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Background. Esophagogastroduodenoscopy (EGD) is an important tool in the evolving specialty of acute care surgery (ACS). Understanding the types of nonelective EGDs performed by ACS groups is important for the development of ACS programs and the training of future general surgeons. Methods. We conducted a retrospective review of all EGDs performed by ACS surgeons at a single urban academic center over a 5-year period (January 2013-December 2018). Results. A total of 495 EGDs were performed, of which 129 (26%) were urgent, nonelective procedures. Patients who underwent urgent EGD were younger than those who underwent elective procedures (median 55 vs 60 years, P = .03), had higher American Society of Anesthesiologists (ASA) classes (median ASA 3 vs 2, P = .0002), and longer hospital stays (median 5 days vs 0 days, P < .0001). The most common indications for urgent endoscopies were the management of leak, dysphagia, or stenosis in patients with a history of foregut surgery, followed by the management of esophageal perforation. The success rate of endoscopic therapy was high (median 88%, interquartile range (IQR) 78-89%). However, some patients required multiple interventions (median 1, IQR 1-3), and patients treated for leaks were less likely to be successfully treated with endoscopic therapy alone than patients treated for other indications (success rate 65% vs 88%, P = .003). Conclusions. Our experience suggests that EGD has an important role in current ACS practice and that endoscopic management is safe and effective in a range of urgent surgical scenarios. Future ACS surgeons should be facile with endoscopic techniques.
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Cirurgiões , Endoscopia Gastrointestinal , Humanos , Tempo de Internação , Estudos RetrospectivosRESUMO
BACKGROUND: Ampullary stenosis following Roux-en-Y gastric bypass (RYGB) is increasingly encountered. We describe cases of biliary obstruction from ampullary stenosis and choledocholithiasis to illustrate the associated diagnostic and interventional challenges with this condition. METHODS: We reviewed medical records of patients with prior RYGB who underwent a biliary access procedure or surgery for non-malignant disease from January 2012-December 2018. RESULTS: We identified 15 patients (4 male, 11 female; mean age 53.7 years) who had RYGB on average 11.7 years (range 1-32) years before diagnosis of biliary obstruction. Fourteen patients reported abdominal pain, 5 had nausea/emesis, 12 had elevated liver function tests, and 6 had ascending cholangitis. Mean common bile duct (CBD) diameter at presentation was 16.9 mm (range 4.0-25.0 mm). Operations included 3 transduodenal ampullectomies (2 with biliary bypass), 2 CBD explorations with stone extraction, 1 laparoscopic cholecystectomy alone, 1 Whipple procedure, 1 balloon enteroscopy with sphincterotomy, and 7 transgastric endoscopic retrograde cholangiopancreatography. All ampulla pathology was benign in patients who underwent resection. At follow-up (mean 15.4 months; range 0.23-44.5 months), 12/15 (80%) reported symptom resolution or improvement. DISCUSSION: Ampullary stenosis after RYGB presents challenges for diagnostic evaluation and intervention, often requiring multi-disciplinary expertise. The underlying pathology remains to be elucidated.
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Coledocolitíase , Derivação Gástrica , Colangiopancreatografia Retrógrada Endoscópica/efeitos adversos , Coledocolitíase/diagnóstico por imagem , Coledocolitíase/cirurgia , Ducto Colédoco/diagnóstico por imagem , Ducto Colédoco/cirurgia , Constrição Patológica , Feminino , Derivação Gástrica/efeitos adversos , Humanos , Masculino , Pessoa de Meia-Idade , Estudos RetrospectivosRESUMO
Background and aims Precut papillotomy is widely used after failed biliary cannulation. Endoscopic ultrasound (EUS)-guided biliary access techniques are newer methods to facilitate access and therapy in failed cannulation. We evaluated the impact of EUS-guided biliary access on endoscopic retrograde cholangiopancreatography (ERCP) success and compared these techniques to precut papillotomy. Patients and methods We retrospectively compared two ERCP cohorts. One cohort consisted of biliary ERCPs (nâ=â1053) attempted in patients with native papillae and surgically unaltered anatomy in whom precut papillotomy and/or EUS-guided biliary access were routinely performed immediately after failed cannulation. This cohort was compared with a similar ERCP cohort (nâ=â1062) in which only precut papillotomy was available for failed cannulation. The following outcomes were compared: conventional cannulation success, rates of attempted advanced access techniques (precut or EUS), precut success, EUS-guided biliary access success, and ERCP failure rates. Results Although conventional cannulation success, rates of attempted advanced access technique (precut or EUS), and precut success were similar, the ERCP failure rate was lower when both EUS-guided biliary access and precut were available (1.0â% [95â% confidence interval (CI) 0.4â-â1.6]), compared with when only precut was possible for failed access (3.6â% [95â%CI 2.5â-â4.7]; Pâ<â0.001). Success for EUS-guided biliary access (95.1â% [95â%CI 89.7â-â100]) was significantly higher than for precut (75.3â% [95â%CI 68.2â-â82.4]; Pâ<â0.001), and mainly due to superiority in malignant obstruction (93.5â% vs. 64â%; Pâ<â0.001). Conclusions EUS-guided biliary access decreases the rate of therapeutic biliary ERCP failure. Our results support the use of EUS-guided biliary access to optimize single-session ERCP success. In experienced hands, these techniques appear as effective, if not more so, than precut papillotomy.
