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Resumen La pancreatitis cronica se asocia a calidad de vida deteriorada, elevada incidencia de comorbilidades, complicaciones graves y mortalidad. Los costes sanitarios son enormes. Algunas sociedades medicas han elaborado guias clinicas basadas en evidencia cientifica, pero el nivel de evidencia para cada aspecto de la enfermedad suele ser bajo y, consecuentemente, las recomendaciones tienden a ser vagas o debiles. En los presentes documentos de posicionamiento de la Societat Catalana de Digestologia y la Societat Catalana de Pancrees hemos buscado redactar declaraciones bien definidas orientadas al clinico, basadas en revisiones actualizadas de la literatura y acuerdos de expertos. El objetivo es proponer el uso de terminologia comun y circuitos diagnostico/terapeuticos racionales basados en el conocimiento actual. Para este fin se revisaron 51 secciones relacionadas con pancreatitis cronica por 21 expertos de 6 especialidades diferentes para generar finalmente 88 declaraciones que buscan armonizar conceptos y formular recomendaciones precisas. La parte 2 de esta serie de documentos discute temas sobre tratamiento y seguimiento. La aproximacion terapeutica debe incluir la evaluacion de factores etiologicos, manifestaciones clinicas y complicaciones. La complejidad de estos pacientes requiere un estudio detallado individualizado en comites multidisciplinares donde todas las opciones (conservadoras, endoscopicas, de radiologia intervencionista y quirurgicas) sean sopesadas. Deberian constituirse unidades especializadas de pancreatologia. Las indicaciones quirurgicas son dolor refractario, complicaciones locales y sospecha de neoplasia. El tratamiento enzimatico esta indicado si existe evidencia de insuficiencia exocrina o tras cirugia pancreatica. La respuesta debe evaluarse mediante parametros nutricionales y sintomas. Se debe planificar un programa de seguimiento para cada paciente.

Main recommendations Malignant disease 1 ESGE recommends placement of partially or fully covered self-expandable metal stents (SEMSs) for palliation of malignant dysphagia over laser therapy, photodynamic therapy, and esophageal bypass.Strong recommendation, high quality evidence. 2 ESGE recommends brachytherapy as a valid alternative, alone or in addition to stenting, in esophageal cancer patients with malignant dysphagia and expected longer life expectancy.Strong recommendation, high quality evidence. 3 ESGE recommends esophageal SEMS placement for sealing malignant tracheoesophageal or bronchoesophageal fistulas. Strong recommendation, low quality evidence. 4 ESGE does not recommend SEMS placement as a bridge to surgery or before preoperative chemoradiotherapy because it is associated with a high incidence of adverse events. Other options such as feeding tube placement are preferable. Strong recommendation, low quality evidence. Benign disease 5 ESGE recommends against the use of SEMSs as first-line therapy for the management of benign esophageal strictures because of the potential for adverse events, the availability of alternative therapies, and their cost. Strong recommendation, low quality evidence. 6 ESGE suggests consideration of temporary placement of self-expandable stents for refractory benign esophageal strictures. Weak recommendation, moderate quality evidence. 7 ESGE suggests that fully covered SEMSs be preferred over partially covered SEMSs for the treatment of refractory benign esophageal strictures because of their very low risk of embedment and ease of removability. Weak recommendation, low quality evidence. 8 ESGE recommends the stent-in-stent technique to remove partially covered SEMSs that are embedded in the esophageal wall. Strong recommendation, low quality evidence. 9 ESGE recommends that temporary stent placement can be considered for the treatment of leaks, fistulas, and perforations. No specific type of stent can be recommended, and the duration of stenting should be individualized. Strong recommendation, low quality of evidence. 10 ESGE recommends considering placement of a fully covered large-diameter SEMS for the treatment of esophageal variceal bleeding refractory to medical, endoscopic, and/or radiological therapy, or as initial therapy for patients with massive bleeding. Strong recommendation, moderate quality evidence.

Resumen Introduccion En un estudio previo demostramos que un pequeno programa de formacion mejoraba los indicadores de calidad de la esofagogastroduodenoscopia (EGD) que llegaban a los estandares recomendados. Sin embargo, desconocemos el efecto de esta formacion a largo plazo. El objetivo de este estudio fue valorar la calidad de las EGD despues de 3 anos de haber realizado un programa de mejora. Material y metodos Estudio comparativo de 2 cohortes: EGD posteriores a un programa de formacion realizado en 2016 (grupo A) y EGD en enero-marzo de 2019 (grupo B). El grupo B se dividio en 2 subgrupos: endoscopistas que habian participado en el programa de formacion previo (B1) y los que no (B2). Se utilizaron los indicadores de calidad intraprocedimiento recomendados por la ASGE-ACG. Resultados Se analizaron un total de 1.236 EGD, 600 en el grupo A y 636 en el B (439 subgrupo B1 y 197 subgrupo B2). El numero de exploraciones completas fue inferior en el grupo B (566 [94,3%] vs. 551 [86,6%]; p Conclusiones La mejora observada en 2016 tras un programa de formacion no perdura a los 3 anos. Es necesario hacer programas de formacion continuados para mantener la calidad de la EGD por encima de los estandares recomendados.

