RESUMO
OBJECTIVES: The incidence of choledocolithiasis is reported to be increasing in children. As for the adult population, several different therapeutic strategies have been described, however it is unclear which of those should be considered the gold standard. There is evidence-based literature in adults that supports a combined "rendez-vous" endoscopic retrograde cholangiopancreatography-laparoscopic cholecystectomy technique. This allows management of the choledocholithiasis during the same anesthetic episode as the cholecystectomy. By contrast, there are just two case reports in children reporting this approach. The aim of this study is to report our experience with this technique in a series of children with choledocholithiasis. METHODS: All patients who underwent the "rendez-vous technique" at our institution between 2009 and 2020 were reviewed and evaluated for outcomes and complications. RESULTS: Eleven children with cholecysto-choledocholithiasis were evaluated: the procedure was successful in 10 whereas in one patient it was aborted due to technical difficulties. All patients resolved their clinical condition without major complications. CONCLUSION: To our knowledge, this is the first consistent series of "rendez-vous technique" in the pediatric population, proving its feasibility and safety.
Assuntos
Colecistectomia Laparoscópica , Coledocolitíase , Adulto , Criança , Colangiopancreatografia Retrógrada Endoscópica/métodos , Colecistectomia Laparoscópica/métodos , Coledocolitíase/diagnóstico por imagem , Coledocolitíase/cirurgia , HumanosRESUMO
BACKGROUND AND AIM: In presence of malignant dysphagia, in patients unfit for surgery, the placement of a self-expandable metal stent (SEMS) represents a safe and effective palliative treatment. Esophageal stents (ES) present an over-the-wire mechanism where the stent is deployed under X-ray control. Recently a through-the-scope (TTS) ES was launched. The aim of our retrospective study is to assess the technical and clinical success of the new TTS-ES. MATERIALS AND METHODS: Patients with malignant dysphagia caused by esophageal cancer or ab-extrinsic compression, who underwent TTS esophageal stent in six Italian endoscopic referral centers, were retrospectively reviewed. RESULTS: A total of 40 patients were enrolled. TTS stent placement was successful in 39/40 patients (97.5%). 31 patients had an Ogilvie score of 4, nine an Ogilvie 3. After 2 weeks from stent placement 29 reported Ogilvie score of 0, eight a score of 1. None of the patients developed retrosternal pain requiring drugs. No patient experienced perforation, bleeding or migration. A total of seven patients (18%) developed dysphagia as late adverse event (AE). CONCLUSION: Through-the-scope ES presented less AEs, in terms of bleeding and perforation, if compared to the previous published data. An anti-migration system could be helpful, especially when the stent is placed for "ab-extrinseco" malignant dysphagia.
Assuntos
Transtornos de Deglutição , Neoplasias Esofágicas , Transtornos de Deglutição/etiologia , Transtornos de Deglutição/cirurgia , Neoplasias Esofágicas/complicações , Neoplasias Esofágicas/cirurgia , Humanos , Cuidados Paliativos , Estudos Retrospectivos , Stents , Resultado do TratamentoRESUMO
BACKGROUND: Evidence from controlled trials and meta-analyses suggests that laparoendoscopic rendezvous (LERV) is preferable to sequential treatment in the management of common bile duct stones. MATERIALS AND METHODS: With this retrospective analysis of a prospective database that included consecutive patients treated for cholecystocholedocholithiasis at our institution between January 2007 and July 2015, we compared LERV with sequential treatment. The primary endpoint was global cost, defined as the cost/patient/hospital stay, and the secondary end points were efficacy and morbidity. Fisher's exact test or Mann-Whitney test was used. RESULTS: Of a total of 249 consecutive patients, 143 underwent LERV (group A) and 106 a two-stage procedure (group B). Based on an average cost of 613 for 1 day of hospital stay in the General Surgery Department, the overall median cost of treatment was 6403 for group A and 8194 for group B (p < 0.001). Operative time was significantly shorter (p < 0.001), and length of hospital stay was significantly longer for group B (p < 0.001). No mortality in either group was observed. The postoperative complications rate was significantly higher in group B than in group A (24.5 vs. 10.5%; p = 0.003). No significant difference in the postoperative pancreatitis rate or the number of patients with increased serum amylase at 24 h was observed in either group. CONCLUSION: Our study suggests that LERV is preferable to sequential treatment not only in terms of less morbidity, but also of lower costs accrued by a shorter hospital stay. However, the longer operative time raises multiple organizational issues in the coordination of surgery and endoscopy services.