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Doenças Biliares , Cateterismo , Colangiopancreatografia Retrógrada Endoscópica , Endossonografia/métodos , Esfinterotomia Endoscópica/métodos , Idoso , Ampola Hepatopancreática/diagnóstico por imagem , Ampola Hepatopancreática/cirurgia , Doenças Biliares/diagnóstico , Doenças Biliares/cirurgia , Cateterismo/efeitos adversos , Cateterismo/métodos , Colangiopancreatografia Retrógrada Endoscópica/efeitos adversos , Colangiopancreatografia Retrógrada Endoscópica/métodos , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Avaliação de Processos e Resultados em Cuidados de Saúde , Estudos RetrospectivosRESUMO
Diarrhea in patients with acquired immune deficiency syndrome (AIDS) has proven to be both a diagnostic and treatment challenge since the discovery of the human immunodeficiency virus (HIV) virus more than 30 years ago. Among the main etiologies of diarrhea in this group of patients are infectious agents that span the array of viruses, bacteria, protozoa, parasites, and fungal organisms. In many instances, highly active antiretroviral therapy remains the cornerstone of therapy for both AIDS and AIDS-related diarrhea, but other targeted therapies have been developed as new pathogens are identified; however, some infections remain treatment challenges. Once identifiable infections as well as other causes of diarrhea are investigated and excluded, a unique entity known as AIDS enteropathy can be diagnosed. Known as an idiopathic, pathogen-negative diarrhea, this disease has been investigated extensively. Atypical viral pathogens, including HIV itself, as well as inflammatory and immunologic responses are potential leading causes of it. Although AIDS enteropathy can pose a diagnostic challenge so too does the treatment of it. Highly active antiretroviral therapy, nutritional supplementation, electrolyte replacements, targeted therapy for infection if indicated, and medications for symptom control all are key elements in the treatment regimen. Importantly, a multidisciplinary approach among the gastroenterologist, infectious disease physician, HIV specialists, oncology, and surgery is necessary for many patients.
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Infecções Oportunistas Relacionadas com a AIDS/tratamento farmacológico , Antibacterianos/uso terapêutico , Terapia Antirretroviral de Alta Atividade/métodos , Enteropatia por HIV/tratamento farmacológico , HIV , Humanos , Resultado do TratamentoRESUMO
OBJECTIVES: To assess the completeness of gastrointestinal (GI) inpatient consultations at an academic teaching hospital. METHODS: We conducted a prospective, cross-sectional study of 278 inpatient GI consultation requests evaluated from 1 July 2005 to 31 May 2007. A questionnaire assessing multiple aspects of the requesting health-care providers' knowledge and documentation of patient information was completed by first-year GI fellows. Completeness of the consultation was evaluated by the GI consultation attending physician. RESULTS: The most frequent consultation requests pertained to patients with GI hemorrhage (52.5%) and were made by first-year residents (56.8%). In 15% of requests, health-care providers lacked basic knowledge about the patients for whom consultations were sought. Conversely, in 17% of consultations, pertinent information could not be located in patients' paper medical chart/electronic medical record. The strongest predictors for a complete consultation were requesters' knowledge of patients' past medical history (P < 0.001), documentation of patients' current illness (P < 0.001), and presence of the providers' admission note in the paper medical chart (P = 0.002). Consultations requested between 5 and 10 PM were assessed to be more complete (P = 0.02), and more incomplete consultations occurred in the first 3 months of the academic year (P = 0.04). CONCLUSIONS: In 16% of inpatient GI consultation requests analyzed, crucial patient data were missing or were unknown by the requesting provider. Several aspects of requesting providers' knowledge and documentation of patient information were strongly associated with completeness of inpatient GI consultations.
