A novel system for endoscopic closure of iatrogenic colon perforations using the Ovesco® clip and omental patch.

The growing endoscopic activity, both diagnostic and therapeutic, are also globally makes frequent endoscopic complications, perforation being one of the most serious. However, we also have more possibilities for endoscopic resolution of iatrogenic caused. We report the case of a sigmoid perforation during a colonoscopy that was resolved satisfactorily, avoiding surgery, by endoscopic closure with a nitinol clip Ovesco®.

Endoscopic treatment with self-expanding metal stents for Crohn's disease strictures.

BACKGROUND: Balloon dilation (with or without steroid injection) is the endoscopic treatment of choice for short strictures in Crohn's disease (CD). The placement of a stent has only rarely been reported in this setting, and it may be a good alternative. AIM: To describe the efficacy of temporary placement of a self-expanding metallic stent (SEMS) in the endoscopic treatment of symptomatic strictures in CD. METHODS: We included 17 CD patients treated with SEMS (4 partially covered SEMS and 21 fully covered SEMS) for symptomatic strictures refractory to medical and/or endoscopic treatment. RESULTS: We placed 25 stents in 17 patients with stenosis (<8 cm), in the colon and in the ileocolonic anastomosis. In two cases, two stents were placed in the same endoscopic procedure. All except three cases had previously been unsuccessfully treated with endoscopic dilatation. The stents were maintained for an average of 28 days (1­112). The treatment was effective in 64.7% of the patients after a mean follow-up time of 60 weeks (5­266). In four cases, removal of the stents was technically difficult due to stent impaction (moderate adverse events-AEs) and one patient had a proximal stent migration requiring delayed surgery (severe AE). CONCLUSION: The placement of self-expanding metallic stent in Crohn's disease maintained over a period of 4 weeks is a safe, effective treatment for strictures refractory to medical treatment and/or balloon dilatation, and might be an alternative endoscopic

Covered metal stents for the treatment of biliary complications after orthotopic liver transplantation.

BACKGROUND: Biliary complications, a major source of morbidity after orthotopic liver transplantation (OLT), are increasingly being treated by endoscopic retrograde cholangiopancreatography (ERCP). Endoscopic management has been shown to be superior to percutaneous therapy and surgery. Covered self-expandable metal stents (CSEMSs) may be an alternative to the current endoscopic standard treatment with periodic plastic stent replacement. OBJECTIVE: To assess the safety and efficacy of temporary CSEMS insertion for biliary complications after OLT. METHODS: From November 2001 to December 2009, the 242 OLT performed in 226 patients included 67 cases that developed post-OLT leaks or strictures (29.6%), excluding ischemic biliary complications. CSEMSs were used in 22 patients (33%), 18 male and 4 female, with an overall median age of 55 years (range, 29-69). In-house OLT patients underwent an index ERCP at 26 days (range, 8-784) after OLT. Their records were reviewed to determine ERCP findings, technical success, and clinical outcomes. RESULTS: ERCP with sphincterotomy was performed in all 22 patients, revealing 18 with biliary strictures alone (82%), 3 with strictures and leaks (14%), and 1 with strictures and choledocholithiasis (4%). All strictures were anastomotic. All patients had 1-2 plastic stents inserted across the anastomosis (11 had prior balloon dilation); stones were successfully removed, for an initial technical success rate of 100% (22/22). CSEMSs, were placed at the second ERCP in 14 patients, at the third in 7, and at the fourth in 1. With a median follow-up of 12.5 months (range, 3-25) after CSEMS removal, 21/22 patients (95.5%) remain stricture free and one relapsed, requiring repeat CSEMS insertion. Four patients experienced pain after CSEMS insertion. At CSEMS removal, migration was noted in 5 cases, into either the distal duodenum (n=4) or the proximal biliary tree (n=1), and embedding was seen in 1 case. There were no serious complications; no patients needed hepatojejunostomy. CONCLUSIONS: ERCP is a safe first-line approach for post-OLT biliary complications. It was highly successful in a population with anastomotic leaks and strictures. The therapeutic role of ERCP to manage biliary complications after OLT in the long term is not well known. In our experience, the high rate (close to 95%) of efficacy and its relative safety allowed us to use CSEMS to manage refractory biliary post-OLT strictures. CSEMS insertion may preclude most post-OLT hepatojejunostomies.

