RESUMO
BACKGROUND AND AIMS: Bile leaks are uncommon but are a painful postoperative complication of hepatobiliary interventions. Many authors advocate treating them with biliary stenting. We compared the outcomes in patients treated with endoscopic biliary sphincterotomy (EBS) alone versus EBS with biliary stenting. METHODS: We reviewed charts of patients treated endoscopically for bile leak from 2009 to 2015 at our tertiary care center. Based on endoscopists' practice preference, patients underwent EBS alone or with a biliary stent. Clinical resolution of bile leak and total number of endoscopic and nonendoscopic interventions were compared between patients treated with EBS alone versus EBS with a biliary stent. RESULTS: Fifty-eight patients were included; etiology was cholecystectomy (52), hepatic resection (5), and liver trauma (1). The leak was from the cystic duct (22), duct of Luschka (23), common bile, or hepatic duct (2), and intrahepatic duct (11). Thirty-seven patients had EBS alone (EBS group), and 21 had stents (stent group). Single intervention resolved the bile leak in 34 (92%) patients in EBS group and 19 (90%) in the stent group (p = 0.85). Resolution was slower (p = 0.02) and more patients required second intervention (p < 0.01) in the stent group. CONCLUSION: EBS with or without a biliary stent is highly effective in the management of bile leak. Clinical resolution of the bile leak is quicker with EBS alone, requires fewer interventions, and may cost less.
Assuntos
Ductos Biliares/cirurgia , Bile/metabolismo , Esfinterotomia Endoscópica , Stents , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Resultado do TratamentoRESUMO
BACKGROUND: Only a small proportion of patients with biliary tree infection grow microorganisms in blood cultures. Antibiotics chosen or tailored based on organisms identified on blood cultures have a potential for under-treatment and unfavorable outcomes, including recurrent infection and early stent occlusion. In our current practice, we collect bile for culture if an Endoscopic Retrograde Cholangio-Pancreatography (ERCP) is performed in patients with suspected cholangitis. In this study, we compare the microbial yield of blood cultures and ERCP-obtained bile cultures in patients with ascending cholangitis. METHODS: We reviewed medical records of all the patients treated for ascending cholangitis who had blood cultures and ERCP-obtained bile cultures at a tertiary care center between 2010 and 2016. Bile was collected for culture before injecting contrast, via a catheter after discarding the initial 3 mL. RESULTS: Ninety-three patients were included with mean age of 71 (±15) years. Out of 93 patients, 11 (12%) had prior sphincterotomy, 29 (31%) had an indwelling biliary stent, and malignant obstruction was the most common etiology (34%). ERCP-obtained bile cultures were positive in 90 out of 93 (97%) patients with monomicrobial growth in 34 out of 93 (39%) patients. Mixed intestinal flora was noted in 3 patients. Blood cultures were positive in only 30 out of 93 patients (32%) and 24 out of 93 (26%) patients had monomicrobial growth. Totally 26 out of 30 patients (87%) grew the same organism as the bile culture, 3 grew an organism different from bile cultures, and one had no growth in the bile culture. On multivariable analysis, the presence of an indwelling biliary stent was the lone factor associated with polymicrobial growth, 83 vs. 52%, p = 0.007. CONCLUSION: ERCP-obtained bile cultures are a reliable and feasible mechanism to evaluate patients with suspected biliary tree infection. This technique has a significantly higher yield when compared to blood culture. Selection and tailoring of antibiotics based on bile culture in the management of ascending cholangitis are advised.
