Asunto(s)
Colestasis/terapia , Endoscopía del Sistema Digestivo/métodos , Trasplante de Hígado , Complicaciones Posoperatorias/terapia , Brasil , Colestasis/diagnóstico por imagen , Colestasis/economía , Colestasis/etiología , Análisis Costo-Beneficio , Endoscopía del Sistema Digestivo/economía , Endoscopía del Sistema Digestivo/instrumentación , Humanos , Complicaciones Posoperatorias/diagnóstico por imagen , Complicaciones Posoperatorias/economíaRESUMEN
BACKGROUND: Patients with liver cirrhosis frequently undergo diagnostic or therapeutic upper GI endoscopy (UGIE), and the liver disease might impair the metabolism of drugs usually administered for sedation. OBJECTIVE AND SETTING: To compare sedation with a combination of propofol plus fentanyl and midazolam plus fentanyl in cirrhotic outpatients undergoing UGIE. DESIGN: A prospective, randomized, controlled trial was conducted between February 2008 and February 2009. MAIN OUTCOMES MEASUREMENTS: Efficacy (proportion of complete procedures using the initial proposed sedation scheme), safety (occurrence of sedation-related complications), and recovery time were measured. RESULTS: Two hundred ten cirrhotic patients referred for UGIE were randomized to 2 groups: midazolam group (0.05 mg/kg plus fentanyl 50 µg intravenously) or propofol group (0.25 mg/kg plus fentanyl 50 µg intravenously). There were no differences between groups regarding age, sex, weight, etiology of cirrhosis, and Child-Pugh or American Society of Anesthesiologists classification. Sedation with propofol was more efficacious (100% vs 88.2%; P < .001) and had a shorter recovery time than sedation with midazolam (16.23 ± 6.84 minutes and 27.40 ± 17.19 minutes, respectively; P < .001). Complication rates were similar in both groups (14% vs 7.3%; P = .172). LIMITATIONS: Single-blind study; sample size. CONCLUSION: Both sedation schemes were safe in this setting. Sedation with propofol plus fentanyl was more efficacious with a shorter recovery time compared with midazolam plus fentanyl. Therefore, the former scheme is an alternative when sedating cirrhotic patients undergoing UGIE.
Asunto(s)
Analgésicos Opioides/farmacocinética , Periodo de Recuperación de la Anestesia , Sedación Consciente/métodos , Sedación Profunda/métodos , Endoscopía Gastrointestinal , Hipnóticos y Sedantes/farmacocinética , Cirrosis Hepática/metabolismo , Analgésicos Opioides/administración & dosificación , Analgésicos Opioides/efectos adversos , Bradicardia/etiología , Sedación Consciente/efectos adversos , Sedación Profunda/efectos adversos , Femenino , Fentanilo/administración & dosificación , Fentanilo/efectos adversos , Humanos , Hipnóticos y Sedantes/administración & dosificación , Hipnóticos y Sedantes/efectos adversos , Hipotensión/etiología , Hipoxia/etiología , Masculino , Midazolam/administración & dosificación , Midazolam/efectos adversos , Persona de Mediana Edad , Propofol/administración & dosificación , Propofol/efectos adversos , Método Simple Ciego , Estadísticas no ParamétricasAsunto(s)
Adenocarcinoma Mucinoso/diagnóstico , Colestasis/terapia , Ictericia Obstructiva/terapia , Neoplasias Hepáticas/secundario , Cuidados Paliativos , Neoplasias Pancreáticas/diagnóstico , Adenocarcinoma Mucinoso/complicaciones , Adenocarcinoma Mucinoso/secundario , Anciano , Colestasis/etiología , Endoscopía del Sistema Digestivo , Humanos , Ictericia Obstructiva/etiología , Neoplasias Hepáticas/diagnóstico por imagen , Metástasis Linfática , Masculino , Conductos Pancreáticos/anomalías , Neoplasias Pancreáticas/complicaciones , Cintigrafía , StentsRESUMEN
AIM: To review results of endoscopic treatment for anastomotic biliary strictures after orthotopic liver transplantation (OLT) during an 8-year period. METHODS: This is a retrospective review of all endoscopic retrograde cholangiopancreatographys (ERCPs) performed between May 2006 and June 2014 in deceased OLT recipients with anastomotic stricture at a tertiary care hospital. Patients were divided into 2 groups, according to the type of stent used (multiple plastic or covered self-expandable metal stents), which was chose on a case-by-case basis and their characteristics. The primary outcome was anastomotic stricture resolution rate determined if there was no more than a minimum waist at cholangiography and a 10 mm balloon could easily pass through the anastomosis with no need for further intervention after final stent removal. Secondary outcomes were technical success rate, number or ERCPs required per patient, number of stents placed, stent indwelling, stricture recurrence rate and therapy for recurrent anastomotic biliary stricture (AS). Stricture recurrence was defined as clinical laboratorial and/or imaging evidence of obstruction at the anastomosis level, after it was considered completely treated, requiring subsequent interventional procedure. RESULTS: A total of 195 post-OLT patients were assessed for eligibility. One hundred and sixty-four (164) patients were diagnosed with anastomotic biliary stricture. ERCP was successfully performed in 157/164 (95.7%) patients with AS, that were treated with either multiple plastic (n = 109) or metallic billiary stents (n = 48). Mean treatment duration, number of procedures and stents required were lower in the metal stent group. Acute pancreatitis was the most common procedure related complication, occurring in 17.1% in the covered self-expandable metal stents (cSEMS) and 4.1% in the multiple plastic stent (MPS) group. Migration was the most frequent stent related complication, observed in 4.3% and 5.5% (cSEMS and MPS respectively). Stricture resolution was achieved in 86.8% in the cSEMS group and in 91% in MPS group. Stricture recurrence after a median follow up of 20 mo was observed in 10 (30.3%) patients in the cSEMS and 7 (7.7%) in the plastic stent group, a statistically significant difference (P = 0.0017). Successful stricture resolution after secondary treatment was achieved in 66.6% and 62.5% of patients respectively in the cSEMS and plastic stents groups. CONCLUSION: Multiple plastic stents are currently the first treatment option for AS in patients with duct-to-duct anastomosis. cSEMS was associated with increased pancreatitis risk and higher recurrence rate.
