Pathology results of endoscopic ultrasound-guided tissue acquisition in retroperitoneal masses: a multicenter study.

Background: Malignant etiologies are found in 70-80% of symptomatic retroperitoneal masses. Histology is required for diagnosis and treatment. Information about endoscopic ultrasound (EUS)-guided tissue acquisition (EUS-GTA) is scant for retroperitoneal masses. This study aimed to assess the pathology results of EUS-GTA for diagnosing retroperitoneal masses. Methods: This retrospective, multicenter study involved patients from 5 care centers. All patients with retroperitoneal masses who underwent EUS evaluation were enrolled. We recorded demographic and clinical characteristics, location and size of the mass, type of needle (FNA/FNB), and complications related to the procedure. Results: A total of 43 patients were included. The median age was 50.5 (range: 23-83) years, and 22 (51.2%) were female. The initial symptom was abdominal pain in 23 (52.3%) cases and weight loss in 11 (25%). Initial imaging was by computed tomography in 33 (75%) patients. Diagnosis with EUS-GTA was reached in 67.5% (29/43) cases. The most frequent histological diagnosis was carcinoma, in 25.5% (11/43). A malignant etiology was found in 31 (72%): 20 were primary tumors from the retroperitoneum, and 11 were metastases. In patients with metastasis, surgery was avoided and medical treatment was indicated. No adverse events were reported. Conclusion: EUS and EUS-GTA can frequently provide accurate tissue diagnosis and significantly impact the subsequent management.

Can topical epinephrine application to the papilla prevent pancreatitis after endoscopic retrograde cholangiopancreatography? Results from a double blind, multicentre, placebo controlled, randomised clinical trial.

BACKGROUND AND STUDY AIMS: Post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis (PEP) is a complication associated with important morbidity, occasional mortality and high costs. Preventive strategies are suboptimal as PEP continues to affect 4% to 9% of patients. Spraying epinephrine on the papilla may decrease oedema and prevent PEP. This study aimed to compare rectal indomethacin plus epinephrine (EI) versus rectal indomethacin plus sterile water (WI) for the prevention of PEP. PATIENTS AND METHODS: This multicentre randomised controlled trial included patients aged >18 years with an indication for ERCP and naive major papilla. All patients received 100 mg of rectal indomethacin and 10 mL of sterile water or a 1:10 000 epinephrine dilution. Patients were asked about PEP symptoms via telephone 24 hours and 7 days after the procedure. The trial was stopped half way through after a new publication reported an increased incidence of PEP among patients receiving epinephrine. RESULTS: Of the 3602 patients deemed eligible, 3054 were excluded after screening. The remaining 548 patients were randomised to EI group (n=275) or WI group (n=273). The EI and WI groups had similar baseline characteristics. Patients in the EI group had a similar incidence of PEP to those in the WI group (3.6% (10/275) vs 5.12% (14/273), p=0.41). Pancreatic duct guidewire insertion was identified as a risk factor for PEP (OR 4.38, 95% CI (1.44 to 13.29), p=0.009). CONCLUSION: Spraying epinephrine on the papilla was no more effective than rectal indomethacin alone for the prevention of PEP. TRIAL REGISTRATION NUMBER: This study was registered with ClinicalTrials.gov (NCT02959112).

Utility of endoscopic ultrasound in idiopathic acute recurrent pancreatitis.

Idiopathic acute recurrent pancreatitis (IARP) is defined as at least two episodes of acute pancreatitis with the complete or near-complete resolution of symptoms and signs of pancreatitis between episodes, without an identified cause. There is a paucity of information about the usefulness of endoscopic ultrasound (EUS) in IARP. OBJECTIVES: To determine the diagnostic yield of EUS in IARP. DESIGN: A retrospective study was performed in patients with IARP evaluated by EUS between January 2009 and December 2016. Follow-up assessments of acute pancreatitis recurrence were carried out. RESULTS: Seventy-three patients with 102 EUS procedures were included. EUS was able to identify the cause of IARP in 55 patients (75.3%). The most common findings were chronic pancreatitis in 27 patients (49.1%), followed by lithiasic pathology in 24 patients (43.6%), and intraductal papillary mucinous neoplasm in four patients (7.3%). A directed treatment against EUS findings had a protective tendency associated with the final resolution of recurrence. There were no complications reported. CONCLUSION: EUS performed in patients with IARP helped to identify a possible cause in 2/3 of the cases. The majority of patients have a treatable disease.