Assuntos
Antibacterianos/uso terapêutico , Bile/metabolismo , Colangiopancreatografia Retrógrada Endoscópica , Colangite/tratamento farmacológico , Doença Aguda , Adulto , Idoso , Idoso de 80 Anos ou mais , Antibacterianos/farmacologia , Bactérias/efeitos dos fármacos , Bactérias/crescimento & desenvolvimento , Bile/microbiologia , Colangite/sangue , Colangite/microbiologia , Feminino , Humanos , Masculino , Pessoa de Meia-IdadeRESUMO
BACKGROUND/AIMS: The vast majority of serous cystic neoplasms of the pancreas are benign, and small, asymptomatic lesions, which are generally managed with observation. However, some of these tumors may attain a large size and occasionally metastasize. METHODS: In this study, we present a 78-year-old man with serous cystadenocarcinoma of the pancreas with liver metastases treated by distal pancreatectomy and liver ablation, who went on to develop new liver metastases 5 years after the initial operation. We perform a literature review to determine the number of these malignant neoplasms previously reported and to identify features associated with malignant lesions. RESULTS: Literature reveals that metastatic serous cystadenocarcinomas of the pancreas are rare tumors, occurring in less than 3% of cases of serous cystic neoplasms. All malignant cases reported have been in tumors >4 cm in size. CONCLUSIONS: Serous cystic neoplasms of the pancreas >4 cm have malignant potential and therefore should be considered for surgical management.
Assuntos
Cistadenocarcinoma Seroso/secundário , Cistadenocarcinoma Seroso/cirurgia , Neoplasias Hepáticas/cirurgia , Neoplasias Pancreáticas/patologia , Neoplasias Pancreáticas/cirurgia , Idoso , Ablação por Cateter , Cistadenocarcinoma Seroso/diagnóstico por imagem , Humanos , Neoplasias Hepáticas/diagnóstico por imagem , Neoplasias Hepáticas/secundário , Masculino , Pancreatectomia , Neoplasias Pancreáticas/diagnóstico por imagem , Tomografia Computadorizada por Raios X , Carga TumoralRESUMO
BACKGROUND: Unresectable tumors of the pancreatic head are encountered in up to 20% of patients taken for resection. The objective of this study was to evaluate the complications and outcome associated with palliative surgical procedures to help guide management decisions in these patients. METHODS: Patients with pancreatic head adenocarcinoma taken to the operating room with curative intent who did not undergo pancreatectomy were evaluated. RESULTS: From 1997 to 2013, 50 patients were explored and found be unresectable due to M1 disease (n = 27, 54.0%) or vascular invasion (n = 23, 46.0%). Among unresectable patients, 34 (68.0%) had a palliative procedure performed including double bypass (n = 13), biliary bypass (n = 7), gastrojejunostomy (n = 5), or cholecystectomy (n = 9). Complications occurred in 22 patients (44.0%), and patients who had a palliative operation had a longer hospital stay and more major complications. Overall survival was reduced in patients treated with a palliative operation. CONCLUSIONS: Despite advancements in endoscopic palliation, operative bypasses are still commonplace in patients with unresectable pancreatic head cancer. In this study, patients treated with operative procedures had a high rate of complications without a notable improvement in outcome. These findings highlight the importance of identifying unresectable disease prior to surgery and support a selective approach to palliative operations.