RESUMEN
INTRODUCTION: Adequate sedation is one of the cornerstones of good quality gastrointestinal endoscopy (GIE). Propofol sedation has increased significantly but there has been much debate over whether it can be administered by endoscopists. The aim of this prospective trial was to compare nonanesthesiologist-administered propofol (NAAP) and monitored anesthesia care (MAC). METHODS: A total of 2000 outpatients undergoing GIE at Hospital Albert Einstein (São Paulo, Brazil), a tertiary-care private hospital, were divided into two matched groups: NAAP (nâ=â1000) and MAC (nâ=â1000). In NAAP, propofol doses were determined by the endoscopist. A second physician stayed in the room during the entire procedure, according to local regulations. In MAC, the anesthesiologist administered propofol. RESULTS: In total, 1427 patients (71.3â%) were ASA (American Society of Anesthesiologists) class I and 573 were ASA class II. In NAAP, patients received more propofolâ+âfentanyl (61.1â% vs. 50.5â%; Pâ<â0.05) and there were fewer cases of deep sedation (44.7â% vs. 66.1â%; Pâ<â0.05). Hypoxemia rates were similar (12.8â% for NAAP and 11.2â% for MAC; Pâ=â0.3) but these reverted more rapidly in MAC (4.22 seconds vs. 7.26 seconds; Pâ<â0.05). Agitation was more frequent in MAC (14.0â% vs. 5.6â%; Pâ<â0.05). No later complications were observed. Patient satisfaction was very high and similar in both groups. CONCLUSION: In this setting, NAAP was as safe and effective as MAC for healthy patients undergoing GIE. Clinical trial ref. no.: U1111-1134-4430.
RESUMEN
Retroperitoneal perforation during therapeutic endoscopic retrograde cholangiopancreatography (ERCP) is uncommon and is usually manifested by abdominal pain, fever and leukocytosis. We report the case of a patient with post-ERCP subcutaneous emphysema, pneumomediastinum and pneumothorax treated conservatively. A 79-year-old woman with a diagnosis of choledocholitiasis was referred to our institution for an elective outpatient therapeutic ERCP. At the end of the procedure, subcutaneous emphysema was observed, and a thoracic computed tomography revealed a right pneumothorax and pneumomediastinum. Supportive care was instituted and she was discharged asymptomatic after 10 days of hospitalization. Subcutaneous emphysema, pneumothorax and pneumomediastinum are potencial complications of ERCP and sphincterotomy. We review the other cases previously reported and discuss the management.
