Cecostomía endoscópica percutánea, una terapia eficaz en el síndrome de Ogilvie: relato de caso y revisión bibliográfica / Percutaneous endoscopic cecostomy, effective therapy for the treatment of Ogilvie syndrome: case and literature review

Ogilvie syndrome, or Acute Colonic Pseudo-Obstruction (ACPO) is characterized by colonic distension in the absence of mechanical obstruction. In general, it evolves favorably following a conservative treatment, and surgical procedures are not necessary6. We describe a case of ACPO with evolution of two days, in a 79-year old male patient, with asthma, type 2 diabetes mellitus, systemic arterial hypertension and policystic kidneys. After failure of conservative treatment based on support measures and neostigmine, percutaneous endoscopic support cecostomy, using a gastrostomy tube. The technique and its early execution were chosen considering that it was easy to be implemented, low cost and need for immediate colonic decompression due to high risk of ischemia and perforation of the colon, associated to a rapid clinical deterioration of the patient

El síndrome de Ogilvie o Pseudoobstrucción colónica aguda (ACPO) se caracteriza por la distensión del colon en ausencia de obstrucción mecánica. En general, el tratamiento conservador es favorable, no siendo necesaria una intervención quirúrgica. Describimos el caso de una ACPO con dos días de evolución, en paciente masculino de 79 años, asmático, portador de diabetes mellitus tipo 2, hipertensión arterial sistémica y riñones poliquísticos. Después del fracaso del tratamiento conservador con medidas de soporte y neostigmina, se optó por la realización de cecostomía endoscópica percutánea de protección, utilizando una sonda de gastrostomía. La elección de la técnica y su realización precoz se dio teniendo en vista su facilidad de ejecución, su bajo costo y la necesidad de descompresión colónica inmediata por el elevado riesgo de isquemia y perforación del colon, asociado al rápido empeoramiento clínico del paciente.

Rendez-Vous laparoendoscopic after ERCP failure in patient with Billroth II gastrectomy / Laparoscopía por Rendez-Vous luego de falla de CPRE en un paciente con gastectomía Billroth II

Endoscopic retrograde cholangiopancreatography (ERCP) is the treatment of choice in patients with choledocholithiasis. However, despite its high success rate, in some cases it is not successful, requiring alternative therapy. Billroth II partial gastrectomy is a condition associated with an important failure rate of ERCP. When endoscopic treatment fails, surgical exploration of the bile duct is the most common approach. However, the surgery is related to a greater complexity of execution and morbimortality. We describe the case of a patient with choledocholithiasis and Billroth II partial gastrectomy, submitted to the combined treatment called rendez-vous laparoendoscopic, after failure of ERCP, which unites in a single stage the endoscopic treatment of choledocholithiasis and laparoscopic removal of the gallbladder. We conclude that this therapeutic approach was effective, safe, with low cost and without complications.

La colangiopancreatografía endoscópica retrógrada (CPRE) es el tratamiento de elección en pacientes portadores de coledocolitiasis. Sin embargo, a pesar de su elevada tasa de éxito, en algunos casos no es exitosa, exigiendo terapia alternativa. La gastrectomía parcial con reconstrucción a Billroth II es una condición asociada a la importante tasa de fracaso de la CPRE. Cuando el tratamiento endoscópico falla, la exploración quirúrgica de la vía biliar es un enfoque más común. Sin embargo, la cirugía se relaciona con una mayor complejidad de ejecución y morbimortalidad. Describimos el caso de un paciente con coledocolitiasis y gastrectomía parcial con reconstrucción a Billroth II, sometido al tratamiento combinado denominado rendez-vous laparoendoscópico tras fallo de la CPRE, que une en una sola etapa el tratamiento endoscópico de la coledocolitiasis y la retirada laparoscópica de la vesícula biliar. Llegamos a la conclusión de que este enfoque terapéutico fue eficaz, seguro, de bajo costo y sin complicaciones.