Assuntos
Adenocarcinoma/cirurgia , Neoplasias Pancreáticas/cirurgia , Complicações Pós-Operatórias/epidemiologia , Adenocarcinoma/mortalidade , Adenocarcinoma/patologia , Adulto , Idoso , Idoso de 80 Anos ou mais , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estadiamento de Neoplasias , Cuidados Paliativos , Neoplasias Pancreáticas/mortalidade , Neoplasias Pancreáticas/patologia , Complicações Pós-Operatórias/etiologia , Estudos RetrospectivosRESUMO
OBJECTIVE: To report the experience in surveillance and early detection of cholangiocarcinoma (CC) and in using en bloc total hepatectomy-pancreaticoduodenectomy-orthotopic liver transplantation (OLT-Whipple) to achieve complete eradication of early-stage CC complicating primary sclerosing cholangitis (PSC). METHODS: Asymptomatic PSC patients underwent surveillance using endoscopic ultrasound and endoscopic retrograde cholangiopancreatography (ERCP) with multilevel brushings for cytological evaluation. Patients diagnosed with CC were treated with combined extra-beam radiotherapy, lesion-focused brachytherapy, and OLT-Whipple. RESULTS: Between January 1988 and February 2001, 42 of 119 PSC patients were followed according to the surveillance protocol. CC was detected in 8 patients, 6 of whom underwent OLT-Whipple. Of those 6 patients, 4 had stage I CC, and 2 had stage II CC. All 6 OLT-Whipple patients received combined external-beam and brachytherapy radiotherapy. The median time from diagnosis to OLT-Whipple was 144 days. One patient died 55 months post-transplant of an unrelated cause, without tumor recurrence. The other 5 were well without recurrence at 79, 82, 108, 128, 129 and 145 months. CONCLUSIONS: For patients with PSC, ERCP surveillance cytology and intralumenal endoscopic ultrasound examination allow for early detection of CC. Broad and lesion-focused radiotherapy combined with OLT-Whipple to remove the biliary epithelium en bloc offers promising long-term, tumor-free survival. All patients tolerated this extensive surgery well with good quality of life following surgery and recovery. These findings support consideration of the complete excision of an intact biliary tree via OLT-Whipple in patients with early-stage hilar CC complicating PSC.
Assuntos
Neoplasias dos Ductos Biliares/cirurgia , Ductos Biliares Intra-Hepáticos , Colangiocarcinoma/cirurgia , Adolescente , Adulto , Neoplasias dos Ductos Biliares/diagnóstico , Neoplasias dos Ductos Biliares/radioterapia , Colangiocarcinoma/diagnóstico , Colangiocarcinoma/radioterapia , Intervalo Livre de Doença , Diagnóstico Precoce , Feminino , Seguimentos , Hepatectomia , Humanos , Transplante de Fígado , Masculino , Programas de Rastreamento , Pessoa de Meia-Idade , Pancreaticoduodenectomia , Estudos RetrospectivosRESUMO
BACKGROUND: Bilateral vs unilateral biliary stenting is used for palliation in malignant biliary obstruction. No clear data is available to compare the efficacy and safety of bilateral biliary stenting over unilateral stenting. AIM: To assess the efficacy and safety of bilateral vs unilateral biliary drainage in inoperable malignant hilar obstruction. METHODS: PubMed, Embase, Scopus, and Cochrane databases, as well as secondary sources (bibliographic review of selected articles and major GI proceedings), were searched through January 2019. The primary outcome was the re-intervention rate. Secondary outcomes were a technical success, early and late complications, and stent malfunction rate. Pooled odds ratio (OR) and 95% confidence interval (CI) were calculated for each outcome. RESULTS: A total of 9 studies were included (2 prospective Randomized Controlled Study, 5 retrospective studies, and 2 abstracts), involving 782 patients with malignant hilar obstruction. Bilateral stenting had significantly lower re-intervention rate compared with unilateral drainage (OR = 0.59, 95%CI: 0.40-0.87, P = 0.009). There was no difference in the technical success rate (OR = 0.7, CI: 0.42-1.17, P = 0.17), early complication rate (OR = 1.56, CI: 0.31-7.75, P = 0.59), late complication rate (OR = 0.91, CI: 0.58-1.41, P = 0.56) and stent malfunction (OR = 0.69, CI: 0.42-1.12, P = 0.14) between bilateral and unilateral stenting for malignant hilar biliary strictures. CONCLUSION: Bilateral biliary drainage had a lower re-intervention rate as compared to unilateral drainage for high grade inoperable malignant biliary strictures, with no significant difference in technical success, and early or late complication rates.
