Endoscopic Skills Training: The Impact of Virtual Exercises on Simulated Colonoscopy.

Background: A previous study suggested that psychomotor training improves the performance on colonoscopy. Since then, newer exercises have been included in the latest generation of GI Mentor®. In order to optimize a colonoscopy training program, we aimed to determine the impact of 3 virtual exercises in simulated colonoscopy skills. Methods: This was a prospective and randomized study. Nineteen residents completed a pre-training questionnaire and a colonoscopy trial before randomization in a study group (n = 10) that performed three exercises (Endobubble I, Navigation I, and Mucosal Evaluation I) until they achieved expert level, and a control group (n = 9). Both groups performed 10 repetitions of a simulated colonoscopy and were assessed on a final case. Learning curves and skills transfer were assessed by four parameters: mucosal surface examined (%), time to reach the cecum (s), screening efficiency (%), and time the patient was in pain (%). We also evaluated the construct validity for the exercises. Results: Construct validity was confirmed for Endobubble I and verified in Navigation I (experts were faster than novices; 5 vs. 7 s, p = 0.040), but not for Mucosal Evaluation I. Analyzing the learning curves and performance in the 10 repetitions, the study group reached the cecum faster (278 vs. 356 s, p = 0.035) and achieved a higher screening efficiency (83% vs. 75%, p = 0.019). Concerning skills transfer, the control group took longer to reach the cecum (241 vs. 292 s, p = 0.021) and the percentage of time the patient was in pain was higher (6% vs. 9%, p = 0.021). General performances of the study group had smaller interquartile variations. Conclusion: Psychomotor training has a significant impact on the homogeneous acquisition and assimilation of colonoscopy skills. Endobubble I and Navigation I should be considered in the training programs for novices.

Introdução: Um estudo anterior sugeriu que o treino psicomotor melhora o desempenho em colonoscopia. Desde então, outros exercícios virtuais foram incluídos na nova geração do simulador GI Mentor®. De forma a otimizar o programa de treino em colonoscopia procurou-se determinar o impacto de três exercícios virtuais nas competências de colonoscopia simulada. Métodos: Estudo prospetivo e randomizado. Dezanove internos completaram um questionário pré-treino e uma colonoscopia, tendo sido depois randomizados: Grupo de Estudo (n = 10) que realizou três exercícios (Endobubble I, Navigation I, Mucosal Evaluation I) até atingir o nível expert e Grupo Controlo (n = 9). Posteriormente, ambos os grupos realizaram dez repetições de um caso de colonoscopia simulada e um caso de avaliação final. As curvas de aprendizagem e a transferência de competências foram avaliadas com quatro métricas: superfície da mucosa examinada (%), tempo para atingir o cego (s), taxa de eficiência (%) e tempo que o doente teve dor (%). Adicionalmente, avaliou-se a validade do constructo para os novos exercícios. Resultados: Foi confirmada a validade do constructo no Endobubble I e verificada no Navigation I (os experts foram mais rápidos do que os formandos; 5 vs. 7 s, p = 0.040), mas não no Mucosal Evaluation I. Analisando as curvas de aprendizagem e o desempenho nas 10 repetições, o Grupo de Estudo atingiu mais rapidamente o cego (278 vs. 356 s, p = 0.035) e apresentou uma taxa de eficiência mais elevada (83% vs. 75%, p = 0.019). Na transferência, o Grupo Controlo demonstrou uma degradação significativa no tempo para atingir o cego (241 vs. 292 s, p = 0.021) e na % de tempo que o doente teve dor (6% vs. 9%, p = 0.021). O desempenho do Grupo de Estudo apresentou uma menor variabilidade interquartil. Conclusão: O treino psicomotor teve um impacto significativo na aquisição e assimilação homogénea de competências em colonoscopia. Os exercícios Endobubble I e Navigation I devem ser considerados nos programas de treino em simulador para iniciados.

Comprehensive geriatric assessment of older patients and associated factors of admission to Emergency Departments in pre-covid 19 Era - A Portuguese study.

