[Relationship between technical difficulty to cannulate papila of Vater and fluoroscopy time]. / Relación entre grado de dificultad para canular papila de Vater, realización del procedimiento y tiempo de fluoroscopia.

BACKGROUND: Exposure to radiation during endoscopic retrograde cholangiopancreatography (ERCP) could have adverse effects on the endoscopic team members and patients. There is an inverse relationship between fluoroscopy time and endoscopist experience. OBJECTIVE: To determine the relationship between the technical difficulty to cannulate Vater's papilla, and time to perform the procedure and fluoroscopy time. METHODS: Patients scheduled for ERCP were divided in two groups depending on the degree of difficulty of the process according to Schutz classification: group A (grades 1-3) and group B (grades 4 and 5). We registered demographic variables, reference diagnosis, endoscopic and radiological diagnoses, degree of difficulty to cannulate Vater's papilla (Freeman scale), duration of procedure, fluoroscopy time and endoscopic complications. RESULTS: 213 patients were included: 101 in group A and 112 in group B. Mean fluoroscopy time was 59.15 seconds in group A and 93.59 seconds in group B (p <0.0001). Mean time to perform the procedure was 13.18 minutes in group A and 20.23 minutes in group B (p <0.0001). Factors related to increased fluoroscopy time were technical difficulty for the CPE according to Schutz (p <0.0001), stent placement (p = 0.021) and hydrostatic dilation (p <0.0001). CONCLUSIONS: The fluoroscopy time increased proportionally to technical difficulty to perform the procedure.

[Epidemiology of bilio-pancreatic cancer in Specialty Hospital UMAE N°71 IMSS in Torreón, Coahuil]. / Epidemiología de neoplasias bilio-pancreáticas en el Hospital de Especialidades UMAE No. 71, IMSS. Torreón, Coahuila.

BACKGROUND: There is a worldwide increase in the incidence of cancer of the biliopancreatic ducts; early diagnosis is difficult and prognosis is poor. OBJECTIVE: To analyze the frequency of malignant biliary strictures diagnosed by Endoscopio Retrograde Cholangiopancreatography (ERCP) at the "Hospital de Especialidades No. 71 UMAE IMSS", Torreon, Coahuila, Mexico. METHODS: A 5-year retrospective study of consecutive patients referred for ERCP at our institution was performed. Medical records from patients with malignant neoplasms were reviewed. Demographic variables, post-ERCP and final diagnosis, based on cytological and endoscopic or surgical biopsies, imaging studies and clinical outcome were registered. RESULTS: The frequency of biliary-pancreatic neoplasm was 15.6% (301 cases in 1924 ERCP) determined by bile duct cancer (40.7%), pancreas (27.9%) and Vater´s ampulla (12.3%). Brushing was performed for histopathological analysis in 86.7% of cases. The cytology was positive in 91.2%, negative 8.8%, and it was no possible in 13.3% of cases. Therapeutic endoscopy was performed in 273 patients with complications in 1.3% and no procedure-related mortality. Patients with malignant strictures had a higher risk for unsuccessful ERCP (RR 3.01, 95% CI 1.77 - 5.11) and carrying out pre-cut sphincterotomy (RR 1.80, 95% CI 1.38 - 2.35). CONCLUSION: In our center the incidence of biliary-pancreatic neoplasm was 15.6% among patients sent to ERCP and its presence increases the degree of difficulty in performing diagnostic and therapeutic endoscopic procedures.

[Effect of different doses of fentanyl and butylhyoscine on the rabbit's sphincter of Oddi]. / Efecto del fentanilo a diferentes dosis y de la butilhioscina en el esfínter de Oddi del conejo.