Assuntos
Neoplasias dos Ductos Biliares/complicações , Colestase/cirurgia , Drenagem/métodos , Tumor de Klatskin/complicações , Cuidados Paliativos/métodos , Neoplasias dos Ductos Biliares/cirurgia , Colestase/etiologia , Constrição Patológica/etiologia , Constrição Patológica/cirurgia , Drenagem/efeitos adversos , Drenagem/instrumentação , Ducto Hepático Comum/patologia , Ducto Hepático Comum/cirurgia , Humanos , Tumor de Klatskin/cirurgia , Complicações Pós-Operatórias/epidemiologia , Complicações Pós-Operatórias/etiologia , Reoperação/estatística & dados numéricos , Stents/efeitos adversos , Fatores de Tempo , Resultado do TratamentoRESUMO
This retrospective study reviews our experience in surveillance and early detection of cholangiocarcinoma (CC) and in using en bloc total hepatectomy-pancreaticoduodenectomy-orthotopic liver transplantation (OLT-Whipple) to achieve complete eradication of early-stage CC complicating primary sclerosing cholangitis (PSC). Asymptomatic PSC patients underwent surveillance using endoscopic ultrasound and endoscopic retrograde cholangiopancreatography (ERCP) with multilevel brushings for cytological evaluation. Patients diagnosed with CC were treated with combined extra-beam radiotherapy, lesion-focused brachytherapy, and OLT-Whipple. Between 1988 and 2001, 42 of 119 PSC patients were followed according to the surveillance protocol. CC was detected in 8 patients, 6 of whom underwent OLT-Whipple. Of those 6 patients, 4 had stage I CC, and 2 had stage II CC. All 6 OLT-Whipple patients received combined external-beam and brachytherapy radiotherapy. The median time from diagnosis to OLT-Whipple was 144 days. One patient died 55 months post-transplant of an unrelated cause, without tumor recurrence. The other 5 are well without recurrence at 5.7, 7.0, 8.7, 8.8, and 10.1 years. In conclusion, for patients with PSC, ERCP surveillance cytology and intralumenal endoscopic ultrasound examination allow for early detection of CC. Broad and lesion-focused radiotherapy combined with OLT-Whipple to remove the biliary epithelium en bloc offers promising long-term, tumor-free survival. All patients tolerated this extensive surgery well with good quality of life following surgery and recovery. These findings support consideration of the complete excision of an intact biliary tree via OLT-Whipple in patients with early-stage hilar CC complicating PSC.
Assuntos
Neoplasias dos Ductos Biliares/radioterapia , Neoplasias dos Ductos Biliares/cirurgia , Ductos Biliares Intra-Hepáticos , Colangiocarcinoma/radioterapia , Colangiocarcinoma/cirurgia , Hepatectomia/métodos , Transplante de Fígado/métodos , Adolescente , Adulto , Neoplasias dos Ductos Biliares/etiologia , Colangiocarcinoma/etiologia , Colangiopancreatografia Retrógrada Endoscópica , Colangite Esclerosante/complicações , Terapia Combinada , Intervalo Livre de Doença , Humanos , Pessoa de Meia-Idade , Pancreaticoduodenectomia/métodos , Estudos Retrospectivos , Fatores de Tempo , Resultado do TratamentoRESUMO
Carbohydrate intolerance to lactose is widely accepted as a cause of gastrointestinal symptoms, but controversy persists on how important dietary fructose intolerance (DFI) is in causing gastrointestinal pain and suffering and if an elimination diet can control the presenting complaints. The objective of this study was to identify a group of well-defined DFI patients and explore whether dietary education followed by dietary compliance could control symptoms and improve quality of life. During a 5-year period, patients referred to a pancreato-biliary clinic were evaluated for dietary carbohydrate intolerances if they presented with gastrointestinal pain and/or gas and/or bloating and/or diarrhea. Patients were tested with a standardized mixture of glucose, fructose, and lactose diluted in sterile water. End-expiratory breath samples were collected for hydrogen and methane measurement. Symptoms were scored using a 9-point symptom questionnaire. The patients underwent in-depth education by a dietician, and were provided with access to a cookbook, a newsletter, and a support group. A dietary questionnaire was used to evaluate compliance with the fructose-restricted diet. DFI can cause significant gastrointestinal symptoms that may not respond to medications or surgical interventions. Symptoms can improve and self-rated health does improve in DFI patients willing to adhere to a low fructose diet.