OBJECTIVES: Identifying frequent users' (≥3admissions/year) associated factors in an emergency department (ED), using a comprehensive geriatric assessment (CGA), describing the characteristics of patients over 65 years of age. METHODS: A cross-sectional study was performed between August 2017 and June 2018 in an ED in Lisbon, Portugal. CGA was applied and completed with clinical records. Clinical, functional, mental and social scores were created based in Portuguese Society of Internal Medicine, and a statistical model was developed. RESULTS: CGA was applied to 426 patients over 64 years old in an ED. The mean age was 79.3, 84.7% had multimorbidity. 51.2%, 75.6%, and 40% had dependence on basic, instrumental, and walking activities, respectively. 52% had depressive symptoms, 65.7% had cognitive impairment, 63% were undernourished/at risk for malnutrition. 33.1% were socially at risk. Polypharmacy was present with a use on average of 6.5 drugs daily. Social, clinical, functional, and mental scores were unfavourable in 48.6%, 79.6%, 54.9% and 83.1% of the population, respectively. There were 2.7 hospital admissions/year and 39.9% were frequent ED users (≥3/year). The logistic regression model was weak, but showed that patients with polypharmacy, elevated Charlson Comorbidity index and an impairment nutritional status presented higher risk of being frequent users. CONCLUSIONS: This study showed that 97.1% of patients had needs that would justify an interventional care plan. This intervention should be extended to primary care and nursing homes. While not providing a robust model, our study has indicated nutritional problems, polypharmacy, and an elevated Charlson index as the features with more weight in frequent users' admissions.

Dieulafoy Lesion: Predictive Factors of Early Relapse and Long-Term Follow-Up.

INTRODUCTION: The Dieulafoy lesion (DL) is a rare cause of gastrointestinal bleeding. Advances in the endoscopy field have allowed an increased rate of detection and therapeutic efficacy. However, doubts remain about the most effective hemostatic approach, the affecting variables of therapeutic failure, and early relapse, as well as in the long-term follow-up. AIMS: To assess the efficacy of endoscopic treatment of DL and to identify possible risk factors for early relapse and long-term results. METHODS: All patients with DL admitted to a tertiary hospital between 01/01/2007 and 12/31/2018 were evaluated. The form of presentation, associated pathologies, chronic medication, therapeutic approach, and eventual relapse were determined. A telephone interview was conducted for all patients to find out the long-term results. RESULTS: We identified 73 patients with DL, 45 (61.6%) males, with a mean age of 74 ± 15 years. Thirty-nine patients presented the DL in the stomach, 15 in the duodenum, 2 in the small bowel, 3 in the colon, and 11 in the rectum. The median number of endoscopic examinations required for diagnosis was 2. Median Rockall was 4 (range 2-7). After endoscopic treatment, in 95% of the cases, no active bleeding was evident. Only 2 patients required interventional radiology procedures and 1 needed surgery. Fourteen patients (19%) had a rebleeding, 12 during hospitalization and 2 after a median time of 51 months (range 1-117). There was no difference between the groups with and without early relapse in relation to age, gender, hemoglobin values at presentation, presence of shock, associated pathologies, and anticoagulation. Antiplatelet agents intake had a statistically significant relationship with early relapse (p = 0.003). CONCLUSION: Endoscopic therapy is safe and effective in DL. Patients under antiplatelet therapy are more likely to have an early relapse. The long-term prognosis is excellent, even in patients only treated with endoscopic methods.

INTRODUÇÃO: A lesão de Dieulafoy (LD) é uma causa pouco frequente de hemorragia digestiva. Os avanços na endoscopia permitiram um aumento na taxa de deteção e na eficácia terapêutica, contudo, permanecem dúvidas na abordagem hemostática mais eficaz, nas causas de falência terapêutica e de recidiva precoce, assim como no follow up a longo prazo. OBJECTIVOS: Avaliar a eficácia do tratamento endoscópico para a LD, identificar eventuais factores de risco para a recidiva precoce e os resultados a longo prazo. Métodos: Avaliaram-se todos os pacientes com LD, admitidos num hospital terciário, entre 01/01/2007 e 31/12/2018. Determinou-se a forma de apresentação, patologias associadas, medicação habitual, abordagem terapêutica e eventual recidiva. Uma entrevista telefónica foi realizada a todos os doentes para averiguar os resultados a longo prazo. RESULTADOS: Identificaramse 73 doentes com LD, 45 (61.6%) do sexo masculino, idade média no diagnóstico 74 ± 15 anos. Trinta e nove apresentavam a LD no estômago, 15 no duodeno, dois no delgado, três no cólon e 11 no recto. Foram necessarios um número mediano de 2 exames endoscópicos para diagnóstico. O Rockall médio, na hemorragia digestiva alta, foi de 4 (range 2­7). Em 95% dos casos não se verificou hemorragia activa após tratamento endoscópico. Apenas dois doentes necessitaram de radiologia de intervenção e um de cirurgia. 14 doentes (19%) apresentaram recidiva, 12 durante o internamento e dois num periodo de follow up mediano de 51 meses (range 1­117). Não houve diferença entre os grupos com e sem recidiva precoce em relação á idade, género, valores de hemoglobina á apresentação, presença de choque, patologias associadas e anticoagulação. A toma de antiagregantes teve uma relação estatisticamente significativa com a recidiva precoce (p = 0.003). CONCLUSÃO: A terapêutica endoscópica é segura e eficaz na LD. Pacientes antiagregados têm maior propabilidade de recidiva precoce. O prognóstico a longo prazo é excelente, mesmo nos pacientes apenas tratados por métodos endoscópicos.