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Gastroenterologia/estatística & dados numéricos , Gastroenteropatias/diagnóstico , Conhecimentos, Atitudes e Prática em Saúde , Pacientes Internados , Encaminhamento e Consulta/estatística & dados numéricos , Estudos Transversais , Documentação , Feminino , Hospitais de Ensino , Humanos , Modelos Lineares , Masculino , Estudos Prospectivos , Inquéritos e QuestionáriosRESUMO
BACKGROUND: : Pancreatic injury occurs in from 3% to 12% of patients with abdominal trauma. In many instances, a lack of impressive findings in the first 24 hours leads to a delay in diagnosis. Because pancreatic duct disruption is the major cause of traumatic pancreatitis, we evaluated our experience with endoscopic retrograde cholangiopancreatography (ERCP) in patients suspected of having of having pancreatic injury. METHODS: : We reviewed the medical records of 26 patients evaluated perioperatively by ERCP for suspected pancreatic duct injury. The examinations were performed in the endoscopy suite or radiography special procedures or operating rooms under direct fluoroscopic control using fiberoptic or videooptic duodenoscopes. RESULTS: : Seventeen men and nine women with a mean age of 32.8 +/- 2.2 years suffered severe abdominal trauma. ERCP was performed in these patients a mean of 19 +/- 11.3 days after trauma. Seven patients underwent ERCP just before or at laparotomy. Eight of 26 (31%) patients were found to have intact pancreatic and bile ducts, whereas 18 (69%) patients had substantial findings unsuspected by pre-ERCP imaging. Nine of these 18 patients with documented ductal injury underwent endoscopic treatment alone without further surgical intervention, including pancreatic sphincterotomies and/or pancreatic ductal stenting. CONCLUSIONS: : ERCP is feasible and strongly indicated in the care of many patients with pancreatic trauma. Patient care and overall surgical and hospital needs may be substantially impacted by the use of both diagnostic and therapeutic endoscopic retrograde colongiopancreatography.
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Traumatismos Abdominais/diagnóstico por imagem , Traumatismos Abdominais/cirurgia , Colangiopancreatografia Retrógrada Endoscópica , Pâncreas/lesões , Adolescente , Adulto , Estudos de Coortes , Estudos de Viabilidade , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Reprodutibilidade dos Testes , Estudos Retrospectivos , Esfinterotomia Endoscópica , Stents , Resultado do Tratamento , Adulto JovemRESUMO
BACKGROUND: Bariatric surgery is the most effective long-term treatment for obesity. Opioid-sparing anesthesia and multimodal analgesia such as lidocaine infusion have been recommended in these patients to reduce opioid-related complications. However, evidence supporting its use for bariatric surgery population is limited. OBJECTIVE: To investigate whether intraoperative lidocaine infusion is associated with decreasing opioid consumption in laparoscopic bariatric surgery. SETTING: A university hospital, California, USA. METHODS: In this retrospective cohort study, outcomes among consecutive obese patients undergoing laparoscopic bariatric surgery between January 2016 to December 2018 were evaluated to determine the impact of adjunctive intraoperative lidocaine infusion on 24-hour postoperative opioid consumption. Secondary outcomes, including opioid consumption during hospitalization, length of stay, and postoperative complications were determined. Post hoc analyses were performed exploring possible dose effects and drug-drug interactions. Univariable and multivariable analyses were performed to identify factors associated with opioid consumption. RESULTS: Among 345 patients, 54 (15.7%) received intraoperative lidocaine infusion (L+) whereas 291 (84.3%) did not receive intraoperative lidocaine infusion (L-). Both L+ and L- groups shared similar demographic characteristics. The 24-hour postoperative opioid consumption was 17.6% lower in L+ (95% confidence interval -28.4 to -5.2, P = .007), but nonsignificantly lower in the multivariate model (12.8%, 95% confidence interval -24.4 to .5, P = .06). Opioid consumption during hospitalization, length of stay, and other clinically significant outcomes did not differ. However, subgroup analysis restricted to opioid-naïve patients indicated significantly reduced opioid consumption in the L+ group. Post hoc analysis suggested interaction between lidocaine and ketamine in decreasing 24-hour postoperative opioid consumption. CONCLUSIONS: Intraoperative lidocaine infusion was not significantly associated with decreasing 24-hour postoperative opioid consumption in obese patients undergoing laparoscopic bariatric surgery.
