RESUMO
BACKGROUND AND STUDY AIMS: Data from Japanese series show that surface morphology of laterally spreading tumors (LST) in the colon identifies lesions with different incidence and pattern of submucosal invasion. Such data from western countries are scarce. We compared clinical and histological features of LST in a western country and an eastern country, with special interest on mucosal invasiveness of LST, and investigated the effect of clinical factors on invasiveness in both countries. PATIENTS AND METHODS: Patients with LST lesions ≥20mm were included from a multicenter prospective registry in Spain and from a retrospective registry from the National Cancer Center Hospital East, Japan. The primary outcome was the presence of submucosal invasion in LST. The secondary outcome was the presence of high-risk histology, defined as high-grade dysplasia or submucosal invasion. RESULTS: We evaluated 1102 patients in Spain and 663 in Japan. Morphological and histological characteristics differed. The prevalence of submucosal invasion in Japan was six-fold the prevalence in Spain (Prevalence Ratio PR=5.66; 95%CI: 3.96, 8.08), and the prevalence of high-risk histology was 1.5 higher (PR=1.44; 95%CI: 1.31, 1.58). Compared to the granular homogeneous type and adjusted by clinical features, granular mixed, flat elevated, and pseudo-depressed types were associated with higher odds of submucosal invasion in Japan, whereas only the pseudo-depressed type showed higher risk in Spain. Regarding high-risk histology, both granular mixed and pseudo-depressed were associated with higher odds in Japan, compared with only the granular mixed type in Spain. CONCLUSION: This study reveals differences in location, morphology and invasiveness of LST in an eastern and a western cohort.
Assuntos
Colonoscopia , Neoplasias Colorretais , Neoplasias Colorretais/epidemiologia , Neoplasias Colorretais/patologia , Humanos , Mucosa Intestinal/patologia , Invasividade Neoplásica/patologia , Estudos RetrospectivosRESUMO
OBJECTIVE: The aim of this study was to compare and validate the different classifications of severity in acute pancreatitis (AP) and to investigate which characteristics of the disease are associated with worse outcomes. SUMMARY OF BACKGROUND DATA: AP is a heterogeneous disease, ranging from uneventful cases to patients with considerable morbidity and high mortality rates. Severity classifications based on legitimate determinants of severity are important to correctly describe the course of disease. METHODS: A prospective multicenter cohort study involving patients with AP from 23 hospitals in Spain. The Atlanta Classification (AC), Revised Atlanta Classification (RAC), and Determinant-based Classification (DBC) were compared. Binary logistic multivariate analysis was performed to investigate independent determinants of severity. RESULTS: A total of 1655 patients were included; 70 patients (4.2%) died. RAC and DBC were equally superior to AC for describing the clinical course of AP. Although any kind of organ failure was associated with increased morbidity and mortality, persistent organ failure (POF) was the most significant determinant of severity. All local complications were associated with worse outcomes. Infected pancreatic necrosis correlated with high morbidity, but in the presence of POF, it was not associated to higher mortality when compared with sterile necrotizing pancreatitis. Exacerbation of previous comorbidity was associated with increased morbidity and mortality. CONCLUSION: The RAC and DBC both signify an advance in the description and differentiation of AP patients. Herein, we describe the complications of the disease independently associated to morbidity and mortality. Our findings are valuable not only when designing future studies on AP but also for the improvement of current classifications.