RESUMEN
BACKGROUND: ERCP has become widely available for the diagnosis and treatment of benign and malignant pancreaticobiliary diseases. In this prospective study, the overall complication rate and risk factors for diagnostic and therapeutic ERCP were identified. METHODS: Data were collected prospectively on patient characteristics and endoscopic techniques from 1223 ERCPs performed at a single referral center and entered into a database. Univariate and multivariate analyses were used to identify risk factors for ERCP-associated complications. RESULTS: Of 1223 ERCPs performed, 554 (45.3%) were diagnostic and 667 (54.7%) therapeutic. The overall complication rate was 11.2%. Post-ERCP pancreatitis was the most common (7.2%) and in 93% of cases was self-limiting, requiring only conservative treatment. Bleeding occurred in 10 patients (0.8%) and was related to a therapeutic procedure in all cases. Nine patients had cholangitis develop, most cases being secondary to incomplete drainage. There was one perforation (0.08%). All other complications totaled 1.5%. Variables derived from cannulation technique associated with an increased risk for post-ERCP pancreatitis were precut access papillotomy (20%), multiple cannulation attempts (14.9%), sphincterotome use to achieve cannulation (13.1%), pancreatic duct manipulation (13%), multiple pancreatic injections (12.3%), guidewire use to achieve cannulation (10.2%), and the extent of pancreatic duct opacification (10%). Patient characteristics associated with an increased risk of pancreatitis were sphincter of Oddi dysfunction (21.7%) documented by manometry, previous ERCP-related pancreatitis (19%), and recurrent pancreatitis (16.2%). Pain during the procedure was an important indicator of an increased risk of post-ERCP pancreatitis (27%). Independent risk factors for post-ERCP pancreatitis were identified as a history of recurrent pancreatitis, previous ERCP-related pancreatitis, multiple cannulation attempts, pancreatic brush cytology, and pain during the procedure. CONCLUSIONS: The most frequent ERCP-related complication was pancreatitis, which was mild in the majority of patients. The frequency of post-ERCP pancreatitis was similar for both diagnostic and therapeutic procedures. Bleeding was rare and mostly associated with sphincterotomy. Other complications such as cholangitis and perforation were rare. Specific patient- and technique-related characteristics that can increase the risk of post-ERCP complications were identified.
Asunto(s)
Colangiopancreatografia Retrógrada Endoscópica/efectos adversos , Pancreatitis/etiología , Adolescente , Adulto , Anciano , Anciano de 80 o más Años , Enfermedades de las Vías Biliares/diagnóstico , Enfermedades de las Vías Biliares/terapia , Femenino , Humanos , Masculino , Persona de Mediana Edad , Análisis Multivariante , Estudios Prospectivos , Recurrencia , Factores de RiesgoRESUMEN
BACKGROUND: The liver is a common site of metastases for various malignancies. EUS-guided fine needle aspiration (EUS-FNA) of liver masses has only been reported in small series from single centers. METHODS: A retrospective questionnaire was sent by e-mail to 130 EUS-FNA centers around the world regarding indications, complications, and findings of EUS-FNA of the liver. RESULTS: Twenty-one centers reported 167 cases of EUS-FNA of the liver. A complication was reported in 6 (4%) of 167 cases including the following: death in 1 patient with an occluding biliary stent and biliary sepsis, bleeding (1), fever (2), and pain (2). EUS-FNA diagnosed malignancy in 23 of 26 (89%) cases after nondiagnostic fine needle aspiration under transabdominal US guidance. EUS localized an unrecognized primary tumor in 17 of 33 (52%) cases in which CT had demonstrated only liver metastases. EUS image characteristics were not predictive of malignant versus benign lesions. CONCLUSION: EUS-guided FNA of the liver appears to be a safe procedure with a major complication rate of approximately 1%. EUS-FNA should be considered when a liver lesion is poorly accessible to US-, or CT-guided FNA should be considered when US- or CT-guided FNA fail to make a diagnosis, when a liver lesion(s) is detected (de novo) by EUS, and for investigation of possible upper GI primary tumors in the setting of liver metastases.
Asunto(s)
Biopsia con Aguja/efectos adversos , Endoscopía del Sistema Digestivo/efectos adversos , Endosonografía/efectos adversos , Encuestas de Atención de la Salud , Cooperación Internacional , Neoplasias Hepáticas/diagnóstico por imagen , Neoplasias Hepáticas/secundario , Hígado/diagnóstico por imagen , Hígado/patología , Actitud del Personal de Salud , Humanos , Neoplasias Hepáticas/terapia , Evaluación de Resultado en la Atención de Salud , Reproducibilidad de los Resultados , Estudios Retrospectivos , Sensibilidad y EspecificidadRESUMEN
Embora seja descrita comm pouca freqüência, a transmissäo de infecçao por endoscopia é preocupaçäo crescente. Muitos säo os fatores que podem dificultar a realizaçäo da desinfecçäo de alto nível, que é preconizada para os endoscópicos: configuraçäo do equipamento, necessidade de pessoal especializado e relaçäo entre o número de endoscópios disponíveis e o número de exames realizados no serviço. Baseados em estudos recentes, elaboramos um questionário que foi encaminhado a 83 hospitais da cidade de säo Paulo, com o intuito de avaliar como é feito o reprocessamento desse material. Para nossa surpresa, em apenas um hospital as recomendaçöes da literatura médica säo seguidas, embora a maioria deles apresentasse infra-estrutura que permitiria a realizaçäo da desinfecçäo de alto nível. As falhas estiveram presentes em todas as etapas: limpeza, desinfecçäo, enxágüe e estocagem. Podemos concluir que divulgaçäo das medidas a serem seguidas e educaçäo continuada dos profissionais responsáveis por esses serviços säo fundamentais para que possamos atingir padröes internacionais no que diz respeito à desinfecçäo do equipamento utilizado em endoscopia digestiva.