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Cirurgia Bariátrica , Laparoscopia , Analgésicos Opioides , Anestésicos Locais , Humanos , Lidocaína , Obesidade/cirurgia , Medição da Dor , Dor Pós-Operatória/tratamento farmacológico , Dor Pós-Operatória/etiologia , Estudos RetrospectivosRESUMO
BACKGROUND: To evaluate, at a university tertiary referral center, the safety and efficacy of laparoscopic Roux-en-Y gastric bypass (LRYGB) in patients with end-stage renal disease (ESRD) and laparoscopic sleeve gastrectomy (LSG) in patients with cirrhosis or end-stage lung disease (ESLD); and to determine whether these procedures help patients become better candidates for transplantation. METHODS: A retrospective review was performed of selected patients with end-stage organ failure who were not eligible for transplantation because of morbid obesity who underwent LRYGB or LSG. The prospectively collected data included demographics, operative details, complications, percentage of excess weight loss, postoperative laboratory data, and status of transplant candidacy. RESULTS: Of the 15 patients, 7 with ESRD underwent LRYGB and 6 with cirrhosis and 2 with ESLD underwent LSG. Complications developed in 2 patients (both with cirrhosis); no patient died. The mean follow-up was 12.4 months, and the mean percentage of excess weight loss at > or =9 months was 61% (ESRD), 33% (cirrhosis), and 61.5% (ESLD). Obesity-associated co-morbidities improved or resolved in all patients. Serum albumin and other nutritional parameters at > or =9 months after surgery were similar to the preoperative levels in all 3 groups. At the most recent follow-up visit, 14 (93%) of 15 patients had reached our institution's body mass index limit for transplantation and were awaiting transplantation; 1 patient with ESLD underwent successful lung transplant. CONCLUSION: The results of this pilot study have provided preliminary evidence that LRYGB in patients with ESRD and LSG in patients with cirrhosis or ESLD is safe, well-tolerated, and improves their candidacy for transplantation.
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Derivação Gástrica/métodos , Falência Renal Crônica/cirurgia , Transplante de Rim , Laparoscopia , Cirrose Hepática/cirurgia , Transplante de Fígado , Pneumopatias/cirurgia , Transplante de Pulmão , Obesidade Mórbida/cirurgia , Adulto , Anastomose em-Y de Roux , Feminino , Humanos , Falência Renal Crônica/complicações , Cirrose Hepática/complicações , Pneumopatias/complicações , Masculino , Pessoa de Meia-Idade , Obesidade Mórbida/complicações , Projetos Piloto , Estudos RetrospectivosRESUMO
BACKGROUND: The aims of this study were to determine the rate of gastrojejunostomy (GJ) stricture following Roux-en-Y gastric bypass (RYGBP), the independent predictors of stricture, and clinical outcomes with and without a stricture. METHODS: Univariate and multivariate analysis of peri-operative and outcomes data were prospectively collected from 379 morbidly obese patients who underwent consecutive open or laparoscopic RYGBP from January 2003 to August 2006. Predictors studied were age, gender, BMI, co-morbidities, surgical technique (hand-sewn vs linear stapler vs 21-mm vs 25-mm circular stapler; open vs laparoscopic; retrocolic retrogastric vs antecolic antegastric Roux limb course, and Roux limb length), and surgeon experience. Outcomes studied consisted of occurrence of GJ strictures, technical details and outcomes after endoscopic therapy, and excess weight loss (EWL) at 12 months. RESULTS: 15 patients (4.1%) developed a GJ stricture. The use of a 21-mm circular stapler was identified as the only independent predictor of a GJ stricture (odds ratio 11.3; 95% CI 2.2-57.4, P = 0.004). Endoscopic dilation relieved stricture symptoms in all patients (60% one dilation only). There was no significant difference in %EWL at 12 months between the patients with a stricture (median EWL 54%, IQR 49-63) vs. those without a stricture (median EWL 61%, ent predictor of GJ stricture. Endoscopic dilation relieved symptoms in all patients. Weight loss is independent of the anastomotic technique used and occurrence of a GJ stricture.
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Derivação Gástrica/efeitos adversos , Doenças do Jejuno/etiologia , Doenças do Jejuno/cirurgia , Obesidade Mórbida/cirurgia , Adolescente , Adulto , Idoso , Cateterismo , Estudos de Coortes , Constrição Patológica/etiologia , Constrição Patológica/terapia , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Fatores de Risco , Resultado do TratamentoRESUMO
OBJECTIVE: To study the spectrum of and risk factors for complications after gastric bypass (GBP). DESIGN: Prospective cohort study. SETTING: Academic tertiary referral center. PATIENTS: All morbidly obese patients who underwent open or laparoscopic GBP between January 2003 and December 2006. MAIN OUTCOME MEASURES: Complications were stratified by grade: grade I, only bedside procedure; grade II, therapeutic intervention but without lasting disability; grade III, irreversible deficits; and grade IV, death. Data were analyzed using logistic regression to identify independent risk factors of complications after GBP. Predictors investigated were age, race, sex, marital and insurance status, body mass index, obesity-associated comorbidities, American Society of Anesthesiologists Physical Status Class, operating room time, open or laparoscopic approach, and surgeon experience. RESULTS: Of the 404 morbidly obese patients who underwent consecutive open (n = 72) or laparoscopic (n = 332) GBP, 74 (18.3%) experienced 107 complications. Grade I and II complications were more frequent after open GBP (grade I, 19.4% after open vs 3.9% after laparoscopic operations, P < .001; grade II, 20.8% after open vs 8.4% after laparoscopic operations, P < .001), and 55% were wound related. Grades III and IV complications occurred in only 4 patients (1%), and frequency was similar for open and laparoscopic cases. Three factors were independently predictive of complications: diabetes mellitus (odds ratio [OR], 1.9; 95% confidence interval [CI], 1.1-3.3; P = .02), early surgeon experience (OR, 2.5; 95% CI, 1.4-4.2; P = .001), and open approach (OR, 3.9; 95% CI, 2.1-7.3; P < .001). CONCLUSIONS: Complications occurred in 18.3% of patients, but 95% were treated without leading to lasting disability. Presence of diabetes, early surgeon experience, and an open approach are risk factors of complications.