Assuntos
Colangiopancreatografia Retrógrada Endoscópica/economia , Colecistectomia Laparoscópica/economia , Coledocolitíase/cirurgia , Cálculos Biliares/cirurgia , Custos de Cuidados de Saúde , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Colangiopancreatografia Retrógrada Endoscópica/métodos , Colecistectomia Laparoscópica/mortalidade , Colecistite/cirurgia , Custos e Análise de Custo , Feminino , Cálculos Biliares/economia , Humanos , Tempo de Internação , Masculino , Pessoa de Meia-Idade , Duração da Cirurgia , Complicações Pós-Operatórias/cirurgia , Estudos Retrospectivos , Adulto JovemRESUMO
BACKGROUND AND AIM: Contrast harmonic endoscopic ultrasound (CH-EUS) was recently introduced to clinical practice; its reproducibility among endosonographers is unknown. Our aim was to assess the interobserver agreement (IA) in CH-EUS. METHODS: Fifteen endosonographers (eight experienced and seven non-experienced) from 11 Italian EUS centers evaluated 80 video-cases (40 solid pancreatic lesions, 20 pancreatic cystic lesions and 20 submucosal lesions) of CH-EUS, according to the degree of enhancement, the pattern of distribution and the washout of the contrast agent. IA within each group and between the two groups of observers was assessed with the Fleiss kappa statistic. RESULTS: Overall IA was moderate for the uptake and fair for the pattern of distribution and the washout. In solid pancreatic lesions, IA was moderate for the uptake and fair for the pattern and the washout. In cystic pancreatic lesions, IA was uniformly moderate for the assessment of uptake, slight for the pattern and fair for the washout. In submucosal tumors, IA was substantial for the uptake, slight for the pattern and fair for the washout. Non-experienced endosonographers demonstrated, in most cases, comparable IA with the experienced ones. CONCLUSIONS: Interobserver agreement among endosonographers for CH EUS was satisfactory. In particular, overall IA varied from slight to substantial, being fair in the majority of cases. Inherent structural features of the lesions, as well as technical differences between the variables assessed, could have accounted for the fluctuation of the results. Outcomes of IA were reproducible between experienced and non-experienced endosonographers.
Assuntos
Neoplasias Pancreáticas/diagnóstico por imagem , Adulto , Idoso , Idoso de 80 Anos ou mais , Competência Clínica , Meios de Contraste , Endossonografia/métodos , Endossonografia/normas , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Variações Dependentes do Observador , Cisto Pancreático/diagnóstico por imagem , Fosfolipídeos , Hexafluoreto de Enxofre , Adulto JovemRESUMO
BACKGROUND: Data regarding the effect of orthotopic liver transplantation (OLT) for primary sclerosing cholangitis (PSC) on inflammatory bowel disease (IBD) course are scarce and conflicting. AIMS: To compare the incidence of refractory IBD in two groups (OLT and non-OLT) of patients affected by IBD and PSC. METHODS: An observational, multicentre, cohort retrospective study was conducted by the Italian Group for the study of IBD in Italy. The primary outcome was the need for biologic therapy or bowel resection for medically refractory IBD or hospitalization due to IBD relapse during the follow-up. Secondary outcomes were rate of colonic dysplasia, colorectal cancer, other solid tumours, lymphoma. RESULTS: Eighty-four patients were included in the study. The primary outcome was not different between OLT and non-OLT groups (11/27, 40.7%, versus 20/57, 35.1%, respectively, pâ¯=â¯0.62). The lymphoma and other tumours (thyroid cancer, kidney cancer, ileal tumour, ovarian cancer, cervical cancer) rates were significantly higher in the OLT group (pâ¯=â¯0.04 and pâ¯=â¯0.005, respectively), at the limit of statistical significance for high-grade colonic dysplasia (pâ¯=â¯0.06). CONCLUSION: OLT in patients affected by IBD and PSC is not a risk factor for a more severe IBD course, but it is associated with a higher occurrence of cancer.