Background Colon capsule endoscopy (CCE) and CT colonography (CTC) are minimally invasive techniques for colorectal cancer (CRC) screening. Our objective is to compare CCE and CTC for the identification of patients with colorectal neoplasia among participants in a CRC screening programme with positive faecal immunochemical test (FIT). Primary outcome was to compare the performance of CCE and CTC in detecting patients with neoplastic lesions. Methods The VICOCA study is a prospective, single-centre, randomised trial conducted from March 2014 to May 2016; 662 individuals were invited and 349 were randomised to CCE or CTC before colonoscopy. Endoscopists were blinded to the results of CCE and CTC. Results Three hundred forty-nine individuals were included: 173 in the CCE group and 176 in the CTC group. Two hundred ninety individuals agreed to participate: 147 in the CCE group and 143 in the CTC group. In the intention-to-screen analysis, sensitivity, specificity and positive and negative predictive values for the identification of individuals with colorectal neoplasia were 98.1%, 76.6%, 93.7% and 92.0% in the CCE group and 64.9%, 95.7%, 96.8% and 57.7% in the CTC group. In terms of detecting significant neoplastic lesions, the sensitivity of CCE and CTC was 96.1% and 79.3%, respectively. Detection rate for advanced colorectal neoplasm was higher in the CCE group than in the CTC group (100% and 93.1%, respectively; RR = 1.07; p = 0.08). Both CCE and CTC identified all patients with cancer. CCE detected more patients with any lesion than CTC (98.6% and 81.0%, respectively; RR = 1.22; p = 0.002). Conclusion Although both techniques seem to be similar in detecting patients with advanced colorectal neoplasms, CCE is more sensitive for the detection of any neoplastic lesion. Trial registration ClinicalTrials.gov Identifier: NCT02081742. Registered: September 16, 2013.

Background and study aims The aim of thi systematic review and consensus report is to standardize the practice of endoscopic ultrasound (EUS-guided needle-based confocal laser endomicroscopy (nCLE) for pancreatic cystic lesion (PCL) evaluation. Methods We performed an international, systematic, evidence-based review of the applications, outcomes, procedural processes, indications, training, and credentialing of EUS-nCLE in management of PCLs. Based on available clinical evidence, preliminary nCLE consensus statements (nCLE-CS) were developed by an international panel of 15 experts in pancreatic diseases. These statements were then voted and edited by using a modified Delphi approach. An a priori threshold of 80 % agreement was used to establish consensus for each statement. Results Sixteen nCLE-CS were discussed. Thirteen (81 %) nCLE-CS reached consensus addressing indications (non-communication PCL meeting criteria for EUS-FNA or with prior non-diagnostic EUS-FNA), diagnostic outcomes (improved accuracy for mucinous PCLs and serous cystadenomas with substantial interobserver agreement of image patterns), low incidence of adverse events (fluorescein-associated and pancreatitis), procedural processes (nCLE duration, manipulation of needle with probe), and training (physician knowledge and competence). Conclusion Based on a high level of agreement pertaining to expert consensus statements, this report standardizes the practice of EUS-nCLE. EUS-nCLE should be systematically considered when EUS-FNA is indicated for PCL evaluation.

Regular arrangement of collecting venules (RAC) in gastric mucosa accurately identifies patients without Helicobacter pylori (H pylori) infection. The aim of our study was to evaluate the reproducibility of RAC using white light endoscopy without magnification, in a European country, and to assess the impact of proton pump inhibitors (PPIs).A multicenter prospective study with image capture of the distal lesser gastric curvature and gastric biopsies was performed. The presence of starfish-like minute points regularly distributed throughout lesser curvature was considered as RAC positive (RAC+). A set of 20 images was used for the training phase and inter and intra-observer agreements were calculated.174 patients were included and 85 (48.9%) were taking PPIs. Kappa values for interobserver and intra-observer agreements were substantial (0.786) and excellent (0.906), respectively. H. pylori infection was diagnosed in 29 patients (16.7%): 10/85 with PPIs and 19/89 without PPIs (11.8% vs. 21.3%; p = 0.09). All RAC + patients were free of H. pylori infection, with a sensitivity and negative predictive value of 100%, regardless of PPI intake.The endoscopic diagnosis of H. pylori by RAC is an easy-to-learn and highly reproducible technique, even with PPI intake. Our results warrant RAC as a real-time diagnostic method for H. pylori-negative infection in Western practice.

