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1.
Dis Esophagus ; 34(12)2021 Dec 24.
Artículo en Inglés | MEDLINE | ID: mdl-34184036

RESUMEN

Peroral endoscopic myotomy (POEM) in patients with achalasia who are status post bariatric surgery may be technically challenging due to postsurgical scarring and altered anatomy. The aim of the study was to assess the efficacy and safety of POEM for achalasia in patients with prior bariatric surgery. A review of prospectively maintained databases at three tertiary referral centers from January 2015 to January 2021 was performed. The primary outcome of interest was clinical success, defined as a post-treatment Eckardt score ≤ 3 or improvement in Eckardt score by ≥ 1 when the baseline score was <3, and improvement of symptoms. Secondary outcomes were adverse event rates and symptom recurrence. Sixteen patients status post Roux-en-Y gastric bypass (n = 14) and sleeve gastrectomy (n = 2) met inclusion criteria. Indications for POEM were achalasia type I (n = 2), type II (n = 9), and type III (n = 5). POEM was performed either by anterior or posterior approach. The pre-POEM mean integrated relaxation pressure was 26.2 ± 7.6 mm Hg. The mean total myotomy length was 10.2 ± 2.7 cm. The mean length of hospitalization was 1.4 ± 0.7 days. Pre- and postprocedure Eckardt scores were 6.1 ± 2.1 and 1.7 ± 1.8, respectively. The overall clinical success rate was 93.8% (15/16) with mean follow-up duration of 15.5 months. One patient had esophageal leak on postprocedure esophagram and managed endoscopically. Dysphagia recurred in two patients, which was successfully managed with pneumatic dilation with or without botulinum toxin injection. POEM appears to be safe and effective in the management of patients with achalasia who have undergone prior bariatric surgery.


Asunto(s)
Acalasia del Esófago , Derivación Gástrica , Miotomía , Cirugía Endoscópica por Orificios Naturales , Acalasia del Esófago/cirugía , Esfínter Esofágico Inferior/cirugía , Humanos , Estudios Multicéntricos como Asunto , Resultado del Tratamiento
2.
Br J Surg ; 98(6): 818-24, 2011 Jun.
Artículo en Inglés | MEDLINE | ID: mdl-21523697

RESUMEN

BACKGROUND: Surgeons have not typically utilized an endoscopic approach for diagnosis and management of acute oesophageal perforation, mainly due to fears of increased mediastinal contamination. This study assessed the evolution of endoscopic approaches and their effect on outcomes over time in acute oesophageal perforation. METHODS: All patients with documented acute oesophageal perforation between 1990 and 2009 were enrolled prospectively in an Institutional Review Board-approved database. RESULTS: Of 81 patients who presented during the study period, 52 had upper gastrointestinal endoscopy for diagnosis alone (12 patients; 23 per cent) or as a component of acute management (40 patients; 77 per cent). Use of endoscopy increased from four of 13 patients in the first 5 years of the study to 20 of 24 patients in the final 5 years. Endoscopy was used in conjunction with surgery in 28 patients, of whom 21 underwent primary repair, three had resection, and one a diversion; 12 patients in this group had hybrid operations (combination of surgical and endoscopic management). Primary endoscopic treatment was used in 15 patients (29 per cent), most commonly involving stent placement (7). Of those having endoscopy, complication rates improved (from 3 of 4 to 8 of 20 patients), as did mean length of stay (from 21·8 to 13·4 days) between the initial and final 5 years of the study. There were two deaths (4 per cent). Of 21 patients who had both endoscopic assessment and management in the operating room, endoscopy identified additional pathology in ten, leading to a change in management plan in five patients. CONCLUSION: Endoscopy is a safe and important component of the management of acute oesophageal perforation. It provides additional information that modifies treatment, and its wider use should result in improved outcomes.