The Risk of Contracting COVID-19 Is Not Increased in Patients With Celiac Disease.

The World Health Organization declared coronavirus disease-2019 (COVID-19) a global pandemic in March 2020. Since then, there are more than 34 million cases of COVID-19 leading to more than 1 million deaths worldwide. Numerous studies suggest that celiac disease (CeD), a chronic immune-mediated gastrointestinal condition triggered by gluten, is associated with an increased risk of respiratory infections.1-3 However, how it relates to the risk of COVID-19 is unknown. To address this gap, we conducted a cross-sectional study to evaluate whether patients with self-reported CeD are at an increased risk of contracting COVID-19.

More fuel to the fire: some patients with non-celiac self-reported wheat sensitivity exhibit adaptive immunological responses in duodenal mucosa.

BACKGROUND: In contrast to the well-characterized Celiac Disease (CD), the clinical scenarios encompassed by the non-celiac self-reported wheat sensitivity (NCSRWS) might be related to different antigens that trigger distinct immune-inflammatory reactions. Although an increased number of intestinal intraepithelial lymphocytes is observed at the inception of both diseases, the subsequent immunopathogenic pathways seem to be different. We aimed to describe the cytokine profile observed in the duodenal mucosa of patients with NCSRWS. METHODS: In a blind, cross-sectional study, we included duodenal biopsies from 15 consecutive untreated patients with active CD, 9 individuals with NCSRWS and 10 subjects with dyspepsia without CD and food intolerances. Immunohistochemistry and flow-cytometry were used to determine the presence of pro-inflammatory cytokine expressing monocytes and monocyte-derived dendritic cells involved in innate immune activation, cytokine-driven polarization and maintenance of Th1 and Th17/Th 22, and anti-inflammatory/profibrogenic cytokines. RESULTS: The percentage of cells expressing all tested cytokines in the lamina propria and the epithelium was higher in CD patients than in the control group. Cytokines that induce and maintain Th1 and Th17 polarization were higher in CD than in NCSRWS and controls, also were higher in NCSRWS compared to controls. Similar differences were detected in the expression of IL-4 and TGF-1, while IL-10-expressing cells were lower in NCSRWS patients than in controls and CD subjects. CONCLUSIONS: NCSRWS patients exhibit components of both, innate and adaptive immune mechanisms but to a lesser extent compared to CD.

Increased Mortality from Extrapancreatic Infections in Hospitalized Patients with Acute Pancreatitis.

Nosocomial extrapancreatic infections in patients with acute pancreatitis (AP) are associated with a higher mortality even after adjusting the risk for the severity of the pancreatitis. The aim of this study was to describe the clinical features of hospitalized patients with AP who died during their hospitalization and to evaluate risk factors associated with mortality. We performed a descriptive study of the clinical features of adult patients who died from AP during their hospitalization and a case control study with a paired group of patients that survived AP during a 10-year period. Data of interest were collected from the medical records and are presented with appropriate measures of central tendency and dispersion. For the case control study, the primary outcome evaluated was death, and to evaluate associated clinical features and determine differences between groups, we performed the χ 2 or Fisher's exact tests for categorical variables and the Student t-test or Mann-Whitney U test for continuous variables as appropriate. We found 48 patients with acute pancreatitis who died within the period of the study during hospitalization; from these, 50% were men, mean age was 53.2 years, and the most common etiology was biliary obstruction by gallstones in 45.8%. The global mortality rate was of 2.5%. A total of 43.7% patients had infected pancreatic necrosis, and in 58.3%, some extrapancreatic infection was documented, being the most common urinary tract infection in 50%, bacteremia in 50% and pneumonia in 33.3%. Clinical features associated with mortality were the presence of organ failure (p < 0.001), nosocomial complications (p < 0.001), infected necrosis (p < 0.001), and extrapancreatic infections (p = 0.002). From the different extrapancreatic infections, only bacteremia (p = 0.001) and pneumonia (p = 0.011) were associated with higher mortality. In conclusion, extrapancreatic infections are associated with increased mortality among hospitalized patients with acute pancreatitis, in particular, bacteremia and pneumonia with an isolated pathogen.