Background and study aims Feasibility of EUS-guided choledochoduodenostomy (EUS-CDS) using available lumen-apposing stents (LAMS) is limited by the size of the common bile duct (CBD) (≤ 12 mm, cut-off for experts; 15 mm, cut-off for non-experts). We aimed to assess the prevalence and predictive factors associated with CBD size ≥ 12 and 15 mm in naïve patients with malignant distal biliary obstruction (MDBO). Patients and methods This was a prospective cohort study involving 22 centers with assessment of CBD diameter and subjective feasibility of the EUS-CDS performance in naïve jaundiced patients undergoing EUS evaluation for MDBO. Results A total of 491 patients (mean age 69 ± 12 years) with mean serum bilirubin of 12.7 ± 6.6 mg/dL entered the final analysis. Dilation of the CBD ≥ 12 and 15 mm was detected in 78.8 % and 51.9 % of cases, respectively. Subjective feasibility of EUS-CDS was expressed by endosonographers in 91.2 % for a CBD ≥ 12 mm and in 96.5 % for a CBD ≥ 15 mm. On multivariate analysis, age (P Conclusions Our study showed that at presentation in a large cohort of patients with MDBO, EUS-CDS can be potentially performed in three quarters to half of cases by expert and less experienced endosonographers, respectively. Dedicated stents or devices with different designs able to overcome the limitations of existing electrocautery-enhanced LAMS for EUS-CDS are needed.

Resumen Objetivo Conocer el estado actual de la ultrasonografia endoscopica (USE) en Espana. Metodos Analisis descriptivo a partir de una encuesta nacional con 11 preguntas: 10 relativas a la tecnica y una a la formacion y experiencia de los ecoendoscopistas. Resultados Contestaron 60 endoscopistas correspondientes a 48 de los 97 (49,5%) hospitales que realizan USE en Espana. Se contabilizaron en un ano 28.678 exploraciones (20.311 diagnosticas, 7.446 con puncion y 921 terapeuticas). Un 64% de los hospitales realiza entre 300 y 999 pruebas por ano. Todos los centros disponen de ecoendoscopio radial y sectorial, con una mediana de 2 por hospital (2-8). La aguja de citologia que mas se usa es la de 22 gauges (98%) y de histologia la Procore (72%). El estudio del pancreas y la via biliar es la indicacion mas frecuente de USE diagnostica (60%), seguido de la estadificacion de neoplasias del tubo digestivo (20%). El 72% de los hospitales dispone de un citopatologo en la sala y la sedacion es administrada a partes iguales por los endoscopistas y anestesistas. En cuanto a la experiencia, el 45% de los ecoendoscopistas realizan menos de 300 exploraciones anuales y la mediana de tiempo de formacion es de 6 meses (0,5-36). Conclusiones La USE esta adecuadamente implementada en Espana y se dispone de buen equipamiento. Sin embargo, es necesario establecer un programa estandarizado de formacion en USE, ya que la de muchos ecoendoscopistas podria ser insuficiente segun los estandares establecidos por las Sociedades Cientificas.

Aim To understand the current state of endoscopic ultrasonography (EUS) in Spain. Methods Descriptive analysis from a national survey with 11 questions: 10 related to technique and 1 to the training and experience of the endoscopists. Results Sixty endoscopists from 48 of the 97 (49.5%) hospitals that perform EUS in Spain responded to the survey. A total of 28,678 procedures (20,311 diagnostic, 7446 with puncture and 921 therapeutic) were recorded over the course of one year. Approximately 64% of the hospitals perform between 300 and 999 tests per year. All have radial and sectorial echoendoscopes, with a median of 2 (2–8) scopes. For cytological diagnosis, the 22-gauge needle is the most commonly used (98%) and, for histological diagnosis, the Procore (72%). The study of the pancreas and bile duct is the most common indication for diagnostic EUS (60%), followed by the staging of digestive tract neoplasms (20%). Approximately 72% of the hospitals perform on-site cytopathology evaluations and sedation is administered in equal parts by both endoscopists and anaesthetists. In terms of experience, 45% of echoendoscopists perform fewer than 300 annual exams and the median training duration is 6 months (0.5–36). Conclusions EUS is adequately implemented in Spain and good equipment is available. However, it is necessary to establish a standardised EUS training programme since the one undertaken by many echoendoscopists could prove insufficient according to the standards established by Scientific Societies.