Lysosomal Acid Lipase: Can it be a New Non-Invasive Serum Biomarker of Cryptogenic Liver Fibrosis and Cirrhosis?

INTRODUCTION AND AIM: The association between lysosomal acid lipase (LAL) activity and liver steatosis or fibrosis is poorly studied. The aim of our study was to determine the predictive power of LAL for cryptogenic liver steatosis and cryptogenic significant fibrosis/cirrhosis. MATERIAL AND METHODS: Cross-sectional observational study of 101 adult patients with unexplained elevated liver enzymes/hepatomegaly with or without dyslipidemia submitted to the determination of LAL activity and LIPA gene (E8SJM-C.894G^A) mutation. Seventy-one patients underwent liver biopsy or FibroScan®. Patients with an identifiable liver dysfunction cause and well-stablished NAFLD/NASH risk factors were excluded. Predictors for liver steatosis, significant fibrosis (> F2) or cirrhosis (F4) were evaluated. RESULTS: Liver steatosis and fibrosis were mainly assessed by liver biopsy (74.6%; n = 53). Steatosis was present in 62.0% (n = 44), significant fibrosis in 47.9% (n = 34) and cirrhosis in 39.4% (n = 28). The median LAL was 0.36 (0.21-0.46)nmol/spot/h (vs. 0.29 (0.20-0.47); p = 0.558) for liver steatosis, 0.22 (0.11-0.29) nmol/spot/h (vs. 0.40 (0.34-0.51); p <0.001) for significant fibrosis and 0.21 (0.11-0.27) nmol/spot/h (vs. 0.40 (0.32-0.52); p < 0.001) for cirrhosis. No LIPA gene mutations were found. LAL activity was the strongest predictor of significant fibrosis (AUROC: 0.833; p < 0.001) with a cut-off of 0.265 (sensitivity: 85.9%; specificity: 75.0%) and cirrhosis (AUROC: 0.859; p < 0.001) with a cut-off of 0.235 (sensitivity: 86.2%; specificity: 75.0%), being higher than FIB4, GUCI or APRI. However, LAL activity was not associated with liver steatosis (AUROC: 0.536; p =0.558). CONCLUSION: LAL activity can be considered a non-invasive new marker of cryptogenic liver fibrosis with higher accuracy than other known biomarkers. LAL activity < 0.265 nmol/spot/h was strongly associated with cryptogenic significant fibrosis and <0.235 nmol/spot/h with cryptogenic cirrhosis. LAL activity was not associated with cryptogenic liver steatosis.

Clinical Practice Impact of the Boston Bowel Preparation Scale in a European Country.