BACKGROUND: It was not until the advent of endoscopic retrograde cholangiopancreatography (ERCP) that Oddi's sphincter manometry was performed directly. Use of opioids for the intravenous (IV) sedation of these patients is controversial. OBJECTIVE: To evaluate with manometry the effect of fentanyl at different doses as well as the effect of butylhyoscine on the rabbit's Oddi's sphincter. METHODS: This is an experimental, randomized, double-blind study conducted in New Zealand rabbits distributed in 4 groups (control, fentanyl at doses of 1, 5 and 10 µg/kg of weight) that, after laparotomy and duodenotomy, underwent direct Oddi's sphincter manometry. The analyzed variables included sphincter pressure, wave frequency, amplitude and duration. RESULTS: The baseline measurements of the study variables did not show any differences among the groups. The administration of fentanyl at 1 µg/kg reduced Oddi's sphincter pressure compared with the baseline value (p = 0.003), while the doses of 5 and 10 µg/kg significantly increased it (p <0.0001). Butylhyoscine decreased the sphincter pressure, frequency, amplitude and duration of the waves in all the groups and antagonized the increase in pressure produced by fentanyl. CONCLUSIONS: Fentanyl at 1 µg/kg of body weight relaxes the rabbit's Oddi's sphincter and butylhyoscine can antagonize the increased pressure of the sphincter caused by fentanyl at 5 and 10 µg/kg of weight. These finding suggest a potential beneficial for the ERCP in clinical controlled trials in humans.

[Does the use of fentanyl make Vater's ampulla cannulation difficult? A prospective and comparative study]. / ¿Dificulta la canulación del ámpula de Vater el uso de fentanilo? Un estudio prospectivo y comparativo.

BACKGROUND: Fentanyl is a synthetic opioid with excellent results in perioperative analgesia. It is commonly used for proximal and distal gastrointestinal endoscopic procedures, but its contracting action on the sphincter of Oddi, similar to that of morphine, makes its use for endoscopic cholangiopancreatography (ERCP) controversial. OBJECTIVE: To determinate if intravenous fentanyl as part of deep sedation hinders the cannulation of Vater's papilla during ERCP. MATERIAL AND METHODS: Prospective, comparative, randomized and double-blind trial that enrolled patients undergoing ERCP in 2008, > 18 years old, without previous endoscopic or surgical procedures related with Vater s papilla. Patients were randomized into two groups: patients in whom ERCP was performed with intravenous propofol (group A), and patients in whom the procedure was performed with intravenous fentanyl and propofol (group B). Gender, age, comorbid conditions, reasons for referral, difficulty of cannulation, diagnosis, therapeutic procedures, procedure time and endoscopic complications were all documented. RESULTS: 432 were included: 214 in group A and 218 in group B. Both groups were similar in relation with demographic characteristics, time of sedation and endoscopic procedure. Difficulty in cannulation had not a statistical significance (p = 0.163). The administered dose of propofol were less for group B (p < 0.001). No procedure-related mortality was documented. CONCLUSION: The combination of fentanyl and propofol may be used during ERCP, since it does not hinder the cannulation of Vater's papilla.

[Foreign body reaction to biodegradable esophageal prosthesis. A case report]. / Reacción a cuerpo extraño de una prótesis esofágica biodegradable. Informe de un caso.

Although benign esophageal stricture induced by various factors can often be managed with dilatations using hydrostatic balloons or different dilators, some patients have esophageal stenosis that is refractory to such treatment. Endoprothesis have facilitated the palliation of malignant esophageal strictures. However, the indications for permanent esophageal stenting in patients with benign esophageal strictures have not been established. Everyday, the use of plastic self-expanding endoprosthesis is more common in esophageal strictures because of their advantages over metallic stents, ease of placement and retrieval, and limited local tissue reaction. More recently, biodegradable stents have been used to manage benign esophageal stenosis. We report a case of a 72 years woman who was attended because of the presence of esophageal stenosis secondary to caustic ingestion refractory to dilatation, was placed a biodegradable stent and developed a foreign body reaction.

[Endoscopic cholangiopancreatography in the elderly: a prospective comparative study in northern Mexico]. / Colangiopancreatografía endoscópica en la tercera edad; un estudio prospectivo y comparativo en el norte de México.