Assuntos
Colangite Esclerosante/cirurgia , Doenças Inflamatórias Intestinais/fisiopatologia , Transplante de Fígado/efeitos adversos , Adulto , Colangite Esclerosante/complicações , Progressão da Doença , Feminino , Humanos , Doenças Inflamatórias Intestinais/complicações , Itália , Estimativa de Kaplan-Meier , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Fatores de RiscoRESUMO
BACKGROUND: The impact of narrow band imaging in improving the adenoma detection rate in a screening scenario is still unclear. AIM: To evaluate whether narrow band imaging compared with high definition white light colonoscopy can enhance the adenoma detection rate during screening colonoscopy. METHODS: Consecutive patients presenting for screening colonoscopy were included into this study and were randomly assigned to the narrow band imaging group (Group 1) or standard colonoscopy group (Group 2). Primary end point was the adenoma detection rate and secondary aim was the detection rate of advanced adenomas. RESULTS: Overall, 117 patients were allocated to Group 1 and 120 to Group 2. Both the adenoma detection rate and the detection rate of advanced adenomas were not significantly different between the two groups (respectively, 52.1% vs. 55%, RR=0.95, 95% CI 0.75-1.20; 32.5% vs. 44.2%, RR=0.74, 95% CI 0.53-1.02). No significant difference between the proportions of polypoid and flat adenomas was found. Male gender, no prior history of screening, and endoscopist's adenoma detection rate were independent predictive factors of higher advanced adenoma detection rate. CONCLUSIONS: In a screening scenario, narrow band imaging did not improve the adenoma nor advanced adenoma detection rates compared to high definition white light colonoscopy.
Assuntos
Adenoma/diagnóstico , Colonoscopia/métodos , Neoplasias Colorretais/diagnóstico , Programas de Rastreamento/métodos , Imagem de Banda Estreita/métodos , Sangue Oculto , Adenoma/epidemiologia , Idoso , Neoplasias Colorretais/epidemiologia , Feminino , Seguimentos , Humanos , Processamento de Imagem Assistida por Computador , Incidência , Itália/epidemiologia , Masculino , Estudos ProspectivosRESUMO
Duodenal infusion of levodopa/carbidopa gel (Duodopa) is an effective treatment option for advanced Parkinson's disease (PD). Long-term clinical experience up to 16 years suggests that the safety of this procedure is acceptable, while several observational studies showed that Duodopa reduces motor fluctuations and dyskinesias improving patients' quality of life (QoL). The aim of this study is to investigate the long-term motor and cognitive outcome of Duodopa treatment in advanced PD patients and its' impact on the QoL. Twenty-five consecutive PD patients were assessed using the Unified PD rating scale (UPDRS), a battery of neuropsychological tests, and the PD questionnaire (PDQ-39) at baseline and after a mean period of three years of Duodopa treatment. Seventeen out of 25 patients reached the follow-up evaluation; five patients discontinued Duodopa and three patients died of causes unrelated to drug infusion. Duodopa improved motor complications (UPDRS-IV) and quality of life (PDQ-39). A sub-group of subjects (41 %) developed a significant deterioration of cognitive functions over time. The most common adverse events were dislocation and the kinking of the intestinal tube. In conclusion, Duodopa therapy is effective in the long-term treatment of advanced PD patients. Continuous enteral levodopa infusion achieves a reduction of motor fluctuations and dyskinesias improving patients' QoL, despite the progression of PD motor symptoms and a significant decline in cognitive functions in a sub-group of patients.
Assuntos
Antiparkinsonianos/administração & dosagem , Carbidopa/administração & dosagem , Transtornos Cognitivos/tratamento farmacológico , Duodeno/fisiologia , Levodopa/administração & dosagem , Atividade Motora/efeitos dos fármacos , Doença de Parkinson/tratamento farmacológico , Adulto , Idoso , Transtornos Cognitivos/etiologia , Avaliação da Deficiência , Combinação de Medicamentos , Duodeno/efeitos dos fármacos , Feminino , Humanos , Infusões Parenterais , Estudos Longitudinais , Masculino , Pessoa de Meia-Idade , Testes Neuropsicológicos , Doença de Parkinson/complicações , Doença de Parkinson/psicologia , Qualidade de Vida , Estatísticas não ParamétricasRESUMO