INTRODUCTION: The diagnostic acuity of colonoscopy requires a careful evaluation of the colonic mucosa, so an adequate bowel cleansing is a key element of the procedure. It is internationally recommended that an evaluation of the quality of the intestinal preparation should be included in the colonoscopy report. The Boston Bowel Preparation Scale (BBPS) is a bowel cleanliness rating scale that has gained some preponderance in this context. However, its application implies some degree of subjective appreciation, and it is important to conduct interobserver reproducibility studies in different contexts. The objective of the present study was to evaluate the reliability of the BBPS in the Portuguese gastroenterological community. METHODS: A prospective study involving Portuguese gastroenterologists with clinical practice in several contexts, and using different methods of evaluation of the intestinal preparation. Participants were invited to answer a questionnaire encompassing 93 static images and 12 video segments of colonoscopy examinations, with different levels of intestinal preparation. For each item, the participant gastroenterologist assigned a score of 0-3, according to the BBPS criteria. A statistical analysis was performed with SPSS 20.0 software, using the intraclass correlation coefficient (ICC). RESULTS: From 45 invited gastroenterologists, 36 replied (mean age 39 ± 9 years). Fifteen (41%) had more than 10 years of colonoscopy experience and 20 (56%) performed more than 40 examinations per month. Twenty-seven (77%) usually used the BBPS in their daily practice. Statistical analysis revealed a strong interobserver correlation (ICC = 0.783) in the application of the BBPS, even in those gastroenterologists who did not use the scale in their daily routine (ICC = 0.775) and those with less years of experience (ICC = 0.820). The correlation in the videos was slightly lower than that observed in the static images (ICC = 0.74 vs. ICC = 0.78). CONCLUSION: The application of the BBPS in the Portuguese gastroenterology community is reproducible and can represent a way to harmonize the colonoscopy reports, contributing to its correct interpretation and subsequent patient orientation.

INTRODUÇÃO: A acuidade diagnóstica da colonoscopia exige uma visualização cuidadosa da mucosa, pelo que uma adequada preparação intestinal é um dos elementos chave para otimização do exame. É internacionalmente recomendado que a avaliação da qualidade da preparação intestinal seja incluída no relatório da colonoscopia. A escala de preparação intestinal de Boston (BBPS) tem ganho alguma preponderância neste contexto, mas a sua determinação inclui uma apreciação algo subjetiva, sendo importante realizar estudos de reprodutibilidade interobservador em diferentes contextos. O objetivo do presente estudo foi avaliar esta mesma reprodutibilidade na comunidade gastrenterológica portuguesa. MÉTODOS: Estudo prospetivo envolvendo Gastrenterologistas portugueses de diferentes faixas etárias e com prática clínica em diferentes contextos Os Gastrenterologistas foram convidados, de forma aleatória, para avaliar, online, 93 imagens estáticas e 12 vídeos de segmentos intestinais, com diferentes níveis de preparação. Para cada uma destas imagens/vídeos o participante atribuía uma pontuação de 0 a 3, segundo os critérios da BBPS. A análise estatística foi realizada com o software SPSS 20.0, utilizando o coeficiente de correlação intraclasses (ICC). RESULTADOS: Dos 45 Gastrenterologistas convidados, 36 (Média etária − 39 ± 9 anos) aceitaram participar (taxa de resposta de 80%). Quinze (41%) tinham mais de 10 anos de experiência em colonoscopia e 20 (56%) realizavam mais de 40 exames por mês. Recorriam a diferentes métodos de avaliação da preparação intestinal (27 (77%) utilizavam habitualmente a BBPS). A análise estatística revelou uma correlação interobservador forte (ICC = 0.783) na aplicação da BBPS, mesmo nos Gastrenterologistas que não utilizavam a escala no seu dia-a-dia (ICC = 0.775) e nos com menos anos de experiência (ICC = 0.820). A correlação nos vídeos foi ligeiramente inferior à observada nas imagens estáticas (ICC = 0.74 vs. ICC = 0.78). Conclusão: A aplicação da BBPS na comunidade gastrenterológica portuguesa revela-se reprodutível, podendo representar uma forma de harmonizar os relatórios, contribuindo assim para a sua correta interpretação e posterior orientação dos doentes.

Ulcerative Colitis: Are We Neglecting Its Progressive Character.