BACKGROUND: Endoscopic retrograde cholangiopancreatography (ERCP) is a widely used technique for the diagnosis and treatment of bilio-pancreatic diseases. According to Mexican Statistics, there is increasing life expectancy in Mexican population. The incidence of biliary tract pathologies is also increasing, leading to an increased demand of ERCP. AIM: Compare the utility and safety of ERCP in elderly and younger patients. METHODS: Prospective and comparative study including 450 patients who underwent ERCP during 2007. Patients were divided into two groups: 65 years age and older (group A) and less than 65 years old (group B). We registered gender, age, indication and length of the endoscopic procedure, morbidity and mortality. RESULTS: Mean patient age was 74.5 ± 6.9 and 43.0 ± 13.5 years old in groups A and B respectively. Choledocholithiasis was the more frequent diagnosis in both groups (48.62 %), followed by benign biliary stenosis (22.02 %) and malignant biliary obstruction (16.28 %). In 428 patients (98.16%) therapeutic procedures were performed. Endoscopic complications occurred in 1.37 % and there were not significant differences between groups (p = 0.218). There was no mortality. CONCLUSION: ERCP is a safe procedure in elderly patients with a very low rate of complications and excellent therapeutic efficacy.

[Difficulty to cannulate papilla of Vater in the presence of periampullary duodenal diverticulum]. / Grado de dificultad para canular papila de Vater en presencia de divertículo duodenal periampular.

BACKGROUND: There are conflicting results in the literature regarding the impact of duodenal diverticula on the technical success and complications of endoscopic retrograde cholangiopancreatography (ERCP). AIM: To evaluate if the presence of periampullary duodenal diverticulum increases the risk of failure of ampulla cannulation. METHODS: Patients who underwent ERCP between January 2008 and December 2009 were evaluated. They were divided in group A (without duodenal diverticulum) or group B (with duodenal diverticulum). Gender, age, endoscopic and radiological diagnosis, difficulty to cannulate, endoscopic sphincterotomy, precut technique, therapeutic procedure and complications were documented. RESULTS: 1159 patients were included: 1100 in group A and 59 in group B. A successful cannulation was obtained in 1061 patients of group A and 53 of group B (96.46 vs. 89.83%, p < 0.0001, OR 0.03). The failure of cannulation was observed in 39 patients of group A and 6 of group B (3.54 vs. 10.17%, p= 0.021, OR 2.94). The presence of intradiverticular papilla was the cause of failure in all cases. The therapeutic procedures showed statistical differences in choledocholithiasis clearance as well as endoscopic sphincterotomy and biliary stents insertion, but there was no significant difference in complications. We found statistical significant differences in biliary lithiasis, malignant stenosis, mechanical lithotripsy and insertion of biliary stents. CONCLUSIONS: Periampullary duodenal diverticula increase the risk of failure for cannulation of ampulla. However, it should not be considered as contraindication for ERCP.

[Intravenous sedation in endoscopic cholangiopancreatography: a prospective and comparative trial.]. / Sedación endovenosa en colangiopancreatografía endoscópica; un estudio prospectivo y comparativo.

INTRODUCTION: Endoscopic cholangiopancreatography (ECP) has an established role in the diagnostic and treatment of biliopancreatic diseases. It is performed in supine position, under intravenous sedation to avoid movements and discomfort of the patient. OBJECTIVE: To evaluate the safety of anesthetic procedure in elderly and younger patients who underwent ECP. PATIENTS AND METHODS: A prospective, comparative study enrolling 450 consecutive patients who underwent ERCP in 2007 was performed. The following variables were documented: gender, age, comorbid conditions, reason for referral, diagnostic, therapeutic procedures, American Society of Anesthesiology (ASA) classification, anesthetic drugs, duration of the procedure and complications. RESULTS: Patients were divided into two groups: 126 patients >65 years of age and 324 <65 years of age. Group A had a higher incidence of comorbid conditions (p <0.001). All procedures were performed under sedation with propofol. Anesthetic complications were detected in 6% of patients, without a statistical significance between ASA group (p = 0.7) or age groups (p = 0.1). No procedure-related mortality was documented. CONCLUSION: ECP under deep IV sedation is a safe procedure in elderly patients and has a low anesthetic complication rate.