Laparoendoscopic rendez-vous: a safe alternative to the treatment of choledocholithiasis / Rendez-vous láparo-endoscópico: una alternativa segura en el tratamiento de la colecocolitiasis

The choice treatment for choledocholithiasis when associated with lithiasic cholecystitis is endoscopic retrograde cholangiopancreatography (ERCP). However, in some cases this therapeutic fails, which requires an alternative method to extract the stones. The surgical approach tends to be the next step, but it is related to greater complexity of achievement and higher complications rates. In 1993, Deslandres et al. developed the combined treatment called laparoendoscopic rendez- vous, that unites in a single stage the endoscopic treatment of choledocholithiasis and laparoscopic removal of the gallbladder. We report the case of a patient diagnosed with common bile duct (CBD) stones, in which the conventional CPRE was not successful, and was taken to treatment by laparoendoscopic approach. We conclude, based on this case and on other published studies, that this therapeutic modality has advantages for being feasible, presenting low complications rate, shorter hospital stay and acceptable cost

El tratamiento de elección para la coledocolitiasis cuando se asocia con colecistitis litiásica es la colangiopancreatografía retrógrada endoscópica (CPRE). Sin embargo, en algunos casos ese tratamiento falla, requiriendo un método alternativo para extraer los cálculos. El abordaje quirúrgico tiende a ser el siguiente paso, pero se relaciona con una mayor complejidad de ejecución y mayores tasas de complicaciones. En 1993, Deslandres et al. desarrolló el tratamiento combinado llamado rendez-vous laparoendoscópico, que reúne en una sola etapa el tratamiento endoscópico de la coledocolitiasis y la extracción laparoscópica de la vesícula biliar. Presentamos el caso de una paciente diagnosticada con litiasis en la via biliar común, en el que la CPRE convencional no tuvo éxito, fue entonces enviada al tratamiento laparoendoscópico. Llegamos a la conclusión, basado en este caso y en otros estudios publicados, que esta modalidad terapéutica tiene ventajas por ser factible, teniendo bajos índices de complicaciones, menor estancia hospitalaria y costo aceptable

Perforated Meckel's diverticulum: una entidad inusual / Divertículo de Meckel perforado

We report a patient with diffuse peritonitis due to perforation of Meckel's diverticulum. This patient was referred to the operating room and underwent bowel resection segment encompassing the area of the diverticulum and terminoterminal primary enteroanastomosis on two levels with good evolution. The diverticulum complications are often related to the presence of ectopic mucosa, especially the gastric and pancreatic type. Since preoperative diagnosis is difficult and infrequent, in most cases this anomaly is confirmed only during surgery. Surgical resection of the affected intestinal segment is the mainstay of treatment in both diverticula diagnosed incidentally, as the complicated by inflammation, bleeding, obstruction or perforation. We conclude that in cases of acute abdomen punctured, the diagnosis of Meckel's diverticulum should be considered.

Se describe el caso de un paciente con peritonitis difusa debido a la perforación de un divertículo de Meckel. Este paciente fue llevado a la sala de operaciones y fue sometido a resección del segmento intestinal incluyendo el área del divertículo y enteroanastomosis primaria termino-terminal en dos niveles, con buena evolución. Las complicaciones del divertículo a menudo están relacionadas con la presencia de mucosa ectópica especialmente del tipo gástrica y pancreática. Dado que el diagnóstico preoperatorio es difícil y poco frecuente, en la mayoría de los casos esta anomalía se confirma únicamente durante la intervención quirúrgica. La resección quirúrgica del segmento intestinal afectado es el pilar del tratamiento, tanto en los divertículos hechos con diagnóstico en forma casual, como el complicado por la inflamación, sangrado, obstrucción o perforación. Llegamos a la conclusión de que en los casos de abdomen agudo perforados el diagnóstico de divertículo de Meckel debe ser considerado.

Biliary ileus: case report / Íleo biliar: caso clinico

Biliary ileusis a uncommon cause of mechanical bowel obstruction, affecting older adult patients who often have other significant medical conditions. It is caused by intestinal impaction of a gallstone that enters the bowel via a cholecysto-enteric fistula. The mortality rate is considerable, ranging between 12 and 27%. Treatment in most cases is surgical, aimed at the resolution of the intestinal obstruction. We report the case of a 55 year old patient diagnosed with biliary ileus, wich evolved without complications after a enterolithotomy. We have concluded, based on the literature that an early diagnosis associated with appropriate therapy can lead to a better prognosis

El íleo biliar es una causa poco frecuente de obstrucción intestinal mecánica, que afecta pacientes de edad avanzada que generalmente tienen comorbilidades significativas. Es causada por la impactación de un cálculo biliar en el intestino, que entra en el tracto digestivo por medio de una fístula colecisto-entérica. La tasa de mortalidad es considerable, que va de 12 a 27%. El tratamiento en la mayoría de los casos es quirúrgico y destinado a la resolución de la obstrucción intestinal. Presentamos el caso de una paciente de 55 años diagnosticada con íleo biliar, que evolucionó sin complicaciones después de enterolitotomia. Llegamos a la conclusión, con base en la literatura, que un diagnóstico precoz asociado con el tratamiento adecuado conduce a un mejor pronóstico