INTRODUCTION: Ulcerative colitis (UC) is a chronic disease but its progressive character, with structural damage, is insufficiently studied. OBJECTIVES: To analyze a group of patients without referral bias, regarding its clinical course, the morphological damage, and functional status. METHODS: We evaluated UC patients diagnosed between January 1, 2000 and December 31, 2004, living in the direct referral area of the hospital and determined the medication use, colectomy rate, structural damage ("lead pipe," stenosis, pseudopolyps, fibrous bridges), and anorectal function (prospective evaluation with the Cleveland Clinic Incontinence Score [CCIS] and the Fecal Incontinence Quality of Life Scale). RESULTS: We identified 104 patients, 47% female, with a mean age at diagnosis of 38 ± 17 years, 24% with proctitis, 57% with left colitis, and 19% with pancolitis. In 3 patients, it was not possible to obtain follow-up data. Of the studied patients, 56% needed corticosteroid therapy, 38% immunosuppressants, and 16% anti-tumor necrosis factors (anti-TNFs). After a mean follow-up of 13 ± 2 years, we found structural damage in 25 patients (24%): 5% with proctocolectomy, 15% with "lead pipe," 16% with pseudopolyps, and 3% with stenosis and fibrous bridges. Reference to functional anorectal disorders was identified in 49%, mostly previous and self-limited episodes of incontinence, but including persistent incontinence in 10% (CCIS 8 ± 4.8). There was an increased incidence of structural damage and anorectal dysfunction in patients who needed corticosteroid therapy (p = 0.001), immunosuppressants (p < 0.001), and anti-TNFs (p = 0.002) and an association of structural damage with anorectal dysfunction (p < 0.001). There was no association between age and anorectal dysfunction, including incontinence episodes. CONCLUSIONS: UC is a disease with structural and functional consequences in a significant subset of patients. This should be incorporated when defining the therapeutic strategy.

INTRODUÇÃO: A colite ulcerosa (CU) é uma doença crónica mas o seu carácter progressivo, com danos estruturais, encontra-se insuficientemente estudado. OBJETIVOS: Analisar um grupo de doentes, sem viés de referenciação, quanto ao percurso clínico, aos danos morfológicos e ao estado funcional. MÉTODOS: Avaliaram-se os doentes com diagnóstico de CU estabelecido entre 01-01-2000 e 31-12-2004, com residência na área de referenciação directa do hospital, tendo-se determinado a medicação usada, a taxa de colectomia, os danos estruturais ("cano de chumbo", estenoses, pseudopolipos, pontes fibrosas) ou funcionais ano-rectais (avaliação prospectiva com Cleaveland Clinic Incontinence Score, CCIS e Fecal Incontinence Quality of Life, FIQL). RESULTADOS: Identificaram-se 104 doentes, 47% do sexo feminino, idade média no diagnóstico de 38 ± 17 anos, proctite 24%, colite esquerda 57%, pancolite 19%. Em 3 doentes não foi possível obter dados de seguimento. Dos doentes estudados 56% tiveram necessidade de corticoterapia, 38% de imunossupressores e 16% de anti-TNFs. Após um seguimento médio de 13 ± 2 anos, encontraram-se danos estruturais em 25 doentes (24%), protocolectomia em 5%, "cano de chumbo" 15%, pseudopolipos 16% e estenoses e pontes fibrosas 3%. Verificamos referência a disfunção ano-rectal em 49% (maioritariamente episódios prévios e autolimitados de incontinência) mas incluindo incontinência persistente em 10% (CCIS 8 ± 4.8). Verificou-se uma incidência aumentada de danos estruturais e disfunção ano-rectal nos doentes com necessidade de corticoides (p = 0.001), imunossupressores (p < 0.001) e anti-TNF (p = 0.002) e uma relação entre os danos estruturais e a disfunção ano-rectal (p < 0.001). Não existiu associação entre a idade e a disfunção ano-rectal, incluindo episódios de incontinência. CONCLUSÕES: A CU é uma doença com consequências estruturais e funcionais num subgrupo significativo de doentes. Este facto deve ser integrado na definição da estratégia terapêutica.© 2017 Sociedade Portuguesa de Gastrenterologia Publicado por S. Karger AG, Basel.

Cytomegalovirus ulcerative oesophagitis in a young healthy immunocompetent patient.

Cytomegalovirus (CMV) gastrointestinal disease usually arises in patients with immunodeficiency or immunosuppression, being rare in immunocompetent hosts. Although increasing in incidence, few cases of CMV gastrointestinal disease have been described among young healthy patients. Currently, there is uncertainty in approaching these patients, including the need for antiviral therapy that remains to be established. This case report describes a CMV ulcerative oesophagitis in a young healthy immunocompetent patient with good evolution with no need for antiviral therapy, the youngest case being reported in the literature until now.

Efficacy of Endoscopic Retrograde Cholangiopancreatography in the Treatment of Biliary Complications following Liver Transplant: 10 Years of a Single-Centre Experience.

