,additional imaging is warranted,preferably by endoscopic ultrasonography.CP may lead to pancreatic cancer through oncogenic mutations,mostly in patients with hereditary CP,and in patients in whom risk factors for pancreatic cancer(e.g.,nicotine and alcohol abuse)are also present.Patients with PRSS1-mediated CP and patients with a history of autosomal dominant hereditary CP without known genetic mutations may be considered for surveillance for pancreatic cancer.Pancreatic inflammation may mimic pancreatic cancer by appearing as a focal mass-forming lesion on imaging.Differentiation between the above mentioned benign and malignant disease may be facilitated by specific features like the duct-penetrating sign and the duct-to-parenchyma ratio.Research efforts are aimed towards developing a superior discriminant between pancreatitis and pancreatic cancer in the form of imaging modalities or biomarkers.This may aid clinicians in timely diagnosing pancreatic cancer in a potentially curable stage.
文摘BACKGROUND Preoperative biliary drainage in patients with presumed resectable perihilar cholangiocarcinoma(PHC)is hypothesized to promote the occurrence of seeding metastases.Seeding metastases can occur at the surgical scars or at the site of postoperative drains,and in case of percutaneous biliary drainage,at the catheter port-site.To prevent seeding metastases after resection,we routinely treated PHC patients with preoperative radiotherapy(RT)for over 25 years until January 2018.AIM To investigate the incidence of seeding metastases following resection of PHC.METHODS All patients who underwent resection for pathology proven PHC between January 2000 and March 2019 were included in this retrospective study.Between 2000-January 2018,patients received preoperative RT(3×3.5 Gray).RT was omitted in patients treated after January 2018.RESULTS A total of 171 patients underwent resection for PHC between January 2000 and March 2019.Of 171 patients undergoing resection,111 patients(65%)were treated with preoperative RT.Intraoperative bile cytology showed no difference in the presence of viable tumor cells in bile of patients undergoing preoperative RT or not.Overall,two patients(1.2%)with seeding metastases were identified,both in the laparotomy scar and both after preoperative RT(one patient with endoscopic and the other with percutaneous and endoscopic biliary drainage).CONCLUSION The incidence of seeding metastases in patients with resected PHC in our series was low(1.2%).This low incidence and the inability of providing evidence that preoperative low-dose RT prevents seeding metastases,has led us to discontinue preoperative RT in patients with resectable PHC in our center.
