Complications in Patients with Surgically Altered Gastrointestinal Anatomy Undergoing Endoscopic Retrograde Cholangiopancreatography: 15-Year Experience at a Tertiary Care Center in Latin America.

BACKGROUND: Endoscopic retrograde cholangiopancreatography (ERCP) is a common procedure, but it poses challenges in patients with surgically altered gastrointestinal anatomy (SAGA). Alternative techniques like single-balloon enteroscopy (SBE), double-balloon enteroscopy (DBE), or push enteroscopy (PE) have been used, albeit with potential complications. Limited Latin American data exists on ERCP complications in SAGA patients. Our goal is to describe complications of ERCP in SAGA at a national referral institution. METHODS: Retrospective, single-center cohort study. All SAGA ERCP procedures performed at the Gastrointestinal Endoscopy Department of the National Institute of Medical Sciences and Nutrition Salvador Zubirán from January 2008 to May 2023 were included. Extracted data from records included procedure specifics, endoscope type, success, and complications. Complications were evaluated during procedure and 28-day post-procedure and classified using the AGREE system. RESULTS: A total of 266 procedures in 174 patients were included, 74% were women, and the median age was 44 years. Predominant modified anatomy was Roux-en-Y biliary reconstruction (79%), followed by Whipple procedure (13%) and subtotal gastrectomy with Roux-en-Y reconstruction (6.0%). The main indications were cholangitis with stricture (31%), stricture (19%), and cholangitis (19%). DBE was used in 89%, PE in 7.5%, and SBE in 3.4%. Success rates were 77% endoscopic, 72% technical, and 69% therapeutic; in 30%, the procedure was unsuccessful. Complications happened in 18% of cases, most commonly cholangitis (7.5%), followed by perforation (2.6%) and hemorrhage (1.9%). According to the AGREE classification, 10.9% were grades 1 and 2, 6.4% were grade 3, and 0.4% were grade 4 complications. No significant differences emerged between groups with and without complications. Procedures increased over time, but complications and unsuccessful procedures remained stable. CONCLUSION: ERCP complications align with international data, often not requiring invasive treatment. Enhanced exposure to such cases correlates with fewer complications and failures. Prospective studies are essential to identify complication and failure predictors.

Left psoas abscess due to duodenal fistula as a late complication of necrotizing pancreatitis treated by endoscopic approach.

Gastrointestinal fistulas can be a complication of severe acute pancreatitis, and their incidence is low and sporadically reported in the literature. The most frequently reported site is in the colon, followed by duodenal fistulas. Psoas abscess is a rare condition. Iliopsoas abscesses are classified as primary or secondary. Secondary abscesses develop by spreading infection from contiguous anatomical structures, such as the gastrointestinal tract. We present the case of a recurrent left psoas abscess secondary to a duodenal fistula as a late complication of necrotizing pancreatitis resolved by endoscopic treatment.

Portopulmonary Hypertension: An Updated Review.

Portal hypertension may have major consequences on the pulmonary vasculature due to the complex pathophysiological interactions between the liver and lungs. Portopulmonary hypertension (PoPH), a subset of group 1 pulmonary hypertension (PH), is a serious pulmonary vascular disease secondary to portal hypertension, and is the fourth most common subtype of pulmonary arterial hypertension. It is most commonly observed in cirrhotic patients; however, patients with noncirrhotic portal hypertension can also develop it. On suspicion of PoPH, the initial evaluation is by a transthoracic echocardiogram in which, if elevated pulmonary pressures are shown, patients should undergo right heart catheterization to confirm the diagnosis. The prognosis is extremely poor in untreated patients; therefore, management includes pulmonary arterial hypertension therapies with the aim of improving pulmonary hemodynamics and moving patients to orthotopic liver transplantation (OLT). In this article, we review in detail the epidemiology, pathophysiology, process for diagnosis, and most current treatments including OLT and prognosis in patients with PoPH. In addition, we present a diagnostic algorithm that includes the current criteria to properly select patients with PoPH who are candidates for OLT.

[Sustained virologic response in patients with hepatitis C and chronic kidney disease]. / Respuesta viral sostenida en pacientes con hepatitis C y enfermedad renal crónica.

Background: Patients with chronic kidney disease (CKD) have a higher prevalence of hepatitis C virus (HCV) infection compared to the general population, and they also present higher morbidity and mortality if they are not treated. Current treatment is based on different direct-acting antiviral (DAA) schemes, which are available in the Mexican health system. However, the efficacy and safety of DAA treatment in patients with CKD on hemodialysis and HCV infection are unknown in Mexican population. Objective: To determine the efficacy through sustained viral response (SVR) and the safety of DAAs in patients with CKD on hemodialysis and chronic HCV infection in the Mexican population. Material and methods: Real-life cohort study. Patients with CKD on hemodialysis and HCV infection treated with DAAs from a third level hospital were included. Descriptive statistics of the clinical characteristics were performed, efficacy was determined by SVR and safety with the global frequency of adverse effects associated with treatment. Results: 25 patients were included. All of them received treatment with glecaprebir/pibrentasvir for 8 weeks. The mean age was 57.8 years and the median time of CKD on hemodialysis was 5 years. 96% of patients had HCV genotype 1B. 100% of the patients presented SVR and the most frequent adverse effects were headache, nausea and fatigue. Conclusions: In the Mexican population studied, patients with HCV and CKD on hemodialysis presented a sustained viral response of 100% with glecaprevir/pibrentasvir with mild adverse effects.

Introducción: los pacientes con enfermedad renal crónica (ERC) tienen una mayor prevalencia de infección por virus de hepatitis C (VHC) en comparación con la población general y presentan mayor morbimortalidad si no se tratan. El tratamiento actual se basa en diferentes esquemas de antivirales de acción directa (ADD), disponibles en el sistema de salud mexicano; sin embargo, se desconoce su eficacia y seguridad en pacientes con ERC en hemodiálisis e infección por VHC en población mexicana. Objetivo: determinar la eficacia mediante respuesta viral sostenida (RVS) y la seguridad de los AAD en pacientes con ERC en hemodiálisis e infección crónica por VHC en población mexicana. Material y métodos: estudio de cohorte de vida real. Se incluyeron pacientes con ERC en hemodiálisis e infección por VHC tratados con AAD en un hospital de tercer nivel. Se usó estadística descriptiva de las características clínicas, se determinó eficacia mediante RVS y seguridad con la frecuencia global de efectos adversos asociados al tratamiento. Resultados: se incluyeron 25 pacientes. Todos recibieron tratamiento con glecaprebir/pibrentasvir durante ocho semanas. La media de edad fue 57.8 años y la mediana de tiempo de ERC en hemodiálisis fue de 5 años. El 96% de los pacientes presentó genotipo 1B de VHC. El 100% de los pacientes presentaron RVS y los efectos adversos más frecuentes fueron cefalea, náuseas y fatiga. Conclusiones: en la población mexicana estudiada, los pacientes con VHC y ERC en hemodiálisis presentaron respuesta viral sostenida del 100% con glecaprevir/pibrentasvir con efectos adversos leves.