Permanent Indwelling Transmural Stents for Endoscopic Treatment of Patients With Disconnected Pancreatic Duct Syndrome: Long-term Results.

INTRODUCTION: Disconnected pancreatic duct syndrome (DPDS) is defined as the complete disruption of the main pancreatic duct, the result are peripancreatic fluid collections or pancreatic leaks. The aim of this study was to report the results of derivative endoscopic treatment of DPDS in a long-term follow-up period. PATIENTS AND METHODS: We performed a retrospective analysis of prospectively collected data. Endoscopic treatment consisted of transmural drainage with 2 double pigtail plastic stents (7 F and 4 cm) deployed under endoscopic ultrasound guidance. RESULTS: In total, 21 patients were included in our study. There were 15 (71%) men and the median age was 36 years (range, 23 to 86 y). The principal etiology of DPDS was acute pancreatitis. A total of 20 (95.2%) patients were diagnosed with DPDS by endoscopic pancreatography and only 1 (4.8%) patient by magnetic resonance cholangiopancreatography (MRCP). The median follow-up time was 28 months (range, 7 to 76 mo). Technique success was 100% and initial clinical success was 80.9% (17/21). Three (17.6%) of these patients required a new endoscopic procedure with success in all cases. During follow-up, 11 (52%) patients developed diabetes mellitus and 3 patients (14%) developed exocrine pancreatic insufficiency. There were 5 (15%) patients with complications. CONCLUSION: According to our data, endoscopic treatment with the placement of a permanent indwelling transmural stents is a useful and safe tool for the treatment of DPDS.

EUS-guided drainage of pancreatic pseudocysts offers similar success and complications compared to surgical treatment but with a lower cost.

BACKGROUND AND AIM: Pancreatic pseudocysts (PPC) are a complication that occurs in acute and chronic pancreatitis. They comprise 75% of cystic lesions of the pancreas. There are scarce data about surgical versus endoscopic treatment on PPC. The aim of this study was to compare both treatment modalities regarding clinical success, complication rate, recurrence, hospital stay and cost. METHODS: Retrospectively, data obtained prospectively from 2000 to 2012 were analyzed. A PPC was defined as a fluid collection in the pancreatic or peripancreatic area that had a well-defined wall and contained no solid debris or recognizable parenchymal necrosis. Clinical success was defined as complete resolution or a decrease in size of the PPC to 2 cm or smaller. RESULTS: Overall, 64 procedures in 61 patients were included: 21 (33%) cases were drained endoscopically guided by EUS and 43 (67%) cases were drained surgically. The clinical success of the endoscopic group was 90.5 versus 90.7% for the surgical group (P = 0.7), with a complication rate of 23.8 and 25.6%, respectively (P = 0.8), and a mortality rate of 0 and 2.3% for each group, respectively (P = 0.4). The hospital stay was lower for the endoscopic group: 0 (0-10) days compared with 7 (2-42) days in the surgical group (P < 0.0001). Likewise, the cost was lower in the endoscopic group (P < 0.001). The recurrence rate was similar in both groups: 9.5 and 4.5% respectively (P = 0.59). The two recurrences found in the endoscopic group were associated with stent migration, and the recurrence in the surgical group was due to the type of surgery performed (open drainage). CONCLUSION: Endoscopic treatment of PPC offers the same clinical success, recurrence, complication and mortality rate as surgical treatment but with a shorter hospital stay and lower costs.

Impact of formal training in endoscopic submucosal dissection for early gastrointestinal cancer: A systematic review and a meta-analysis.