BACKGROUND AND AIMS: Biliary tract complications following liver transplant remain an important source of morbidity and mortality. Endoscopic retrograde cholangiopancreatography (ERCP) has become a common therapeutic option before other invasive procedures. The aim of this study was to evaluate ERCP efficacy in managing this type of complications. METHODS: Retrospective study of all patients who underwent therapeutic ERCP due to post-liver transplant biliary complications between September 2005 and September 2015, at a deceased donor liver transplantation centre. RESULTS: Therapeutic ERCP was performed in 120 patients (64% men; mean age 46 ± 14 years). Biliary complications were anastomotic strictures (AS) in 70%, non-anastomotic strictures (NAS) in 14%, bile leaks (BL) in 5.8%, and bile duct stones (BDS) in 32%. The mean time between liver transplant and first ERCP was: 19 ± 30 months in AS, 17 ± 30 months in NAS, 61 ± 28 months in BDS, and 0.7 ± 0.6 months in BL (p < 0.001). The number of ERCP performed per patient was: 3.8 ± 2.4 in AS, 3.8 ± 2.1 in NAS, 1.9 ± 1 in BDS, and 1.9 ± 0.5 in BL (p = 0.003). The duration of the treatment was: 18 ± 19 months in AS, 21 ± 17 months in NAS, 10 ± 10 months in BDS, and 4 ± 3 months in BL (p = 0.064). Overall, biliary complications were successfully managed by ERCP in 46% of cases, either as an isolated procedure (43%) or rendez-vous ERCP (3%). Per complication, ERCP was effective in 39% of AS, in 12% of NAS, in 91% of BDS, and in 86% of BL. Globally, the mean follow-up of the successful cases was 43 ± 31 months. Percutaneous transhepatic cholangiography and/or surgery were performed in 48% of patients in whom ERCP was unsuccessful. The odds ratio for effective endoscopic treatment was 0.2 for NAS (0.057-0.815), 12.4 for BDS (1.535-100.9), and 6.9 for BL (0.798-58.95). No statistical significance was found for AS (p = 0.247). CONCLUSIONS: ERCP allowed the treatment of biliary complication in about half of patients, avoiding a more invasive procedure. Endoscopic treatment was more effective for BDS and BL.

INTRODUÇÃO: As complicações biliares após transplante hepático são uma fonte importante de morbilidade e mortalidade. A colangiopancreatografia retrógrada endoscópica (CPRE) é a primeira opção de tratamento em muitos casos, previamente a procedimentos mais invasivos. O objetivo deste trabalho foi avaliar a eficácia da CPRE no tratamento destas complicações. DOENTES E MÉTODOS: Estudo retrospetivo de todos os doentes submetidos a CPRE terapêutica devido a complicações biliares após transplante hepático, entre setembro de 2005 e setembro de 2015. RESULTADOS: Incluídos 120 doentes submetidos a CPRE terapêutica, sendo 64% do sexo masculino, com idade média de 46 ± 14 anos. Complicações biliares: estenose da anastomose (EA) em 70%, estenose não anastomótica (ENA) em 14%, coledocolitíase em 32% e fuga biliar (FB) em 5,8%. Tempo entre transplante e primeira CPRE (meses): 19 ± 30 nas EA, 17 ± 30 nas ENA, 61 ± 28 na coledocolitíase e 0,7 ± 0,6 na FB (p < 0,001). Número de CPRE por doente: 3,8 ± 2,4 nas EA, 3,8 ± 2,1 nas ENA, 1,9 ± 1 na coledocolitíase e 1,9 ± 0,5 na FB (p = 0,003). Duração do tratamento (meses): 18 ± 19 nas EA, 21 ± 17 nas ENA, 10 ± 10 na coledocolitíase e 4 ± 3 nas FB (p = 0,064). Globalmente, a CPRE terapêutica foi eficaz em 46% dos casos (como procedimento isolado em 43% e por rendez-vous em 3%). Eficácia por complicação: 39% nas EA, 12% nas ENA, 91% na coledocolitíase e 86% nas FB. O tempo médio de follow-up foi de 43 ± 31 meses. Em 48% dos doentes, foi realizada terapêutica por colangiografia percutânea e/ou cirurgia por ineficácia da CPRE. Odds ratio para um tratamento endoscópico eficaz: 0,2 para ENA (0,057­0,815), 12,4 para coledocolitíase (1,535­100,9) e 6.9 para FB (0,798­58,95). Não houve diferenças estatisticamente significativas para a presença de uma EA. CONCLUSÕES: A CPRE foi eficaz no tratamento de complicações biliares após transplante hepático em cerca de metade dos casos, evitando outros procedimentos invasivos. O tratamento endoscópico foi particularmente eficaz em casos de coledocolitíase e FB.