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Derivação Gástrica/efeitos adversos , Laparoscopia/efeitos adversos , Obesidade Mórbida/cirurgia , Adulto , Índice de Massa Corporal , Competência Clínica , Estudos de Coortes , Complicações do Diabetes/complicações , Feminino , Derivação Gástrica/métodos , Humanos , Masculino , Pessoa de Meia-Idade , Obesidade Mórbida/complicações , Fatores de Risco , Resultado do Tratamento , Redução de PesoAssuntos
Actinomicose/diagnóstico por imagem , Biópsia por Agulha Fina/métodos , Endossonografia/métodos , Neoplasias Pancreáticas/diagnóstico por imagem , Neoplasias Pancreáticas/patologia , Actinomicose/diagnóstico , Actinomicose/tratamento farmacológico , Actinomicose/patologia , Antibacterianos , Colangiopancreatografia Retrógrada Endoscópica/métodos , Diagnóstico Diferencial , Feminino , Seguimentos , Humanos , Imuno-Histoquímica , Pessoa de Meia-Idade , Neoplasias Pancreáticas/diagnóstico , Pancreatite Alcoólica/diagnóstico , Medição de Risco , Tomografia Computadorizada por Raios XRESUMO
The gastroenterologist, whether in academic or clinical practice, must face the reality that an increasingly large percentage of adult patients are morbidly obese. Morbid obesity is associated with significant morbidity and mortality including enhanced morbidity from cardiovascular, cerebrovascular, hepatobiliary and colonic diseases. Most of these associated diseases are actually preventable. Based on the 1991 NIH consensus conference criteria, for most patients with a body mass index (BMI=weight in kilograms divided by the height in meters squared) of 40 or more, or for patients with a BMI of 35 or more and significant health complications, surgery may be the only reliable option. Currently in the United States, over 250,000 bariatric surgical procedures are being performed annually. The practicing gastroenterologist in every community, large and small, must be familiar with the various surgical procedures together with their associated anatomic changes. These changes may dramatically increase the prevalence of nutritional deficiencies and profoundly alter the clinical and endoscopic approaches to diagnosis and management.
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AIM: Prior studies have reported conflicting results on the yield of esophagogastroduodenoscopy (EGD) in patients with a positive fecal occult blood test (FOBT). Our aim was to compare the yield between EGD and colonoscopy performed in a racially diverse population with a positive FOBT. METHODS: A retrospective, cross-sectional study of FOBT positive patients who underwent EGD and colonoscopy from January 1, 1999 to November 1, 2008. Endoscopic lesions deemed responsible for GI bleeding were identified. RESULTS: Two hundred and eighty-seven patients met entry criteria, among which, 63% were Asian and 81% were immigrants to the U.S. Forty-four patients had EGD findings deemed responsible for a positive FOBT, the most common being esophagitis (25.0%) and gastric ulceration (15.9%). Forty-two patients had colonoscopic findings likely responsible for a positive FOBT with the most frequent lesion being colonic polyps ≥9 mm in diameter (76.2%). Prevalence of lower and upper GI tract lesions responsible for positive FOBT was similar (14.6% vs. 15.3%, p = 0.2). There was no association between a patient reporting upper GI symptoms, or the presence of anemia and the detection of upper GI tract lesions on endoscopy. Gastric adenocarcinoma (n = 3) was as prevalent as colorectal adenocarcinoma (n = 4). All three patients with gastric adenocarcinomas were Asian (prevalence 1.6%). CONCLUSIONS: In our racially diverse population evaluated for a positive FOBT, gastric adenocarcinoma was as prevalent as colorectal adenocarcinoma; however, gastric adenocarcinoma was limited to Asian patients. EGD and colonoscopy should be considered in the evaluation of patient populations similar to ours, particularly Asian immigrants.