AIM: To summarize the clinical impact of a formal training for the effectiveness and safety of endoscopic submucosal dissection for gastrointestinal cancer. METHODS: We searched databases including PubMed, EMBASE and the Cochrane Library and Science citation Index updated to August 2014 to include eligible articles. In the Meta-analysis, the main outcome measurements were en bloc resection rate, local recurrence rate (R0) and the incidence of procedure-related complications (perforation, bleeding). RESULTS: En bloc resection was high for both, dissecting stomach tumors with an overall percentage of 93.2% (95%CI: 90.5-95.8) and dissecting colorectal tumors with an overall percentage of 89.4% (95%CI: 85.1-93.7). Although the number of studies reporting R0 resection (the dissected specimen was revealed free of tumor in both vertical and lateral margins) was small, the overall estimates for R0 resection were 81.4% (95%CI: 72-90.8) for stomach and 85.9% (95%CI: 77.5-95.5) for colorectal tumors, respectively. The analysis showed that the percentage of immediate perforation and bleeding were very low; 4.96 (95%CI: 3.6-6.3) and 1.4% (95%CI: 0.8-1.9) for colorectal tumors and 3.1% (95%CI: 2.0-4.1) and 4.8% (95%CI: 2.8-6.7) for stomach tumors, respectively. CONCLUSION: In order to obtain the same rate of success of the analyzed studies it is a necessity to create training centers in the western countries during the "several years" of gastroenterology residence first only to teach EGC diagnose and second only to train endoscopic submucosal dissection.

Diagnostic yield of endoscopic ultrasound in patients with hypoglicemia and insulinoma suspected.

BACKGROUND AND OBJECTIVES: Noninvasive imaging techniques have shown limitations to identify insulinomas. In few studies reported so far, endoscopic ultrasound (EUS) has proven to be able to locate lesions. The aim of this study was to compare the performance of computed tomography versus EUS for the detection of insulinomas. MATERIALS AND METHODS: In a retrospective manner prospectively collected data were analyzed. Patients with hypoglucemia and hyperinsulinemia were included. Diagnostic yield was measured in relationship to sensitivity, specificity, positive predictive value, negative predictive value and accuracy. Surgical specimens were considered the gold standard. RESULTS: Sensitivity, positive predictive value, and accuracy of EUS was 100%, 95.4% and 95.4%, respectively. In the case of CT the sensitivity was 60%, specificity 100%, positive predictive value 100%, negative predictive value 7%, and accuracy were 68%. CONCLUSIONS: EUS is useful in the preoperative assessment of patients with hypoglycemia and serum hyperinsulinemia.

Characteristics and factors related to quality of life in Mexican Mestizo patients with celiac disease.

BACKGROUND: Celiac disease (CD) is a global health problem and its prevalence is underestimated, especially in Latin American populations. Our aim was to evaluate the clinical features, psychological factors, and health-related quality of life (QoL), before and after diagnosis, in a representative sample of adult Mexican Mestizo patients presenting with CD. METHODS: A cross-sectional analysis was conducted on patients seen at two tertiary referral centers in Mexico. QoL before and after CD diagnosis was evaluated using the EuroQoL 5D, the Hospital Anxiety and Depression Scale (HADS), and the disease-specific Celiac Symptom Index (CSI) questionnaires. RESULTS: We included 80 patients (80% were women, with a mean age of 48.6 ± 14.1 years). The most common symptoms were diarrhea (86%), bloating (77.5%), and abdominal pain (71.3%). Mean symptom duration was 10.33 ± 6.3 years. Fifty-one patients (63.8%) had a previous diagnosis of irritable bowel syndrome (IBS) and 23 (28.8%) had one of functional dyspepsia. Questionnaire respondents rated their health status at 50% before diagnosis (0 = worst imaginable state, 100 = best imaginable state) and there was a significant improvement of 26% after diagnosis. Thirty-nine percent of the patients had a CSI score > 45 and they were the ones that had been previously diagnosed most often with IBS (p = 0.13) or dyspepsia (p = .036). CONCLUSIONS: At the time of diagnosis, Mexican Mestizo patients with CD had poor QoL. Long-standing symptoms and a previous diagnosis of functional disorders were associated with worse QoL. As in other populations, our results support the need for a detailed examination of cost-effective strategies for increasing CD awareness in clinical practice.