Background and study aims The impact of COVID-19 mitigation measures on stent placement procedures has not yet been reported. The aim of this study was to assess the impact of COVID-19 mitigation measures on upper stenting during SARS-CoV-2 outbreak, as well as the use of personal protection equipment (PPE) and risk of contamination for patients and staff. Patients and methods This was a multicenter, retrospective study of consecutive patients who underwent stent placement for upper gastrointestinal obstruction during the second half of SARS-CoV-2 outbreak period in comparison to same period one year before. Results A total of 29 stents were placed for upper gastrointestinal obstruction during the study period, corresponding to an increase of 241 % comparing to the same period in 2019 (n = 12). No significant major differences were found between the two time periods regarding patients’ baseline characteristics, post-stenting management and number of staff involved in stent placement. Fellows’ involvement was significantly lower in 2020 compared to 2019 (21 % vs 67 %; P = 0.01). The majority of procedures were performed using FFP2 /FFP3 mask (76 %), protective eyewear (86 %), two pairs of gloves (65 %), hairnet (76 %) and full disposable gowns (90 %). One patient tested positive for SARS-CoV-2 after the procedure. None of the medical staff involved in stenting procedures developed COVID-19 14 days after procedure. Conclusion Upper gastrointestinal stenting increased during the SARS-CoV-2 outbreak period, which could be related to yearly variation on the number of procedures or reflect a change of oncologic treatment practice during COVID times.

Background & Aims Guidelines recommend routine antibiotic prophylaxis for patients undergoing endoscopic ultrasonography-guided fine needle aspiration (EUS-FNA) of pancreatic cysts, but there is conflicting evidence for its necessity. We investigated whether performing the procedure without antimicrobial prophylaxis increases the incidence of infection. Methods We performed a multicenter, randomized, noninferiority trial to compare prophylaxis with ciprofloxacin vs placebo in patients with a pancreatic cyst requiring EUS-FNA at multiple centers in Spain. From September 2014 to June 2018, patients were randomly assigned to groups that received the prophylaxis with ciprofloxacin (n = 112) or saline solution (n = 114, placebo). We recorded patients' demographic data, lesion characteristics, and procedure data and followed patients for 21 days. A total of 205 patients completed the trial (90.7%), receiving ciprofloxacin or the control, with no statistically significant differences in demographics, baseline data, or procedure characteristics between groups. The primary outcome was FNA-related infection. Secondary outcomes were incidence of fever, procedure complications, and medication-related adverse events. Results The only case of FNA-related infection (0.44%) occurred in a patient in the placebo group (0.87%); this patient developed acute pancreatitis and bacteremia after the procedure. Prevention of infection was not inferior in the control group; the difference between proportions was 0.87% (95% confidence interval, –0.84% to 2.59%). There were no differences between groups in fever (2 patients in each group: 1.78% vs 1.76%; P = 1.00) or other adverse events. Conclusions In a randomized trial of patients undergoing EUS-FNA for pancreatic cyst evaluation, we found the risk of infection to be low. The incidence of infections did not differ significantly with vs without ciprofloxacin prophylaxis. (ClinicalTrials.gov, Number: NCT02261896).

Introduccion: existe poca evidencia cientifica sobre la eficacia de la dilatacion endoscopica con balon (DEB) mediante enteroscopia en el tratamiento de las estenosis de intestino delgado (ID) en la enfermedad de Crohn (EC). Objetivo: evaluar la eficacia y la seguridad de la DEB mediante enteroscopia en pacientes con EC y estenosis en ID. Metodos: estudio observacional retrospectivo en un centro de atencion terciaria en pacientes con EC y estenosis de ID evaluadas por enteroTC o enteroRM. Resultados: desde 2009 hasta 2019 se realizaron 205 dilataciones en 80 pacientes con EC; de ellos 17 (21,25 %) fueron pacientes con estenosis exclusivamente de ID (varones 70,6 %; edad media de 42,2 ± 14,4. El tiempo medio de seguimiento fue de 37,8 ± 28,7 meses. Se realizaron un total de 39 dilataciones. El 94,1 % eran nativas, con una longitud inferior que 5 cm y el 100 % estaban ulceradas. La tasa global de exito tecnico fue 82,4 %. El exito clinico fue del 88,2 %. Durante el seguimiento, el 23,5 % de los sujetos requirieron de intervencion quirurgica (IQ), el 29,4 % de redilatacion endoscopica y la eficacia a largo plazo fue del 76,5 %. No se produjeron complicaciones mayores. No se encontraron factores predictivos asociados con la necesidad de IQ tras la dilatacion. Conclusiones: las estenosis de ID pueden ser tratadas de forma segura y eficaz con DEB mediante enteroscopia asistida por balon (EAB) reduciend la necesidad de IQ a largo plazo.