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Adenocarcinoma/etnologia , Povo Asiático/etnologia , Neoplasias Colorretais/etnologia , Sangue Oculto , Neoplasias Gástricas/etnologia , Adenocarcinoma/diagnóstico , Idoso , Colonoscopia , Neoplasias Colorretais/diagnóstico , Estudos Transversais , Endoscopia do Sistema Digestório , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Prevalência , Estudos Retrospectivos , Neoplasias Gástricas/diagnóstico , Estados Unidos/epidemiologiaRESUMO
BACKGROUND: Clinicians must choose a treatment strategy for patients with symptomatic cholelithiasis without knowing whether common bile duct (CBD) stones are present. The purpose of this study was to determine the most cost-effective treatment strategy for patients with symptomatic cholelithiasis and possible CBD stones. STUDY DESIGN: Our decision model included 5 treatment strategies: laparoscopic cholecystectomy (LC) alone followed by expectant management; preoperative endoscopic retrograde cholangiopancreatography (ERCP) followed by LC; LC with intraoperative cholangiography (IOC) ± common bile duct exploration (CBDE); LC followed by postoperative ERCP; and LC with IOC ± postoperative ERCP. The rates of successful completion of diagnostic testing and therapeutic intervention, test characteristics (sensitivity and specificity), morbidity, and mortality for all procedures are from current literature. Hospitalization costs and lengths of stay are from the 2006 National Centers for Medicare and Medicaid Services data. The probability of CBD stones was varied from 0% to 100% and the most cost-effective strategy was determined at each probability. RESULTS: Across the CBD stone probability range of 4% to 100%, LC with IOC ± ERCP was the most cost-effective. If the probability was 0%, LC alone was the most cost-effective. Our model was sensitive to 1 health input: specificity of IOC, and 3 costs: cost of hospitalization for LC with CBDE, cost of hospitalization for LC without CBDE, and cost of LC with IOC. CONCLUSIONS: The most cost-effective treatment strategy for the majority of patients with symptomatic cholelithiasis is LC with routine IOC. If stones are detected, CBDE should be forgone and the patient referred for ERCP.
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Colangiografia/economia , Colecistectomia Laparoscópica/economia , Colelitíase/economia , Colelitíase/cirurgia , Técnicas de Apoio para a Decisão , Cálculos Biliares/economia , Cálculos Biliares/cirurgia , Adulto , Idoso , Colangiografia/efeitos adversos , Colangiopancreatografia Retrógrada Endoscópica , Colangiopancreatografia por Ressonância Magnética , Colecistectomia Laparoscópica/efeitos adversos , Colecistectomia Laparoscópica/mortalidade , Colelitíase/diagnóstico , Colelitíase/diagnóstico por imagem , Controle de Custos , Análise Custo-Benefício , Endossonografia , Feminino , Cálculos Biliares/diagnóstico , Humanos , Período Intraoperatório , Tempo de Internação , Masculino , Pessoa de Meia-Idade , Período Pós-Operatório , Período Pré-Operatório , Sensibilidade e Especificidade , Resultado do Tratamento , Estados Unidos , Conduta ExpectanteRESUMO
OBJECTIVE: To compare outcome parameters for good-risk patients with classic signs, symptoms, and laboratory and abdominal imaging features of cholecystolithiasis and choledocholithiasis randomized to either laparoscopic cholecystectomy plus laparoscopic common bile duct exploration (LC+LCBDE) or endoscopic retrograde cholangiopancreatography sphincterotomy plus laparoscopic cholecystectomy (ERCP/S+LC). DESIGN: Our study was a prospective trial conducted following written informed consent, with randomization by the serially numbered, opaque envelope technique. SETTING: Our institution is an academic teaching hospital and the central receiving and trauma center for the City and County of San Francisco, California. PATIENTS: We randomized 122 patients (American Society of Anesthesiologists grade 1 or 2) meeting entry criteria. Ten of these patients, excluded from outcome analysis, were protocol violators having signed out of the hospital against medical advice before 1 or both procedures were completed. INTERVENTIONS: Treatment was preoperative ERCP/S followed by LC, or LC+LCBDE. MAIN OUTCOME MEASURES: The primary outcome measure was efficacy of stone clearance from the common bile duct. Secondary end points were length of hospital stay, cost of index hospitalization, professional fees, hospital charges, morbidity and mortality, and patient acceptance and quality of life scores. RESULTS: The baseline characteristics of the 2 randomized groups were similar. Efficacy of stone clearance was likewise equivalent for both groups. The time from first procedure to discharge was significantly shorter for LC+LCBDE (mean [SD], 55 [45] hours vs 98 [83] hours; P < .001). Hospital service and total charges for index hospitalization were likewise lower for LC+LCBDE, but the differences were not statistically significant. The professional fee charges for LC+LCBDE were significantly lower than those for ERCP/S+LC (median [SD], $4820 [1637] vs $6139 [1583]; P < .001). Patient acceptance and quality of life scores were equivalent for both groups. CONCLUSIONS: Both ERCP/S+LC and LC+LCBDE were highly effective in detecting and removing common bile duct stones and were equivalent in overall cost and patient acceptance. However, the overall duration of hospitalization was shorter and physician fees lower for LC+LCBDE. TRIAL REGISTRATION: clinicaltrials.gov Identifier: NCT00807729.