Assuntos
Amilases/sangue , Pancreatite Necrosante Aguda/diagnóstico , Idoso , Biomarcadores/sangue , Progressão da Doença , Feminino , Seguimentos , Humanos , Tempo de Internação/tendências , Masculino , Pessoa de Meia-Idade , Pancreatite Necrosante Aguda/sangue , Pancreatite Necrosante Aguda/mortalidade , Prognóstico , Estudos Prospectivos , Índice de Gravidade de Doença , Espanha/epidemiologia , Taxa de Sobrevida/tendências , Tomografia Computadorizada por Raios XRESUMO
OBJECTIVE: To provide evidence-based recommendations for the management of exocrine pancreatic insufficiency (EPI) after pancreatic surgery. BACKGROUND: EPI is a common complication after pancreatic surgery but there is certain confusion about its frequency, optimal methods of diagnosis, and when and how to treat these patients. METHODS: Eighteen multidisciplinary reviewers performed a systematic review on 10 predefined questions following the GRADE methodology. Six external expert referees reviewed the retrieved information. Members from Spanish Association of Pancreatology were invited to suggest modifications and voted for the quantification of agreement. RESULTS: These guidelines analyze the definition of EPI after pancreatic surgery, (one question), its frequency after specific techniques and underlying disease (four questions), its clinical consequences (one question), diagnosis (one question), when and how to treat postsurgical EPI (two questions) and its impact on the quality of life (one question). Eleven statements answering those 10 questions were provided: one (9.1%) was rated as a strong recommendation according to GRADE, three (27.3%) as moderate and seven (63.6%) as weak. All statements had strong agreement. CONCLUSIONS: EPI is a frequent but under-recognized complication of pancreatic surgery. These guidelines provide evidence-based recommendations for the definition, diagnosis, and management of EPI after pancreatic surgery.
Assuntos
Medicina Baseada em Evidências , Insuficiência Pancreática Exócrina/terapia , Pancreatopatias/cirurgia , Complicações Pós-Operatórias/terapia , Guias de Prática Clínica como Assunto , Humanos , EspanhaRESUMO
BACKGROUND AND AIMS: Pancreatic cysts and solid lesions are routinely examined by EUS-guided FNA (EUS-FNA). The aim of this study was to compare the incidence of adverse events (AEs) of this procedure by using the lexicon recommended by the American Society for Gastrointestinal Endoscopy (ASGE). METHODS: This was a prospective and comparative study of patients who underwent EUS-FNA in which a 22-gauge needle was used. In the pancreatic cystic lesions group (group I), complete fluid evacuation in a single needle pass was attempted, and ciprofloxacin was given during the procedure and for 3 days after. In the pancreatic solid lesions group (group II), the number of passes was determined by the on-site evaluation of the sample. AEs were defined and graded according to the lexicon recommended by the ASGE. Patients were followed for 48 hours, 1 week, and 1 month after the procedure. RESULTS: A total of 146 patients were included, 73 in group I and 73 in group II. Potential factors influencing the incidence of AEs (ie, access route for FNA) were similar in both groups. AEs occurred in 5 of 146 patients (3.4%; 95% confidence interval [CI], 1.3%-8%): 4 in group I (5.5%; 95% CI, 1.7%-13.7%) and 1 in group II (1.4%; 95% CI, -0.5% to 8.1%) (P = .03). Severity was mild in 1 of 5 patients (20%) and moderate in 3 of 5 patients (60%). One patient with a solid mass in the head of the pancreas had a duodenal perforation after EUS and died after surgery. All other AEs occurred in the first 48 hours and resolved with medical therapy. There were 3 incidents of transient hypoxia and self-limited abdominal pain in 1 and 2 patients, respectively. No patients were lost to follow-up. CONCLUSION: EUS-FNA of pancreatic cysts has an AEs rate similar to that of solid pancreatic masses, which is small enough to consider this procedure a safe and effective method for managing patients with both types of lesions. AEs occurred early after EUS-FNA, and patients should be closely followed during the first 2 days after the procedure.