Gonadal dysgenesis and Rokitansky syndrome. A case report.

BACKGROUND: Primary amenorrhea and lack of sexual development occur in gonadal dysgenesis due to missing ovaries. Primary amenorrhea with sexual development occurs in Rokitansky syndrome due to absence of the uterus, with normal ovarian function. The association of these two conditions has been previously described as a rare event. CASE: A 19-year-old woman presented with primary amenorrhea and lack of secondary sexual characteristics. Physical examination confirmed the absence of mammary development and of pubic and axillary hair. Pelvic ultrasound disclosed absence of the uterus and ovaries. Gonadotropin serum levels were in the menopausal range, and the karyotype showed two mosaic cell lines, 45,X/46,Xdic(X). Scanning of a large number of cells by interphase fluorescence in situ hybridization showed 12% of cells with a dicentric X chromosome. Laparoscopic study confirmed the absence of the uterus and ovaries, with normal fallopian tubes. CONCLUSION: This patient had two anomalies affecting reproductive performance, gonadal dysgenesis and congenital absence of the uterus, the first associated with an abnormal karyotype; the second seems to have occurred coincidentally. At this time there is no treatment for the reproductive dysfunction.

[Cervical isthmus myomatosis]. / Miomatosis istmico-cervical.

Ten patients with isthmico-cervical leiomyoma as the only one localization, were surgically treated, from Jan, 1989 to May, 1990. It was 2.8% of all treated myomatosis. Average age was 42.4 years, with gestation of 1.1 per patients. Nine cases were treated by the abdominal via. One case presented with a recurrence. These cases represent a technico-surgical difficulty, due to tumor localization and size, as well as an ample knowledge about pelvic structures, in order to avoid digestive tract lesions, urinary and vascular. The present series confirms that this type of surgery is justified considering morbi-mortality, so it would be possible a definite histopathological evaluation.

Virilizing adrenal adenoma and primary amenorrhea in a girl with adrenal hyperplasia.

We report a 14-year-old girl with primary amenorrhea and virilization. The chromosomal analysis showed a normal 46,XX female karyotype and the hormonal assays disclosed high serum levels of testosterone (T): 450 ng/dL (normal 5-90), dehidroepiandrosterone-sulfate (DHEA-S): 690 microg/dL (normal 30-450) and 17-hydroxiprogesterone (17-OHP) >20 ng/mL (normal <2). A pelvic ultrasound disclosed a small uterus and bilateral enlargement of the ovaries, a computed axial tomographic scan of the abdomen identified a large right mass in the adrenal gland and a norcholesterol-I 131 adrenal gammagraphy revealed a functional adrenal tumor. The histological analysis of the surgical removed tumor revealed and adrenal adenoma. After surgery, a steep decline to normal serum levels of T and DHEA-S was observed, remaining an elevated level of 17-OHP: 5.4 ng/mL. During the first three months of follow up, the hirsutism declined sharply and spontaneous mammary development occurred, remaining elevated the 17-OHP serum level: 4.8 ng/mL. Prednisone 5 mg/day, was initiated decreasing the 17-OHP to normal level: 1.4 ng/mL, appearing the menarche followed by cyclical menses. One year after surgery, prednisone was withdrawn during one week, and an ACTH test and HLA typing were done, disclosing a 17-OHP response of an heterozygote for adrenal hyperplasia, and identifying B65 a subtype of B14, and DR1, that are frequently associated to adrenal hyperplasia. Previous reports have informed silent adrenal tumors associated to adrenal hyperplasia, but this is the first report of a functional adrenal tumor associated to adrenal hyperplasia.