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Colecistolitíase/cirurgia , Coledocolitíase/cirurgia , Ducto Colédoco/cirurgia , Cálculos Biliares/cirurgia , Adulto , Procedimentos Cirúrgicos do Sistema Biliar/métodos , Colangiopancreatografia Retrógrada Endoscópica , Colecistectomia Laparoscópica , Feminino , Cálculos Biliares/terapia , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Esfinterotomia EndoscópicaAssuntos
Criptosporidiose/patologia , Infecções por Citomegalovirus/patologia , Endoscopia Gastrointestinal , Infecções por HIV/patologia , Síndrome da Imunodeficiência Adquirida/patologia , Anti-Inflamatórios não Esteroides/efeitos adversos , Cápsulas , Histoplasmose/patologia , Humanos , Linfoma/patologia , Masculino , Pessoa de Meia-Idade , Infecção por Mycobacterium avium-intracellulare/patologia , Úlcera Péptica/induzido quimicamente , Úlcera Péptica/patologia , Sarcoma de Kaposi/patologia , Tuberculose Gastrointestinal/patologiaRESUMO
Although colonoscopy is used in the diagnostic evaluation of patients with diverticular hemorrhage, data on colonoscopic treatment outcomes are limited. We reviewed records of inpatients undergoing colonoscopy to identify patients that were colonoscopically diagnosed and treated for acute diverticular hemorrhage. Eleven patients with acute diverticular hemorrhage had active bleeding (n = 7) or non-bleeding visible vessel (n = 4) at colonoscopy. Endoclip treatment (preceded by epinephrine injection in 64%) achieved hemostasis in all patients without procedural complications. Patients were discharged within three days without evidence of early rebleeding. During a median follow-up of 15 months, late recurrent bleeding occurred in two patients (18.2%). Colonoscopic treatment of patients with acute diverticular hemorrhage using endoclips appears to be effective and safe, with high rates of immediate and long-term success. Colonoscopy should be considered in patients with suspected acute diverticular hemorrhage, as it may enable definitive therapy without the need for more invasive treatment.
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Colonoscopia/métodos , Divertículo do Colo/cirurgia , Hemorragia/cirurgia , Instrumentos Cirúrgicos , Doença Aguda , Idoso , Idoso de 80 Anos ou mais , Feminino , Seguimentos , Hemostasia Cirúrgica/métodos , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Instrumentos Cirúrgicos/efeitos adversos , Resultado do TratamentoRESUMO
Computed tomography (CT) is widely used to assess patients with nonspecific abdominal pain or who are suspected of having colitis. The authors recommend multidetector CT with oral, rectal, and intravenous contrast material and thin sections, which can accurately demonstrate inflammatory changes in the colonic wall and help assess the extent of disease. In most cases, the final diagnosis of the type of colitis is based on clinical and laboratory data and colonoscopic and biopsy findings, but specific CT features help narrow the differential diagnosis. Ulcerative colitis is distinguished from granulomatous colitis (Crohn disease) in terms of location of involvement, extent and appearance of colonic wall thickening, and type of complications. Ulcerative colitis and Crohn disease (granulomatous colitis) are rarely associated with ascites, which is often seen in infectious, ischemic, and pseudomembranous colitis. Pseudomembranous colitis also demonstrates marked wall thickening and, occasionally, skip areas but is associated with broad-spectrum antibiotic treatment or chemotherapy. Neutropenic colitis is characterized by right-sided colonic and ileal involvement, whereas ischemic colitis is characterized by vascular distribution pattern and history. Diverticulitis is a focal asymmetric process with fascial thickening and inflamed diverticula. Dilatation of a thick-walled appendix with increased enhancement and adjacent stranding suggests appendicitis, but inflammatory changes may extend to the cecum and terminal ileum. Epiploic appendagitis is a focal rim-enhancing area next to the colon, usually without any substantial colonic wall thickening.