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Duodenopatias/etiologia , Aspiração por Agulha Fina Guiada por Ultrassom Endoscópico/efeitos adversos , Endoscopia Gastrointestinal , Perfuração Intestinal/etiologia , Cisto Pancreático/patologia , Neoplasias Pancreáticas/patologia , Sociedades Médicas , Terminologia como Assunto , Dor Abdominal/etiologia , Idoso , Feminino , Humanos , Hipóxia/etiologia , Masculino , Pessoa de Meia-Idade , Estudos ProspectivosRESUMO
BACKGROUND AND AIMS: Initial reports suggest that fully covered self-expandable metal stents (FCSEMSs) may be better suited for drainage of dense pancreatic fluid collections (PFCs), such as walled-off pancreatic necrosis. The primary aim was to analyze the effectiveness and safety of FCSEMSs for drainage of different types of PFCs in a large cohort. The secondary aim was to investigate which type of FCSEMS is superior. METHODS: This was a retrospective, noncomparative review of a nationwide database involving all hospitals in Spain performing EUS-guided PFC drainage. From April 2008 to August 2013, all patients undergoing PFC drainage with an FCSEMS were included in a database. The main outcome measurements were technical success, short-term (2 weeks) and long-term (6 months) effectiveness, adverse events, and need for surgery. RESULTS: The study included 211 patients (pseudocyst/walled-off pancreatic necrosis, 53%/47%). The FCSEMSs used were straight biliary (66%) or lumen-apposing (34%). Technical success was achieved in 97% of patients (95% confidence interval [CI], 93%-99%). Short-term- and long-term clinical success was obtained in 94% (95% CI, 89%-97%) and 85% (95% CI, 79%-89%) of patients, respectively. Adverse events occurred in 21% of patients (95% CI, 16%-27%): infection (11%), bleeding (7%), and stent migration and/or perforation (3%). By multivariate analysis, patient age (>58 years) and previous failed drainage were the most important factors associated with negative outcome. CONCLUSIONS: An FCSEMS is effective and safe for PFC drainage. Older patients with a history of unsuccessful drainage are more likely to fail EUS-guided drainage. The type of FCSEMS does not seem to influence patient outcome.
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Drenagem/instrumentação , Pâncreas/cirurgia , Pseudocisto Pancreático/cirurgia , Sistema de Registros , Stents Metálicos Autoexpansíveis , Idoso , Bases de Dados Factuais , Procedimentos Cirúrgicos do Sistema Digestório/instrumentação , Procedimentos Cirúrgicos do Sistema Digestório/métodos , Drenagem/métodos , Endossonografia , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Necrose , Pâncreas/patologia , Estudos Retrospectivos , Fatores de Risco , Espanha , Cirurgia Assistida por Computador/instrumentação , Cirurgia Assistida por Computador/métodos , Resultado do TratamentoRESUMO
Endoscopic ultrasound (EUS) and endoscopic retrograde cholangiopancreatography (ERCP) have much in common, including their main indications (biliopancreatic disorders), powerful therapeutic capacities and a steep learning curve. Over the years they have evolved from novel diagnostic procedures to interventional therapeutic techniques, but along different paths (different scopes or devices and endoscopists specializing exclusively in one or the other technique). However, EUS has gradually developed into a therapeutic technique that requires skills in the use of ERCP devices and stents, leading some ERCP specialists to explore the therapeutic potential of EUS. The corresponding literature, which has grown exponentially, includes recent experiments on combining the two techniques, which have gradually come to be used in routine care in a number of centers, with positive technical, clinical and financial outcomes. We review EUS and ERCP as individual or combined procedures for managing biliopancreatic disorders.