Clinical applicability of Tokyo guidelines 2018/2013 in diagnosis and severity evaluation of acute cholangitis and determination of a new severity model.

OBJECTIVE: To determine the diagnostic accuracy of Tokyo guidelines (TG) 2018/2013 (TG18/TG13) and predictors of poor prognosis in acute cholangitis. METHODS: Retrospective 1-year study of consecutive hospital admissions for acute cholangitis. Prognosis was defined in terms of 30 d in-hospital mortality. RESULTS: Of the 183 patients with acute cholangitis, diagnostic accuracy based on Charcot's triad, TG07 and TG18/TG13 was 67.8, 86.9 and 92.3% (p < .001), respectively. Regarding severity based on TG18/TG13, 30.6% of cases were severe. A poor prognosis was found in 10.9% of patients. After multivariate analysis, systolic blood pressure <90 mmHg (OR 11.010; p < .001), serum albumin <3 g/dL (OR 1.355; p = .006), active oncology disease (OR 3.818; p = .006) and malignant aetiology of obstructive jaundice (OR 2.224; p = .021) were independent predictors of poor prognosis. The discriminative ability of the model with these four variables was high (AUROC 0.842; p < .001), being superior to TG18/TG13 (AUROC 0.693; p = .005). CONCLUSIONS: TG18/TG13 showed high diagnostic accuracy in acute cholangitis. Compared with TG18/TG13, the simplified severity model ≥2 allows easy selection of patients who will benefit from admission to the intensive care unit and early biliary decompression.

Auxiliary Liver Transplantation as a Transient Treatment for Acute Liver Failure: Two Cases.

INTRODUCTION: Acute liver failure is an uncommon condition associated with a high mortality. Most patients do not survive without liver transplantation. In the last decades, auxiliary liver transplantation has emerged as a therapeutic option. CLINICAL CASE: The authors present two cases of acute liver failure that required liver transplantation. Given the patients' young age and the preserved macroscopic liver pattern evaluated in surgery, auxiliary liver transplantation was executed using different surgical approaches. Afterwards, following confirmed full native liver regeneration, the patients were submitted to auxiliary liver hepatectomy, which was accomplished without complications. CONCLUSION: Auxiliary liver transplantation can be regarded as an effective temporary treatment for acute liver failure in selected cases, allowing an immunosuppression-free life.

INTRODUÇÃO: A falência hepática aguda é uma entidade clínica pouco comum, mas associada a elevada mortalidade. A maioria dos doentes não sobreviverá sem transplante hepático. Nas últimas décadas, o transplante hepático auxiliar tem sido utilizado como uma opção terapêutica valorizável. CASO CLÍNICO: Apresentam-se dois casos de falência hepática aguda tratados com transplante hepático. Tendo em conta a idade jovem dos doentes e a noção de preservação macroscópica do fígado, recorreu-se à opção de transplante hepático auxiliar utilizando técnicas diferentes. Posteriormente, após confirmação de regeneração hepática completa, procedeu-se à hepatectomia do fígado auxiliar. CONCLUSÃO: O transplante hepático auxiliar constitui uma terapêutica transitória eficaz em alguns casos de falência hepática aguda, permitindo um futuro isento de imunossupressão.

Challenging and uncommon diagnosis of long-evolution ascites.

This is a case report of a 45-year-old Caucasian man with chronic alcoholism. No history of liver disease or asbestos exposure. He complained of ascites during the last 3 years with worsening in the last year with severe ascites development. Diagnostic paracentesis showed SAAG 1.1 and high cellularity with neutrophil count >250 cells/µL. Ascitic fluid cytology revealed reactive mesothelial hyperplasia. Thoracoabdominopelvic ultrasonography/CT/MRI and fludeoxyglucose positron emission tomography/CT showed 'omental cake' pattern suggesting peritoneal carcinomatosis. An exploratory laparoscopy revealed moderate interloop adhesions and necrosis with whitish exudate in the right pelvic excavation. Biochemical/cytological/histological/microbiological study only revealed reactive mesothelial cells, necrosis and lymphohistiocytic inflammatory infiltrate. A second exploratory laparoscopy with liver and peritoneal biopsies and appendectomy/mesoappendix excision showed a well-differentiated tubulopapillary mesothelioma. The patient was referred for intraperitoneal chemotherapy and is undergoing monthly therapeutic paracentesis.