BackgroundNeoadjuvant therapy (NAT) for pancreatic adenocarcinoma (PDAC) patients has shown promising results in non-randomized trials. This is a multi-institutional phase II trial of NAT in resectable PDAC patients.MethodsPatients with confirmed resectable PDAC after agreement by two expert radiologists were eligible. Patients received three cycles of GEM (1000mg/m(2)/week) plus daily erlotinib (ERL) (100mg/day). After re-staging, patients without progressive disease underwent 5 weeks of therapy with GEM (300mg/m(2)/week), ERL 100mg/day and concomitant radiotherapy (45Gy). Efficacy was assessed using tumor regression grade (TRG) and resection margin status. Using a single-arm Simon's design, considering the therapy not useful if R070% (alpha 5%, beta 10%), 24 patients needed to be recruited. This trial was registered at ClinicalTrials.gov, number NCT01389440.ResultsTwenty-five patients were enrolled. Adverse effects of NAT were mainly mild gastrointestinal disorders. Resectability rate was 76%, with a R0 rate of 63.1% among the resected patients. Median overall survival (OS) and disease-free survival (DFS) were 23.8 (95% CI 11.4-36.2) and 12.8 months (95% CI 8.6-17.1), respectively. R0 resection patients had better median OS, compared with patients with R1 resection or not resected (65.5 months vs. 15.5 months, p=0.01). N0 rate among the resected patients was 63.1%, and showed a longer median OS (65.5 vs. 15.2 months, p=0.009).ConclusionThe results of this study confirm promising oncologic results with NAT for patients with resectable PDAC. Therefore, the present trial supports the development of phase II randomized trials comparing NAT vs. upfront surgery in resectable pancreatic cancer.

Purpose The outcome of locally advanced adenocarcinoma of the esophagogastric junction (AEG) treated with preoperative chemoradiotherapy is heterogeneous, and favorable response to this treatment is a key factor in the patient's prognosis. The aim of this study was to evaluate F-FDG PET/CT in assessing metabolic response in patients with AEG. Materials and methods This prospective study evaluated all consecutive patients with potentially operable locally advanced AEG who were candidates for neoadjuvant chemoradiotherapy. PET/CT and contrast-enhanced thoracoabdominal CT were performed at baseline and 2 weeks after completion of chemoradiotherapy for response evaluation. The response rate was assessed using Response Evaluation Criteria in Solid Tumors criteria for contrast-enhanced thoracoabdominal CT and Positron Emission Tomography Response Criteria in Solid Tumors criteria for PET/CT. The regression rate was assessed using a 5-grade histopathology scoring system of the surgically resected tumor. Metastatic lesions were confirmed by histopathology examination or imaging and clinical follow-up at 6 months. Results A total of 40 cases were finally included in the study. Distant metastases were found in the baseline PET/CT in 6 of 40 cases (retroperitoneal [2] or mediastinal/hiliar [1] lymph nodes and liver [2] or bone [1] metastases) and were therefore excluded from surgery. Pathologic response correlated with the ΛSUVmax threshold of ≤45% (P = 0.033). CT response correlated well with both the baseline SUVmax (P = 0.039) and the ΛSUVmax (P = 0.001). Five-year survival curves for AEG correlated with the ΛSUVmax using a threshold of ≤45% for both progression-free and overall survival. Conclusions F-FDG PET/CT is useful for diagnosing nonsuspected metastasis before neoadjuvancy in potentially operable AEG. The ΛSUV correlates with pathologic response and is a long-term independent prognostic factor of survival.

In a previous study we demonstrated that a simple training programme improved quality indicators of Oesophagogastroduodenoscopy (OGD) achieving the recommended benchmarks. However, the long-term effect of this intervention is unknown. The aim of this study was to assess the quality of OGDs performed 3 years after of having completed a training programme.A comparative study of 2 cohorts was designed as follows: Group A included OGDs performed in 2016 promptly after a training programme and Group B with OGDs performed from January to March 2019, this group was also divided into 2 subgroups: subgroup B1 of Endoscopists who had participated in the previous training programme and subgroup B2 of Endoscopists who had not. The intra-procedure quality indicators proposed by ASGE-ACG were used.A total of 1236 OGDs were analysed, 600 from Group A and 636 from Group B (439 subgroup B1 and 197 subgroup B2). The number of complete examinations was lower in Group B (566 [94.3%] vs. 551 [86.6%]; p0.001). A significant decrease was observed in nearly all quality indicators and they did not reach the recommended benchmarks: retroflexion in the stomach (96% vs. 81%; p0.001); Seattle biopsy protocol (86% vs. 50%; p=0.03), description of the upper GI bleeding lesion (100% vs. 62%; p0.01), sufficient intestinal biopsy specimens (at least 4) in suspected coeliac disease (92.5% vs. 18%; p0.001), photo documentation of the lesion (94% vs. 90%; p0.05). Regarding the overall assessment of the procedure (including correct performance and adequate photo documentation), a significant decrease was also observed (90.5% vs. 62%; p0.001). There were no differences between subgroups B1 and B2.The improvement observed in 2016 after a training programme did not prevail after 3 years. In order to keep the quality of OGDs above the recommended benchmarks, it is necessary to implement continuous training programmes.