Follow-up of patients with pseudotumoral chronic pancreatitis: outcome and surveillance.

AIM: To follow up patients with pseudotumoral chronic pancreatitis (PCP) to assess their outcome and identify an optimal surveillance interval. METHODS: Data obtained prospectively were analyzed in a retrospective manner. Patients with clinical evidence of chronic pancreatitis (abdominal pain in the epigastrium, steatorrhea, and diabetes mellitus), endoscopic ultrasound (EUS) criteria > 4, and EUS-fine needle aspiration (FNA) were included. A pseudotumor was defined as a non-neoplastic space-occupying lesion, a cause of chronic pancreatitis that may mimic changes typical of pancreatic cancer on CT or endoscopic ultrasound but without histological evidence. A real tumor was defined as a neoplastic space-occupying lesion because of pancreatic cancer confirmed by histology. RESULTS: Thirty-five patients with chronic pancreatitis were included, 26 (74.2%) of whom were men. Nine (25.7%) patients were diagnosed with pseudotumoral chronic pancreatitis and two (2/35; 5.7%) patients with pseudotumoral chronic pancreatitis were diagnosed with pancreatic cancer on follow-up. The time between the diagnosis of pseudotumoral chronic pancreatitis and pancreatic adenocarcinoma was 35 and 30 d in the two patients. Definitive diagnosis of pancreatic adenocarcinoma was made by surgery. In the remaining six patients with pseudotumoral chronic pancreatitis, the median of follow-up was 11 mo (range 1-22 mo) and they showed no evidence of malignancy on surveillance. In the follow-up of patients without pseudotumoral chronic pancreatitis but with chronic pancreatitis, none were diagnosed with pancreatic cancer. According to our data, older patients with chronic pancreatitis are at risk of pseudotumoral chronic pancreatitis. CONCLUSION: According to characteristics of patient, detection of PCP should lead a surveillance program for pancreatic cancer with EUS-FNA in < 1 mo or directly to surgical resection.

Clinical and Immunopathologic Profile of Mexican Patients with IgG4 Autoimmune Pancreatitis.

Autoimmune pancreatitis is part of the spectrum of IgG4-associated diseases. Its diagnostic criteria and histological subtypes have been formally proposed recently and although based on current data it has been suggested that there are differences in clinical presentation among populations, more research is needed to properly establish if this heterogeneity exists. In this paper, we describe 15 cases of autoimmune pancreatitis diagnosed at a Mexican centre of reference, all of them associated to the lymphoplasmocytic sclerosing pancreatitis variant. The mean age at the onset of symptoms was 47.5 ± 14.4 years, and 53% of patients were male. The main manifestations were weight loss (87%), obstructive jaundice (53%), and acute (27%) and chronic (27%) pancreatitis. Only 20% of patients had high IgG4 serum levels at the time of diagnosis. All patients receiving prednisone responded favourably, both in their pancreatic and extrapancreatic manifestations. Clinical manifestations of Mexican patients showed certain differences with respect to those usually reported.

Impact on quality of life after pancreatoduodenectomy: a prospective study comparing preoperative and postoperative scores.