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Colite/diagnóstico por imagem , Tomografia Computadorizada por Raios X , Colite/etiologia , HumanosRESUMO
OBJECTIVES: AIDS cholangiopathy, once considered to have extremely poor prognosis, is now rarely fatal. This study was designed to assess the survival of patients with AIDS cholangiopathy and investigate prognostic variables, especially in the era of highly active antiretroviral therapy (HAART). METHODS: Ninety-four patients with AIDS cholangiopathy were diagnosed at the San Francisco General Hospital from 1983 to 2001. The mortality status, demographic and clinical variables, and ERCP results were collected through death certificates, chart review, and endoscopic reports. RESULTS: The median survival time from the diagnosis of AIDS and AIDS cholangiopathy was 23 and 9 months, respectively. HAART significantly improved the mortality of patients with AIDS cholangiopathy (hazard ratio [HR] = 0.08, 95% confidence interval [CI] = 0.02-0.35). The presence or history of any opportunistic infection involving the digestive tract, lung, eye, nervous system, skin, or systemic involvement at the time when AIDS cholangiopathy was diagnosed was an indicator of poor prognosis (HR = 3.24, 95% CI = 1.45-7.26); this was especially true for cryptosporidial infection (HR = 2.05, 95% CI = 1.24-3.38). Patients with high serum ALP levels, especially greater than 1000 IU/L or eight times the normal value (HR = 2.69, 95% CI = 1.10-6.60), tended to have a shorter life expectancy than those with normal or slightly elevated serum ALP levels. CD4 lymphocyte counts, type of cholangiopathy, and the performance of sphincterotomy were not correlated with the survival of patients with AIDS cholangiopathy. CONCLUSIONS: HAART administration most likely accounts for the recent dramatic improvement in survival of patients with AIDS cholangiopathy. Underlying immunosuppressive status, reflected by the presence or history of any opportunistic infections, is associated with a worse outcome. Serum ALP levels might be a good clinical indicator for the prognosis of patients with AIDS cholangiopathy.
Assuntos
Infecções Oportunistas Relacionadas com a AIDS/mortalidade , Síndrome da Imunodeficiência Adquirida/mortalidade , Doenças Biliares/diagnóstico , Doenças Biliares/mortalidade , Infecções Oportunistas Relacionadas com a AIDS/diagnóstico , Síndrome da Imunodeficiência Adquirida/diagnóstico , Síndrome da Imunodeficiência Adquirida/tratamento farmacológico , Adulto , Terapia Antirretroviral de Alta Atividade/métodos , Doenças Biliares/terapia , Colangiopancreatografia Retrógrada Endoscópica/métodos , Estudos de Coortes , Intervalos de Confiança , Feminino , Humanos , Incidência , Masculino , Pessoa de Meia-Idade , Valor Preditivo dos Testes , Probabilidade , Prognóstico , Estudos Retrospectivos , Medição de Risco , Índice de Gravidade de Doença , Análise de SobrevidaRESUMO
BACKGROUND & AIMS: In the United States, upper gastrointestinal endoscopy is usually performed using intravenous sedation. Sedation increases the rate of both complications and costs of endoscopy. Unsedated esophagogastroduodenoscopy (EGD) using conventional 8-11-mm endoscopes is an alternative to sedated endoscopy but is generally perceived as unacceptable to many American patients. Unsedated EGD using ultrathin 5-6-mm endoscopes is better tolerated. A randomized trial comparing unsedated ultrathin EGD (UT-EGD) with sedated conventional EGD (C-EGD) in a diverse American population is needed. METHODS: In this multicenter, randomized, controlled trial, 80 patients scheduled to undergo elective outpatient EGD were randomized to unsedated UT-EGD or sedated C-EGD. The study was carried out at San Francisco General Hospital, San Francisco Veterans Affairs Medical Center, and the Liver and Digestive Health Medical Clinic, San Jose. RESULTS: Baseline characteristics of patients randomized to unsedated UT-EGD and sedated C-EGD were similar. Moreover, there were no significant differences in overall patient satisfaction and willingness to repeat endoscopy in the same manner among the 2 study groups. There was, however, a significant difference in median total procedure time between the 2 study groups of 1.5 hours (P < 0.0001). The mean (+/- SD) total procedure cost was 512.4 US dollars (+/- 100.8 US dollars) for sedated C-EGD and 328.6 US dollars (+/- 70.3 US dollars) for unsedated UT-EGD (P < 0.0001). CONCLUSIONS: Patients undergoing unsedated UT-EGD are as satisfied as patients undergoing sedated C-EGD and are just as willing to repeat an unsedated UT-EGD. Unsedated UT-EGD was also faster, less costly, and may allow greater accessibility to this procedure.