PURPOSE The aim of this study was to evaluate F-FDG PET/CT compared with conventional imaging techniques in the clinical management of patients with locally advanced gastric cancer (LAGC). METHODS A prospective study between January 2010 and December 2011 in patients with suspected LAGC was conducted in our hospital. F-FDG PET/CT, contrast-enhanced CT (CECT), endoscopic ultrasound, and laparoscopy were performed in all cases. Standard whole-body F-FDG PET/CT images were obtained centered on the stomach at 1 and 2 hours after injection of 4.0 MBq/kg of F-FDG. Findings were confirmed by histopathology or by imaging follow-up in nonoperable patients. RESULTS Fifty consecutive patients with confirmed LAGC (20 women, 30 men) with a mean ± SD age of 65.7 ± 12.1 years were included. Using Lauren classification, 24 patients were intestinal subtype, and 26 were diffuse subtype. Thirty-five patients with locoregional lymph node involvement and 22 with distant metastases were confirmed as peritoneal metastases (n = 15), retroperitoneal (n = 2) or mediastinal lymph nodes (n = 1), and liver (n = 3) or bone metastases (n = 1). Patients with signet ring carcinoma showed significantly less F-FDG uptake (P = 0.001). SUVmax correlated with tumor grading (P < 0.05). Standard and delayed F-FDG PET/CT and CECT images identified LAGC in 24, 27, and 28 of 30 patients, respectively. The sensitivity and specificity for F-FDG PET/CT and CECT to detect metastases were 68% and 100% and 64% and 93%, respectively. Contrast-enhanced CT and F-FDG PET/CT diagnosed only 6 of the 15 patients with confirmed peritoneal metastases. The impact in therapeutic management of F-FDG PET/CT and CECT was 24% and 22%, respectively. Kaplan-Meier survival curves for the LGAC showed a significant correlation between SUVmax and overall survival using an SUVmax threshold of less than 3.96 (P = 0.04). CONCLUSIONS F-FDG PET/CT should be recommended for staging of LAGC; however, F-FDG PET/CT and CECT cannot replace laparoscopy to rule out peritoneal metastases. Delayed F-FDG PET/CT images show an increase of F-FDG uptake in most cases, improving LAGC detection. The grade of F-FDG uptake represents a significant prognostic tool in this series.

The use of sedation for diagnostic procedures including gastrointestinal endoscopy is rapidly growing. Recovery of cognitive function after sedation is important because it would be important for most patients to resume safe, normal life soon after the procedure. Computerized tests have shown being accurate descriptors of cognitive function. The purpose of the present study was to evaluate the time course of cognitive function recovery after sedation with propofol and remifentanil. A prospective observational double blind clinical study conducted in 34 young healthy adults undergoing elective outpatient colonoscopy under sedation with the combination of propofol and remifentanil using a target controlled infusion system. Cognitive function was measured using a validated battery of computerized cognitive tests (Cogstate™, Melbourne, Australia) at different predefined times: prior to starting sedation (Tbaseline), and then 10 min (T10), 40 min (T40) and 120 min (T120) after the end of colonoscopy. Tests included the assessment of psychomotor function, attention, visual memory and working memory. All colonoscopies were completed (median time: 26 min) without significant adverse events. Patients received a median total dose of propofol and remifentanil of 149 mg and 98 µg, respectively. Psychomotor function and attention declined at T10 but were back to baseline values at T40 for all patients. The magnitude of psychomotor task reduction was large (d = 0.81) however 100% of patients were recovered at T40. Memory related tasks were not affected 10 min after ending sedation. Cognitive impairment in attention and psychomotor function after propofol and remifentanil sedation was significant and large and could be easily detected by computerized cognitive tests. Even though, patients were fully recovered 40 min after ending the procedure. From a cognitive recovery point of view, larger studies should be undertaken to propose adequate criteria for discharge after sedation.

Resumen Introduccion El registro y la medicion de los indicadores de calidad suponen una oportunidad de mejora. Sin embargo, no existen experiencias previas en nuestro medio sobre su cumplimiento en la esofagogastroduodenoscopia (EGD). Objetivo Analizar el cumplimiento de los criterios de calidad de las EGD y evaluar la mejora tras la realizacion de un programa de formacion. Pacientes y metodos Estudio comparativo de 2 cohortes: una, retrospectiva (grupo control) y otra, prospectiva (grupo intervencion), antes y despues de un programa de formacion que consistio en una sesion informativa y la mejora del programa de elaboracion de informes. Se utilizaron los indicadores de calidad propuestos por la American Society for Gastrointestinal Endoscopy y el American College of Gastroenterology. Resultados Se incluyeron un total de 1.200 EGD de forma secuencial (600 en cada grupo). Tras el programa de formacion se observo una mejoria significativa en los siguientes indicadores: indicacion documentada (93 vs. 99,8%; p Conclusion Un programa de formacion muy sencillo mejora los indicadores de calidad de la EGD, alcanzando la mayoria los estandares recomendados por la American Society for Gastrointestinal Endoscopy y el American College of Gastroenterology.