EUS-guided biliary drainage in distal malignant biliary obstruction: a new tool when ERCP fails / Drenagem biliar ecoguiada no câncer biliar distal: uma nova ferramenta na falha da CPRE

Introduction: most of patients with biliary tract cancer are diagnosed at an advanced stage. EUS-guided biliary drainage (EBD) is an alternative to percutaneous transhepatic or surgical drainage techniques after failure at conventional access by endoscopic retrograde cholangiopancreatography (ERCP). Objectives: to evaluate EBD efficacy and safety in patients with malignant biliary obstruction at the Gastrointestinal Endoscopy Department from Hospital das Clínicas of São Paulo University. Methods: there were included in our study patients that had a clinical history of obstructive jaundice and failure at biliary drainage by ERCP. EBD was performed under radioscopic control. The efficacy was analyzed according to clinical outcome and improvement in quality of life after the procedure, which was assessed by the application of a quality of life measurement test, and an evaluation of laboratory tests, signs, symptoms and procedure-related complications. Results: from April 2010 to September 2011, 32 patients with advanced biliary tract cancer were included in our study. Three (9.4%) patients had technical failure at EBD procedure. Technical success was achieved in 90.6% (29/32) and clinical improvement occurred in 100% (29/29). EUS-guided choledochoduodenostomy was the most common drainage procedure (58.62%). Duodenal self-expandable metallic stents were placed in 7 (21.85%) cases. There were a significant ecrease in bilirubin levels (p <0.001) and patients had improvement in quality of life after the procedure (p < 0.05). Complications occurred in 6 (18.75%) patients and the median survival was 90 days. Conclusion: EBD was an effective and safe procedure with acceptable complication rates, providing significant improvement in quality of life.

Introdução: a maioria dos pacientes com câncer biliar é diagnosticada em estágio avançado. A drenagem biliar ecoguiada é uma alternativa à drenagem percutânea e à cirurgia derivativa. Objetivos: avaliar a eficácia e a segurança do método em pacientes com necessidade de drenagem biliar e falha da CPRE prévia. Método: foram incluídos pacientes com obstrução biliar maligna e falha do acesso por CPRE convencional. A eficácia foi avaliada pelo sucesso clínico e pela avaliação da qualidade de vida. Avaliação laboratorial e clínica foram estudadas e computadas por teste estatístico. Resultados: entre abril e setembro, 32 pacientes foram incluídos no protocolo. Em três verificou-se insucesso do acesso ecoguiado. O sucesso técnico ocorreu em 90,6% (29/32) e o sucesso clínico em 100% dos casos. Coledocoduodenostomia ocorreu em 58,6% e foi o acesso mais frequente da casuística apresentada. A melhora da bilirrubina em 7 dias foi significante (p <0,001) e a qualidade de vida foi melhor no seguimento de 30 dias (p <0,05). Complicações ocorreram em 6 (18,75%) e sobrevida média foi de 90 dias. Conclusões: a drenagem biliar ecoguiada é uma ferramenta importante na falha da CPRE prévia e com índices de complicações aceitáveis.

Un estudio prospectivo y randomizado comparando el uso de stents de metal parcialmente cubiertos de plastico versus multistents en el manejo endoscópico de los pacientes con estenosis benignas postoperatorias del ducto biliar en un seguimiento de más de 5 años / A prospective randomized study comparing partially covered metal stent versus plastic multistent in the endoscopic management of patients with postoperative benign bile duct strictures: a follow-up above 5 years