INTRODUCTION: Few studies compare the direct impact of pancreatoduodenectomy (PD) on the patient's quality of life (QOL). The effect of PD in QOL, comparing the preoperative vs. postoperative status, was analyzed. METHOD: A prospective single-center study was performed. PD patients in a 2-year period were included. A general QOL instrument was applied preoperative, 1, 3, 6, and 12 months after surgery and compared with national norms. RESULTS: Thirty-seven patients were recruited. Twenty of 37 were female. Ampullary carcinoma 14/37, ductal adenocarcinoma in 9/37, and other malignant neoplasms 14/37 were diagnosed. Mortality was absent; 48.6% had complications, 13.5 % required reoperation. Three (median) and 4 (mode) questionnaires were answered per individual. 85 % answered the last questionnaire. 4/37 had cancer related death before a year. Median follow-up was 29 (3-72) months. QOL diminished a month after surgery, physical function (67 vs 40, p<0.0001) and emotional role (37 vs 17, p<0.032) did so significantly. Three months after surgery QOL improved yet not significantly. Six and 12 months postoperatively, physical role (9 vs 49, p=0.001), physical pain (51 vs 71, p=0.01), social function (52 vs 63, p=0.014), vitality (54 vs 64, p=0.018), and emotional role (41 vs 69, p=0.006) improved significantly. DISCUSSION: PD has a favorable impact in quality of life as demonstrated by the improvement of most parameters assessed in the postoperative period.

Malignant insulinoma arising from intrasplenic heterotopic pancreas.

CONTEXT: Heterotopic pancreas is defined as ectopic pancreatic tissue without vascular or anatomic continuity with the normal pancreas. The spleen is a rare site of origin. This case report describes a patient with a malignant insulinoma which originated from an intrasplenic heterotopic pancreas. CASE REPORT: A 46-year-old man with three previous episodes of neuroglucopenic and adrenergic symptoms was referred to our hospital. A fasting test was performed and discontinued due to hypoglycemic symptoms. Preoperative studies failed to demonstrate any pancreatic lesions. However, a heterogeneous encapsulated tumor in the spleen was found on MRI. During surgery, only the splenic tumor was found, with neither vascular nor anatomical connections to the normal pancreas. Pathology reported a malignant insulinoma. Insulin and proinsulin were documented by immunohistochemistry. After one year of follow up, the patient is free of symptoms and no recurrent disease has been documented. DISCUSSION: Only seven cases of splenic heterotopic pancreas have been reported, six with cystic mucinous neoplasms. In addition, only one case of a malignant insulinoma arising from heterotopic pancreas has previously been described. This is the second case reported of an insulinoma arising from heterotopic pancreas and the first to originate from intrasplenic heterotopia.

Time frames for analysis of inflammatory mediators in acute pancreatitis: improving admission triage.

Improving the outcome of acute pancreatitis through prognostic markers has been a matter of ample research. We evaluate the clinical usefulness of four serum markers in comparison to Ranson's score. Serum measurements of C-reactive protein (CRP), interleukin-6, -10 (IL-6, IL-10), and pancreatitis-associated protein (PAP) were performed. The usefulness of each marker for predicting severity was compared with that of Ranson's score. Time of evolution was considered for improving their usefulness. Seventy-one patients were studied. Severe cases had higher levels of all markers, although only IL-10 had better accuracy than Ranson's. In patients admitted during the first 48 h, IL-6, IL-10, and PAP had improved accuracy over Ranson's; however, after this time frame, only CRP outperformed Ranson's score. Analysis of time frames improved the accuracy of all markers. Therefore, time of evolution should be considered when using these parameters for a better prognosis.

High prevalence of celiac disease in Mexican Mestizo adults with type 1 diabetes mellitus.

BACKGROUND AND AIMS: Recent studies have shown that celiac disease (CD) could affect 0.5% to 3% of the general population, including Mexican Mestizos, which represents a complex mixture of genetics, and constitutes the core of Mexican and Latin American populations. However, the association between CD and other conditions, specifically type-1 diabetes mellitus, in this population remains unknown. Thus, our aim was to determine the prevalence of both serologic and biopsy proven CD in Mexican Mestizo adults with type-1 diabetes. METHODS: Over a 6-month period, serum samples obtained from consecutive Mexican Mestizo adult patients (age >or=18 y) with type-1 diabetes were tested with a new generation human recombinant protein based IgA tissue transglutaminase enzyme-linked immunosorbent assay commercial kit. All patients with positive serologic test results underwent upper gastrointestinal endoscopy and small intestinal biopsies to confirm CD. RESULTS: Eighty-four type-1 diabetic patients were included (62 women, mean age 28.9+/-9 y). Overall, 9 patients (9/84) were positive for IgA tissue transglutaminase with a point prevalence of 10.7% (95% CI, 4%-17%). Seven patients agreed to undergo endoscopy. Five subjects had biopsy-proven CD (5.9%, 95% CI, 1.9%-13.3%). One patient had chronic diarrhea and other abdominal bloating; whereas the remaining 3 were asymptomatic. CD associated type-1 diabetic patients tended to have higher hemoglobin A1c levels (P=0.07), reflecting poor glycemic control. CONCLUSIONS: As in other populations, we demonstrated a high prevalence of biopsy-proven CD (5.9%) among Mexican Mestizo patients with type-1 diabetes. Clinicians should be aware of this common association in this ethnic group.