BACKGROUND AND AIMS: Safety of propofol sedation in patients with liver cirrhosis undergoing colonoscopy or endoscopic retrograde cholangiopancreatography (ERCP) remains to be studied. The aim of this study was to investigate whether the use of propofol is safe for endoscopic procedures more complex than gastroscopy in patients with liver cirrhosis in a prospective controlled study. METHODS: Two hundred and fourteen consecutive patients, with or without cirrhosis, who underwent colonoscopy or ERCP with propofol sedation were recruited between January and June 2009. Administration of sedation was performed by anesthesiologists and outcome measures were recorded. Main outcomes were complication rates and recovery times. RESULTS: Sixty-one (28.5%) cirrhotic patients and 153 (71.5%) noncirrhotic patients were included. The incidence of sedation-related complications did not significantly differ between the two populations (11.5 vs. 17.0%, respectively, P=0.31). The mean (±SD) dose of propofol administered (213±86 vs. 239±100 mg, P=0.07), the mean time to achieve adequate sedation (3.3±1.1 vs. 3.0±1.2 min, P=0.21), the mean total duration of the endoscopic procedure (24.5±10.6 vs. 27.4±11.8 min, P=0.08), the mean time to reach Observer's Assessment of Alertness and Sedation Scale 5 (17.2±4.4 vs. 18.4±5.6 min, P=0.15), the mean time from completion of the procedure to release (9.0±2.5 vs. 9.1±3.2 min, P=0.86), and the mean time to full recovery (42.2±7.3 vs. 42.3±7.8 min, P=0.88) were very similar between the two groups. The limitation of this study was lack of randomization, and a control group of cirrhotic patients using standard sedation with benzodiazepines and opioids. CONCLUSION: Propofol deep sedation administered by an anesthesiologist with appropriate monitorings seems to be a safe procedure during colonoscopy or ERCP in cirrhotic patients.
Assuntos
Colonoscopia/métodos , Sedação Consciente/efeitos adversos , Hipnóticos e Sedativos/efeitos adversos , Cirrose Hepática/cirurgia , Propofol/efeitos adversos , Adulto , Idoso , Período de Recuperação da Anestesia , Colangiopancreatografia Retrógrada Endoscópica/efeitos adversos , Colangiopancreatografia Retrógrada Endoscópica/métodos , Colonoscopia/efeitos adversos , Sedação Consciente/métodos , Esquema de Medicação , Feminino , Humanos , Hipnóticos e Sedativos/administração & dosagem , Período Intraoperatório , Cirrose Hepática/complicações , Masculino , Pessoa de Meia-Idade , Monitorização Intraoperatória/métodos , Propofol/administração & dosagem , Estudos ProspectivosRESUMO
Endoscopic ultrasonography is an established diagnostic tool for pancreatic masses and chronic pancreatitis. In recent years there has been a growing interest in the worldwide medical community in autoimmune pancreatitis (AIP), a form of chronic pancreatitis caused by an autoimmune process. This paper reviews the current available literature about the endoscopic ultrasonographic findings of AIP and the role of this imaging technique in the management of this protean disease.
Assuntos
Doenças Autoimunes/diagnóstico por imagem , Doenças Autoimunes/diagnóstico , Endossonografia/métodos , Pancreatite/diagnóstico por imagem , Pancreatite/diagnóstico , Doenças Autoimunes/imunologia , Ductos Biliares/diagnóstico por imagem , Ductos Biliares/patologia , Pâncreas/diagnóstico por imagem , Pâncreas/patologia , Pancreatite/imunologiaRESUMO
BACKGROUND/AIMS: Endoscopic retrograde cholangiopancreatography (ERCP) is the standard approach for the management of biliary complications in liver transplant patients; however, its safety and efficacy have not been established in this setting. This study was performed to evaluate the safety and long-term efficacy of ERCP in transplant patients. METHODS: The case reports of 1,500 liver transplant patients were reviewed. Orthotopic liver transplantation (OLT) patients were matched 1:2 with non-OLT patients and followed-up for long-term outcome (median, 7.4 years). RESULTS: Of the 1,500 liver transplant patients, 94 (6.3%) underwent 150 ERCPs after OLT. Anastomotic strictures were present in 45 patients, biliary stones in 24, biliary leaks in 7, papillary stenosis in 2, and primary sclerosing cholangitis in 1. An ERCP success rate of 90.7% was achieved; biliary stenting led to resolution of the bile leak in 7/7 (100%) patients, and biliary stones were removed in 21/24 (87.5%) patients. In addition, 34 of 45 patients with anastomotic stricture underwent endoscopic dilation. We obtained complete resolution in 22/34 (64.7%) patients. OLT patients did not show a higher probability of complications (odds ratio [OR], 1.04), of pancreatitis (OR, 0.80) or of bleeding (OR, 1.34). CONCLUSIONS: ERCP is safe and effective for the treatment of post-OLT biliary complications, has a low rate of pancreatitis and results in a durable effect.