Resumen Introduccion Los polipos gastricos son lesiones habitualmente asintomaticas y constituyen un hallazgo durante la realizacion de una endoscopia. Objetivo Estudiar la frecuencia de los diferentes tipos de polipos gastricos en nuestro medio y su posible asociacion con otros factores. Pacientes y metodos Estudio retrospectivo de las gastroscopias realizadas durante 10 anos en un hospital de tercer nivel. Se recogieron datos demograficos, antecedentes patologicos, indicacion de la gastroscopia y caracteristicas morfologicas e histologicas de los polipos. Resultados Se incluyeron 41.253 gastroscopias, identificandose 827 (2%) con polipos gastricos correspondientes a 709 pacientes. La edad media fue 65,6 anos y un 62% fueron mujeres. El 53,9% tenian multiples polipos. La localizacion mas frecuente fue fundus y la mayoria fueron menores de 1 cm (83,3%). Se obtuvo muestra para anatomia patologica en 607 pacientes, siendo los mas frecuentes los polipos hiperplasicos (42,8%), seguidos de los polipos de glandula fundica (37,7%). Los factores que se asociaron de forma independiente a los polipos hiperplasicos fueron la edad y el ser polipo unico, de tamano ≥ 6 mm y localizacion no fundica. Contrariamente, los de glandula fundica se asociaron a la indicacion por reflujo y el ser multiples, Conclusiones Los polipos de glandula fundica e hiperplasicos son los mas frecuentes en nuestro medio, y tienen rasgos contrarios que pueden orientar al diagnostico histologico. En el caso de polipos unicos es recomendable la toma de biopsias para descartar el diagnostico de adenoma.

Background and Aims: The benefit of rapid on-site evaluation (ROSE) on the diagnostic accuracy of endoscopic ultrasound–guided fine-needle biopsy (EUS-FNB) has never been evaluated in a randomized study. This trial aimed to test the hypothesis that in solid pancreatic lesions (SPLs), diagnostic accuracy of EUS-FNB without ROSE was not inferior to that of EUS-FNB with ROSE. Methods: A noninferiority study (noninferiority margin, 5%) was conducted at 14 centers in 8 countries. Patients with SPLs requiring tissue sampling were randomly assigned (1:1) to undergo EUS-FNB with or without ROSE using new-generation FNB needles. The touch-imprint cytology technique was used to perform ROSE. The primary endpoint was diagnostic accuracy, and secondary endpoints were safety, tissue core procurement, specimen quality, and sampling procedural time. Results: Eight hundred patients were randomized over an 18-month period, and 771 were analyzed (385 with ROSE and 386 without). Comparable diagnostic accuracies were obtained in both arms (96.4% with ROSE and 97.4% without ROSE, P = .396). Noninferiority of EUS-FNB without ROSE was confirmed with an absolute risk difference of 1.0% (1-sided 90% confidence interval, –1.1% to 3.1%; noninferiority P < .001). Safety and sample quality of histologic specimens were similar in both groups. A significantly higher tissue core rate was obtained by EUS-FNB without ROSE (70.7% vs. 78.0%, P = .021), with a significantly shorter mean sampling procedural time (17.9 ± 8.8 vs 11.7 ± 6.0 minutes, P < .0001). Conclusions: EUS-FNB demonstrated high diagnostic accuracy in evaluating SPLs independently on execution of ROSE. When new-generation FNB needles are used, ROSE should not be routinely recommended. (ClinicalTrial.gov number NCT03322592.)

Objective:The aim of our study was to analyze the miRNome of pancreatic ductal adenocarcinoma (PDAC) and its preneoplastic lesion intraductal papillary mucinous neoplasm (IPMN), to find new microRNA (miRNA)-based biomarkers for early detection of pancreatic neoplasia.Objective:Effective early detect