Assuntos
Doenças Biliares/diagnóstico por imagem , Colangiopancreatografia Retrógrada Endoscópica/métodos , Endossonografia/métodos , Imagem Multimodal/métodos , Pancreatopatias/diagnóstico por imagem , Doenças Biliares/patologia , Doenças Biliares/cirurgia , Biópsia por Agulha Fina/métodos , Drenagem , Previsões , Humanos , Curva de Aprendizado , Pancreatopatias/patologia , Pancreatopatias/cirurgia , Estudos Retrospectivos , Ultrassonografia de Intervenção/métodosRESUMO
BACKGROUND: Splanchnic vein thrombosis (SVT) is a well-recognised though little-studied complication in acute pancreatitis (AP). SVT risk factors, its clinical consequences and the role of anticoagulation (AC) therapy is scarce. AIMS: To evaluate the incidence and natural history of SVT in AP. METHODS: Post hoc analysis of a prospective multicentre cohort study involving 23 hospitals in Spain. AP complications were identified by computer tomography, and patients with SVT were re-evaluated after two years. RESULTS: A total of 1655 patients with AP were included. The overall incidence of SVT was 3.6%. SVT was significantly associated with male gender, younger age and alcoholic aetiology. Every local complication increased SVT incidence, and this risk rose gradually with larger extension and infection of necrosis. These patients had a longer hospital stay and underwent a greater number of invasive treatments, regardless of AP severity. Forty-six patients with SVT were followed up. SVT resolution rate was 54.5% in the AC group and 30.8% in the non-AC group with lower thrombotic complications in the SVT resolution group (83.3% vs 22.7%; p<0.001). No AC-related adverse events occurred. CONCLUSION: This study identifies the risk factors and negative clinical impact of SVT in AP. Our results justify future trials to demonstrate the role of AC in this clinical scenario.
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Pancreatite , Trombose , Trombose Venosa , Humanos , Masculino , Pancreatite/complicações , Pancreatite/epidemiologia , Pancreatite/induzido quimicamente , Estudos de Coortes , Estudos Prospectivos , Doença Aguda , Trombose Venosa/epidemiologia , Trombose Venosa/etiologia , Trombose Venosa/tratamento farmacológico , Trombose/complicações , Anticoagulantes/uso terapêuticoAssuntos
Doenças Biliares/etiologia , Cólica/etiologia , Corpos Estranhos/diagnóstico , Ducto Hepático Comum/patologia , Doenças Biliares/diagnóstico , Doenças Biliares/terapia , Colangiopancreatografia Retrógrada Endoscópica , Colangiopancreatografia por Ressonância Magnética , Cólica/diagnóstico , Cólica/terapia , Feminino , Corpos Estranhos/complicações , Corpos Estranhos/terapia , Ducto Hepático Comum/diagnóstico por imagem , Humanos , Pessoa de Meia-Idade , Valor Preditivo dos TestesRESUMO
Primary sclerosing cholangitis is an infrequent extraintestinal manifestation of ulcerative colitis. Damage to bile ducts is irreversible and medical therapies to prevent progression of the disease are usually ineffective. We describe a patient with long-standing ulcerative colitis, which was refractory to corticosteroid therapy who developed primary sclerosing cholangitis (biochemical stage II/IV) in the course of his pancolitis. Treatment with infliximab (5 mg/kg as an induction dose followed by maintenance doses every two months) was indicated because of steroid-dependent disease associated to primary sclerosing cholangitis as well as sacroiliitis and uveitis and previous episode of severe azathioprine-related hepatic toxicity. At present, after two years of follow-up, the patient is asymptomatic with normal liver tests and complete resumption of daily life activities. This case draws attention to the usefulness of anti-tumor necrosis factor-alpha therapy for the management of primary sclerosing cholangitis as extraintestinal manifestation of inflammatory bowel disease.
Assuntos
Anticorpos Monoclonais/uso terapêutico , Colangite Esclerosante/tratamento farmacológico , Colite Ulcerativa/tratamento farmacológico , Resistência a Medicamentos , Imunossupressores/uso terapêutico , Esteroides/uso terapêutico , Idoso , Colangite Esclerosante/diagnóstico , Colangite Esclerosante/etiologia , Colite Ulcerativa/complicações , Colite Ulcerativa/diagnóstico , Humanos , Infliximab , Masculino , Resultado do TratamentoRESUMO
Ulcerative colitis is a chronic inflammatory bowel disease of unknown etiopathogenesis and increasing incidence in recent years. Perianal complications of ulcerative colitis are rare and seem to be associated with higher extent of inflammation and a more severe course of the disease. The cases of two male patients with severe corticoid-dependent ulcerative colitis of protracted clinical course who developed perianal fistulas and abscesses successfully treated with infliximab are reported. Treatment with infliximab was followed by perianal fistula closure with marked improvement in the quality of life over 2-year follow-up period.