FUNDAMENTO: Los Stent de metal autoexpandibles se utilizan a menudo para el drenaje biliar en obstrucción de origen neoplásico, con mejores resultados que los stents plásticos, pero son rara vez utilizados en el drenaje biliar en estenosis de etiología benigna. OBJETIVO: El objetivo final primario: Es verificar la permeabilidad de la vía biliar después de la colocación de los stents auto-expandible de metal y (múltiples) prótesis plásticas en pacientes con estenosis benignas derivadas de la cirugía del conducto biliar con un seguimiento superior a cinco años. Punto final secundario: Evaluar a largo plazo la tasa de complicaciones en pacientes con stents metálicos autoexpandibles y plástico. RESULTADOS: Los stents autoexpandibles de metal se colocaron en 15 pacientes y múltiples stents de plástico en 16. La edad media fue de 45 años, con prevalencia de pacientes de sexo femenino en ambos grupos y no hubo diferencia estadística entre los grupos se observó (Stent metálico: 66,7%; plástico multistent: 62,5%, p = 0,8). La tasa de complicaciones resultantes de los stents fueron más frecuentes en el grupo de stent de metal (40% versus 25%, p = 0,37). En el grupo de stent de metal, las complicaciones más frecuentes fueron hemorragia (n = 3; 20%), la migración del stent (n = 2; 13,3%) y perforación (n = 1; 6,7%). En el grupo multistent plástica, las complicaciones más frecuentes fueron la (n: 2, un 12,5%), hemorragia (n = 1; 6,2%) y la úlcera (n = 1; 6,2%). A largo plazo la tasa de permeabilidad tras el drenaje biliar fue mayor en el grupo de metal autoexpandible, SEMS: 81,67% ± 2,56, IC: 76,47-86,54; plástico multistent: 71,88% ± 2,93, IC: 66.08-77.27. CONCLUSIÓN: El paso temporal de los stents metálicos cubiertos parcialmente auto-expandible es una opción viable para los pacientes con estenosis benignas del conducto biliar.

BACKGROUND: Self-expandable metal stents (SEMS) are often used for biliary drainage due to obstruction of neoplastic etiology, with better results than plastic stents, but seldom for biliary drainage of benign etiology. OBJECTIVE: Primary end point: Verify bile duct patency after placement of self-expandable metal and (multiple) plastic stents in patients with benign strictures resulting from bile duct surgery with follow-up above five years. Secondary end point: Evaluate long-term complication rate in patients with metal self-expandable and plastic stents. RESULTS: Self-expandable stents were placed in 15 patients and multiple plastic stents in 16. Mean age was 45 years with prevalence of female patients in both groups and no statistical difference between groups was observed (SEMS: 66.7%; plastic multistent: 62.5%; p=0.8). Complication rate resulting from stents occurred more often in the metal stent group (40% versus 25%; p=0.37). In the metal stent group, most frequent complications were hemorrhage (n=3; 20%), stent migration (n=2; 13.3%) and perforation (n=1; 6.7%). In plastic multistent group, most frequent complications were perforation (n: 2; 12.5%), hemorrhage (n=1; 6.2%) and ulcer (n=1; 6.2%). Long-term patency rate after biliary drainage was higher in the self-expandable metal stent group, SEMS: 81.67% ± 2.56; CI: 76.47-86.54; plastic multistent: 71.88% ± 2.93; CI: 66.08-77.27. CONCLUSION: The temporary passage of partially covered self-expandable metal stents is a feasible option for patients with benign bile duct strictures.

EUS-guided biliary drainage: a Latin American experience / Drenagem biliar eco-guiada: experiência latino-americana

Our team was the firstly to perform an EUS biliary and pancreatic drainage in Latin america. When distal biliary obstruction (pancreatic and papillary lesions) occurs, EUS-guided fistulization between the common bile duct and duodenal bulb is an efficient and feasible strategy on achieving resolution of jaundice with low morbidity and mortality rates under experienced hands. EUS-guided hepaticogastrostomy and coledochoduodenostomy are advanced procedures on biliary and pancreatic endoscopy and together make up the echo-guided biliary drainage. Hepaticogastrostomy is indicated in cases of hilar obstruction, while the procedure of choice is coledochoduodenostomy in distal lesions. Both procedures must be done only after unsucessfull ERCP. The indication of these procedures must be made under a multidisciplinary view while sharing information with the patient or legal guardian. This study was conducted from june 2007 until march 2010.

Nossa equipe foi a primeira a realizar drenagem pancreáticobiliar na América Latina. Na ocasião de obstrução distal (massas em cabeça de pâncreas e papila duodenal maior), a fistulização eco-guiada entre o colédoco médio e o bulbo duodenal é uma estratégia factível no alívio da icterícia e com baixa morbimortalidade em equipes experientes. A hepaticogastrostomia e coledocoduodenostomia ecoguiadas são procedimentos avançados na endoscopia bilio-pancreática e compõe em conjunto a drenagem biliar eco-guiada. A hepaticogastrostomia é indicada nos casos de obstrução hilar, enquanto a coledocoduodenostomia é procedimento de escolha nas lesões distais. Convém lembrar que a drenagem biliar eco-guiada deve ser a segunda opção depois da falha da colangiografia endoscópica retrógrada. A indicação destes procedimentos deve ter alcance multidisciplinar e compartilhar a informação com o paciente ou responsável legal. Este estudo foi realizado entre junho de 2007 até março de 2010.