Oral challenge with a methionine load in patients with inflammatory bowel disease: a better test to identify hyperhomocysteinemia.

BACKGROUND: Patients with inflammatory bowel disease have an increased risk of thrombosis. Hyperhomocysteinemia is one of the factors that have been related to thromboembolic complications. Patients with hyperhomocysteinemia and normal fasting homocysteine levels can be identified with an oral methionine load. We studied homocysteine levels in patients with IBD during fasting and after methionine load to determine the true prevalence of hyperhomocysteinemia and its relation with thrombotic events. METHODS: Prospective analysis of homocysteine levels in consecutive patients with IBD during fasting and 6-8 hours after an oral methionine load. Levels of folate and vitamin B12 were also determined. History of thrombotic events were recorded. RESULTS: Eighty-two patients with IBD, 56 with UC and 26 with CD were included. Eighteen patients (22%) had hyperhomocysteinemia during fasting. Mean levels of homocysteine after methionine load were 20.4 +/- 18.1 micromol/l (range, 1-79.7 micromol/l), and 43 patients (52%) had hyperhomocysteinemia (> or =20 micromol/l) after methionine load. Six patients (7.3%) had history of thrombosis. The homocysteine levels during fasting and after methionine load were significantly higher in patients with thrombotic events than in patients without thrombosis (15.5 +/- 3.7 micromol/l vs. 6.6 +/- 6.5 micromol/l; P = 0.002; 44.5 +/- 20.9 micromol/l vs. 18.4 +/- 16.5 micromol/l; P < 0.001, respectively). CONCLUSIONS: There is a higher prevalence of hyperhomocysteinemia in IBD patients than previously thought, this can be identified with an oral challenge of a methionine load. Hyperhomocysteinemia increases the risk of thromboembolic complications in patients with IBD.

Pancreaticoduodenectomy in a Latin American country: the transition to a high-volume center.

OBJECTIVE: To analyze data in a single institution series of pancreaticoduodenectomies (PD) performed in a 7-year period after the transition to a high-volume center for pancreatic surgery. BACKGROUND: PD has developed dramatically in the last century. Mortality is minimal yet complications are still frequent (around 40%). There are very few reports of PD in Latin America. METHODS: Data on all PDs performed by a single surgeon from March 2000 to July 2006 in our institution were collected prospectively. RESULTS: During the study's time frame 122 PDs were performed; 84% were classical resections. Mean age was 57.9 years. Of the patients, 51% were female. Intraoperative mean values included blood loss 881 ml, operative time 5 h and 35 min, and vein resection in 14 cases. Both ampullary and pancreatic cancer accounted for 34% of cases (42 patients each), 5.7% were distal bile duct and 4% duodenal carcinomas. Benign pathology included chronic pancreatitis, neuroendocrine tumors, cystic lesions, and other miscellaneous tumors. Overall operative mortality was 6.5% in the 7-year period, 2.2% in the later 5 years. There was a total of 75 consecutive PDs without mortality. Of the patients, 41.8% had one or more complications. Mean survival for pancreatic cancer was 22.6 months and ampullary adenocarcinoma was 31.4 months. CONCLUSION: To our knowledge, this is the largest single surgeon series of PD performed in Latin America. It emphasizes the importance of experience and expertise at high-volume centers in developing countries.