A retrospective study of pediatric endoscopy as performed in an adult endoscopy unit.

Gastrointestinal endoscopy is a safe, efficient technique with minimal complications, and a useful diagnostic tool for the pediatric population. Under ideal conditions endoscopies for children should be performed by experienced pediatric endoscopists. In this study we report our experience with pediatric endoscopy at the general adult endoscopy unit in our hospital. Our goal is to quantify the number of endoscopies performed in children, as well as their indications and findings, the type of sedation or anesthesia used, and the time waiting for the test to occur. Our experience demonstrates that endoscopists in a general adult gastroenterology department, working together with pediatricians, may perform a relevant number of endoscopies in children in a fast, safe, effective manner.

[The adult age in the medical field]. / Mayoría de edad sanitaria.

Two erroneous concepts have been developed over the last two decades In the Spanish medical literature and clinical practice: a) "mature minor," supposed subject whose rights prevail over those of his/her parents and b) "legal age for health care-related decisions" (16 years), really non-existent in our legal regulations. Several thoughts are given concerning the legislations that have been offered with respect to the "legal-age for health care-related decisions".

Validation of the Spanish version of the Phase III ISAAC questionnaire on asthma.

The prevalence of allergic diseases in childhood has increased significantly over the last decades. This increase seems to be closely associated with the way of life of western societies. The high prevalence differences on different regions may be due to linguistic and cultural reasons and not to real variations in prevalence. This is the reason why several authors felt the need to perform an objective validation of their versions. Our working group has published the results of the Phase I validation and now is publishing the Phase III validation in order to guarantee the reliability of this phase results. The study sample is formed by 366 children aged 3 to 17 years. The following steps were followed in this study: I. Assessment of the "Criterion validity" of the Spanish ISAAC-Bronchial Asthma questionnaire, evaluating the sensitivity, specificity, relative value, and positive and negative predictive values. 2. Determine the questionnaire reliability, analysing its "Inner consistency". 3. Statistical comparison between our ISAAC-Bronchial Asthma results and the ones obtained by other groups (external concordance and consistency), in order to prove the previously evaluated reliability. 4. Comparison between the ISAAC-Bronchial asthma questionnaire diagnostic ability and the standard diagnostic criteria universally used in clinical praxis. We could confirm that there is a high and very significant concordance between the questions aimed to detect children with asthma. In this sense, it is especially useful the question about "ever had wheezing" because of its high sensitivity (93.3%) and specificity (89.9%), that make it able to be used as initial screening test in a general population, and that has shown a high concordance percentage with the questions "ever had asthma" (98%), "wheezing with exercise" (75%), and "cough at night"(80%). The questions that give more information about the evolution and control of the asthmatic disease are "wheezing in the last 12 months", "number of attacks in the last 12 months", "wakening at night", "wheezing with exercise" and "dry cough at night in the last 12 months". The questions more related to asthma severity were "number of attacks in the last 12 months", "wakening at night", "stop speaking in order to breath", and "wheezing with exercise". We conclude that ISAAC-Asthma questionnaire Phase III is a useful tool for the assessment of childhood asthma due to its criterion validity, inner consistency and external concordance.

[Photopheresis: new immunomodulatory therapy for T-lymphocite mediated diseases]. / Fotoféresis: nueva terapia inmunomoduladora para enfermedades mediadas por linfocitos T.

The photopheresis (ECP) is a therapeutic approach based on the biological effect of psoralen and ultraviolet light A on mononuclear cells collected by apheresis, and reinfused into the patient. In 1988, the treatment was the first FDA-approved selective immunotherapy for any type of cancer. Convincing data taken from over 160 centers in Europe and the U.S.A. over the past few years have documented that ECP is associated with a very low side-effect profile. Evidence shows that this therapy prolongs the mean survival, and also induces 50-75% response rates in patients with advanced cutaneous T-cell lymphoma. In addition, more and more reports indicate that photopheresis is a potent agent in the therapy of solid organ transplant rejection, graft versus host disease, scleroderma, and other autoimmune diseases resistant to conventional therapy. The mechanism of this treatment is likely due to the induction of cell-mediated anticlonotypic immune response against pathogenic clones of T lymphocytes.