Background and study aims EUS-FNA has suboptimal accuracy in diagnosing gastrointestinal subepithelial tumors (SETs). EUS-guided 22-gauge fine needle biopsy (EUS-FNB) and single-incision with needle knife (SINK) were proposed to increase accuracy of diagnosis. This study aimed to prospectively compare the diagnostic accuracy and safety of EUS-FNB with SINK in patients with upper gastrointestinal SETs. Patients and methods All adult patients referred for EUS evaluation of upper gastrointestinal SETs ≥ 15 mm in size were eligible for inclusion. Patients were randomized to undergo EUS-FNB or SINK. Lesions were sampled with a 22-gauge reverse beveled core needle in the EUS-FNB group and by a conventional needle-knife sphincterotome and biopsy forceps in the SINK group. Patients were blinded to the technique used. The primary outcome was diagnostic accuracy. Secondary outcomes included adverse events, histological yield and procedure duration. Study enrollment was terminated early due to poor recruitment. Results A total of 56 patients (31 male (55.37 %); mean age, 67.41 ± 12.70 years) were randomized to either EUS-FNB (n = 26) or SINK (n = 30). Technical success was 96.15 % and 96.66 %, respectively. The majority of lesions were gastrointestinal stromal tumors (51.78 %). No significant difference was found between EUS-FNB and SINK in terms of diagnostic accuracy for a malignant or benign disease (76 % vs. 89.28 %, respectively; P = 0.278). The rate of adverse events (none severe) was also comparable (7.69 % vs. 10 %, respectively; P = 1.0) including two abdominal pain episodes in the EUS-FNB group compared to two delayed bleeding (one requiring hospitalization and radiologic embolization) and 1 abdominal pain in the SINK group. Conclusion EUS-FNB and SINK are equally effective techniques for upper gastrointestinal SETs sampling. SINK can be associated with mild to moderate delayed bleeding.

Background and Aims Helicobacter pylori is the major cause of gastritis and gastritis-associated diseases. Detection of a regular arrangement of collecting venules (RAC) in the lesser gastric curvature correlates with negative H pylori status with a sensitivity and negative predictive value (NPV) higher than 90% in Asian countries. The aim of the study was to evaluate the value of RAC as a diagnostic method of H pylori infection in a European population. Methods A prospective study with high-definition endoscopes without magnification was performed by 3 endoscopists. The presence of starfish-like minute points regularly distributed throughout the lesser curvature of the gastric body was considered RAC positive (RAC+). Gastric biopsies were performed during the procedure for H pylori diagnosis. Results One hundred forty patients were included from February 2017 to May 2018. The prevalence of H pylori infection was 31% and 47 of 140 patients (34%) were RAC+; 13 of 23 patients in whom H pylori was eradicated were RAC+. The mean age of RAC+ patients was lower (44.4 vs 52.4 years, P = .004) and they had less- significant endoscopic findings (9; 19.1% vs 38; 80.9%; P = .017). Gender, use of nonsteroidal anti-inflammatory drugs, antithrombotic or anticoagulants treatments, and a history of H pylori eradication did not show differences in the RAC pattern. The absence of RAC was associated with H pylori infection in 47.3% (44/93) of cases. In contrast, all RAC+ patients were free of H pylori infection, with sensitivity and NPV of 100% for the exclusion of H pylori infection. Conclusion The presence of RAC+ in the lesser curvature evaluated with high-definition endoscopy can accurately identify patients without H pylori.

OBJECTIVES: Pancreatic ductal adenocarcinoma (PDAC) presents the lowest survival rate of all cancers because only 6% of patients reach five-year survival. Alterations in the expression of several microRNAs (miRNAs) occur in the tumor of PDAC and in preneoplastic lesions as the called intraductal papillary mucinous neoplasm (IPMN). Here, we aimed at identifying which miRNAs are significantly altered in liquid biopsies from patients with PDAC and IPMN to find new noninvasive biomarkers for early detection of PDAC. METHODS: We analyzed by real-time quantitative reverse transcription-PCR (qRT-PCR) the expression of 17 circulating miRNAs, previously found to be significantly overexpressed in tissue pancreatic neoplasms, in a set of 182 plasma samples (94 PDAC, 19 IPMN, 18 chronic pancreatitis, and 51 disease-free controls). Then, we analyzed CA19.9 levels in the same plasma set, and we assessed the diagnostic values of differentially expressed miRNAs, CA19.9, and all possible combinations. RESULTS: Of note, 16, 14, and 9 miRNAs were significantly increased in PDAC, IPMN, and chronic pancreatitis, respectively, compared with control plasmas. miR-21-5p, miR-33a-3p, miR-320a, and miR-93-5p showed the highest discriminating capacity for pancreatic neoplasia (PDAC or IPMN) with an area under the receiver operating characteristic curve (AUC) of 0.86, 0.85, 0.85, and 0.80, respectively. 2-miRNA combinations improved these performances reaching AUC = 0.90 for “miR-33a-3p+miR-320a.” Addition of CA19.9 increased the diagnostic potential of miRNA signatures even further achieving an AUC of 0.95 (93% sensitivity and 85% specificity) for the combination of “miR-33a-3p+miR-320a+CA19.9.” CONCLUSIONS: Novel signatures combining miRNAs and CA19.9 could be used as noninvasive biomarkers for early detection of PDAC.