Endoscopic Management of Colonic Perforation due to Ventriculoperitoneal Shunt: Case Report and Literature Review.

The authors report the case of a 41-year-old woman with a colonic perforation due to a ventriculoperitoneal shunt (VPS) catheter. Left-sided colonic perforation was diagnosed by abdominal computed tomography 28 years after shunt placement, following acute meningitis caused by Escherichia coli. The proximal end of the VPS was exteriorized and it was decided to remove the distal end by colonoscopy. After pulling out the catheter with a polypectomy snare, it broke at the site where it was entering the colon, leaving a small perforation in the colonic wall which was closed with 2 endoclips. The endoluminal fragment of the catheter, being 20 cm in length, was removed through the rectum. The patient is asymptomatic at the 12-month follow-up. A review of the literature regarding 9 endoscopically managed cases of digestive tract perforation caused by VPS is presented.

Os autores descrevem o caso de uma mulher de 42 anos com perfuração do cólon por cateter de derivação ventrículo-peritoneal (DVP) colocado 28 anos antes. No contexto de meningite aguda a Escherichia coli, o estudo complementar com tomografia computadorizada abdominal identificou a extremidade distal do cateter de DVP no interior do lúmen do cólon esquerdo. Após remoção da extremidade ventricular do cateter, optou-se pela tentativa de extração da extremidade intra-cólica por colonoscopia. Durante a extração do cateter com ansa de polipectomia, constatou-se secção do mesmo no local de entrada na parede cólica, observando-se um pequeno orifício. Procedeu-se ao encerramento da perfuração com 2 endoclips e extração do fragmento livre endoluminal do cateter, com cerca de 20 cm, pelo reto. A doente permanece assintomática após 12 meses de seguimento. Uma revisão da literatura identificou 9 casos de perfuração do tubo digestivo por cateter de DVP tratados com endoscopia.

Uncertainties in the Management of a Lynch Syndrome Patient: A Case Report.

INTRODUCTION: Lynch syndrome (LS), the most common hereditary colorectal cancer syndrome, is characterized by mutations in mismatch repair (MMR) genes leading to an increased cancer risk, namely colorectal cancer. CASE: In the context of surveillance colonoscopy, a 40-mm flat lesion (0-IIa+b, Paris classification) was identified and submitted to piecemeal mucosal endoscopic resection in a 64-year-old LS patient with an MLH1 germline mutation (262delATC) and two previous segmental resections due to metachronous colorectal cancer. Pathology raised the suspicion of superficial submucosal invasive carcinoma with poor differentiation. Immunochemistry showed heterogeneous MLH1 expression and PMS2 loss. In a short-term follow-up colonoscopy, another 30-mm advanced carcinoma was identified. The patient was referred to surgery. CONCLUSION: This case raises several issues: (1) the potentially fast tumorigenesis and progression to carcinoma in LS and implications for endoscopic screening and surveillance; (2) pitfalls in the interpretation of MMR proteins immunochemistry; (3) the role of endoscopic resection in LS.

INTRODUÇÃO: O síndrome de Lynch (SL), a causa mais frequente de cancro colorectal hereditário, é caracterizado por mutações nos genes de reparação do ADN e risco aumentado de cancro, nomeadamente colorectal. CASO: No contexto de vigilância endoscópica, uma lesão plana com 40mm (0-IIa+b, classificação de Paris) foi identificada e submetida a resseção endoscópica fragmentada num doente de 64 anos com SL com mutação germinativa do gene MLH1 (262delATC) e duas resseções segmentares prévias por cancro colorectal metacrónico. A histologia era suspeita de invasão submucosa superficial por carcinoma pouco diferenciado. A imunohistoquímica mostrou expressão heterogénea de MLH1 e perda de PMS2. O diagnóstico de um segundo carcinoma avançado com 30 mm em reavaliação endoscópica determinou a referenciação para cirurgia. CONCLUSÕES: Este caso levanta várias questões: (1) tumorigénese e progressão para carcinoma aceleradas no SL e implicações no rastreio e vigilância endoscópica; (2) problemas na interpretação da imunohistoquímica das proteínas MMR; (3) papel da resseção endoscópica no SL.