Assuntos
Carboidratos da Dieta/administração & dosagem , Frutose/administração & dosagem , Síndromes de Malabsorção/dietoterapia , Dor Abdominal/dietoterapia , Dor Abdominal/etiologia , Testes Respiratórios , Diarreia/dietoterapia , Diarreia/etiologia , Carboidratos da Dieta/efeitos adversos , Carboidratos da Dieta/metabolismo , Feminino , Flatulência/dietoterapia , Flatulência/etiologia , Frutose/efeitos adversos , Frutose/metabolismo , Humanos , Síndromes de Malabsorção/etiologia , Masculino , Cooperação do Paciente , Educação de Pacientes como Assunto , Qualidade de Vida , Inquéritos e Questionários , Edulcorantes/metabolismoAssuntos
Neoplasias dos Ductos Biliares/patologia , Ductos Biliares Extra-Hepáticos/patologia , Carcinoma de Células em Anel de Sinete/patologia , Colangiocarcinoma/patologia , Neoplasias dos Ductos Biliares/diagnóstico , Neoplasias dos Ductos Biliares/fisiopatologia , Neoplasias dos Ductos Biliares/terapia , Ductos Biliares Extra-Hepáticos/diagnóstico por imagem , Carcinoma de Células em Anel de Sinete/diagnóstico , Carcinoma de Células em Anel de Sinete/fisiopatologia , Carcinoma de Células em Anel de Sinete/terapia , Colangiocarcinoma/diagnóstico , Colangiocarcinoma/fisiopatologia , Colangiocarcinoma/terapia , Evolução Fatal , Feminino , Humanos , Metástase Linfática , Pessoa de Meia-Idade , Cuidados PaliativosRESUMO
My colleagues and I present 2 cases of hemorrhagic postesophagectomy gastritis after chemoradiotherapy for esophageal cancer. On the basis of the location of the gastritis (lesser curve and midstomach) and the classic radiation injury appearance, radiation damage was believed to be the cause. In both patients, hyperbaric oxygen therapy rapidly arrested bleeding. This is the first description in which hyperbaric oxygen therapy was used to treat hemorrhagic postesophagectomy gastritis.
Assuntos
Esofagectomia/efeitos adversos , Gastrite/terapia , Hemorragia Gastrointestinal/etiologia , Hemorragia Gastrointestinal/terapia , Oxigenoterapia Hiperbárica/métodos , Lesões por Radiação/terapia , Idoso , Neoplasias Esofágicas/complicações , Neoplasias Esofágicas/radioterapia , Gastrite/etiologia , Humanos , Masculino , Pessoa de Meia-Idade , Lesões por Radiação/etiologia , Resultado do TratamentoRESUMO
OBJECTIVE: The aim of this work is to evaluate the potential radiation exposure to medical personnel by comparing results from phantom studies of two different fluoroscopic units used for ERCP, and to determine which equipment or behavior modification can reduce radiation exposure. METHODS: Radiation exposures using an opaque tissue equivalent chest phantom with an abdominal insert were performed on a stationary dedicated fluoroscopy unit and a mobile C-arm unit, comparing varying equipment manipulations. Scatter radiation was recorded at 1) the patients' head, 2) where the endoscopist stands, and 3) where the equipment personnel stands. RESULTS: Radiation exposures were significantly higher for the mobile C-arm unit, revealing a 4160-times greater dosage increase for head and neck and a 8660-times increase for body than the fixed unit. Tower position and vertically stationed lead shields facilitated exposure reduction by means of equipment manipulation. The positioning of the endoscopist away from the right corner of the units also decreased exposure. CONCLUSIONS: Dedicated stationary fluoroscopy units provide significantly less radiation exposure. Equipment and behavior modification including tower positioning down and vertical shielding are essential for reduction in radiation exposure to medical personnel.