Asunto(s)
Perforación del Esófago/cirugía , Esofagoscopía/métodos , Enfermedad Aguda , Adulto , Anciano , Anciano de 80 o más Años , Análisis de Varianza , Nutrición Enteral/instrumentación , Perforación del Esófago/etiología , Humanos , Yeyunostomía/instrumentación , Persona de Mediana Edad , Estudios Prospectivos , Stents , Resultado del Tratamiento , Adulto Joven
3.
Endoscopy ; 43(5): 434-7, 2011 May.
Artículo en Inglés | MEDLINE | ID: mdl-21360424

RESUMEN

Complete obstruction of the proximal esophagus is an uncommon complication of radiotherapy. Standard endoscopic dilation is not possible because no lumen exists. We describe a retrospective case series in which rendezvous endoscopy, tissue puncture, dilation, and stenting were used to restore function to a group of patients with complete esophageal obstruction. The series consisted of patients referred for complete esophageal obstruction after radiation therapy over 5 years. Ultimately, five patients underwent successful initial recanalization via rendezvous endoscopy. All patients were able to resume eating and four have been able to maintain oral alimentation with periodic dilation. One patient developed self-limited pneumomediastinum after needle puncture and cervical osteomyelitis after stenting, and another developed an anterior neck abscess after stenting. Rendezvous endoscopy can successfully treat complete esophageal obstruction resulting from radiation therapy. Temporary stenting may allow patients to swallow immediately and leave the hospital sooner but does not appear to reduce the need for subsequent dilation and may result in serious complications.


Asunto(s)
Cateterismo , Estenosis Esofágica/terapia , Esofagoscopía/métodos , Traumatismos por Radiación/terapia , Stents , Anciano , Estenosis Esofágica/etiología , Esófago/efectos de la radiación , Femenino , Neoplasias de Cabeza y Cuello/radioterapia , Humanos , Masculino , Persona de Mediana Edad , Estudios Retrospectivos , Resultado del Tratamiento
4.
Surg Endosc ; 22(5): 1326-33, 2008 May.
Artículo en Inglés | MEDLINE | ID: mdl-18027044

RESUMEN

BACKGROUND: Historically, esophageal fistulas, perforations, and benign and malignant strictures have been managed surgically or with the placement of permanent endoprostheses or metallic stents. Recently, a removable, self-expanding, plastic stent has become available. The authors investigated the use of this new stent at their institution. METHODS: The study reviewed all the patients who received a Polyflex stent for an esophageal indication at the authors' institution between January 2004 and October 2006. Duration of placement, complications, and treatment efficacy were recorded. RESULTS: A total of 37 stents were placed in 30 patients (14 women and 16 men) with a mean age of 68 years (range, 28-92 years). Stent placement included 7 for fistulas, 3 for perforations, 1 for an anastomotic leak, 7 for malignant strictures, and 19 for benign strictures (8 anastomotic, 1 caustic, 5 reflux, 2 radiation, and 2 autoimmune esophagitis strictures, and 1 post-Nissen gas bloat stricture). The mean follow-up period was 6 months. Stent deployment was successful for all the patients, and no complications resulted from stent placement or removal. Nine stents migrated spontaneously. Three of three perforations and three of five fistulas sealed. Only one stent was removed because of patient discomfort. One patient with a radiation stricture experienced tracheoesophageal fistulas secondary to pressure necrosis. Of 20 patients with stricture, 18 experienced improvement in their dysphagia. CONCLUSION: Self-expanding, removable plastic stents are easily and safely placed and removed from the esophagus. This has facilitated their use in the authors' institution for an increasing number of esophageal conditions. Further studies to help define their ultimate role in benign and malignant esophageal pathology are warranted.


Asunto(s)
Enfermedades del Esófago/cirugía , Esofagoscopía/métodos , Implantación de Prótesis/instrumentación , Implantación de Prótesis/métodos , Stents , Adulto , Anciano , Anciano de 80 o más Años , Materiales Biocompatibles/uso terapéutico , Remoción de Dispositivos , Enfermedades del Esófago/diagnóstico por imagen , Femenino , Fluoroscopía , Migración de Cuerpo Extraño/diagnóstico por imagen , Migración de Cuerpo Extraño/etiología , Migración de Cuerpo Extraño/cirugía , Humanos , Masculino , Persona de Mediana Edad , Poliésteres/uso terapéutico , Diseño de Prótesis , Implantación de Prótesis/efectos adversos , Radiografía Intervencional/efectos adversos , Estudios Retrospectivos , Siliconas/uso terapéutico , Resultado del Tratamiento
5.
Endoscopy ; 44(4): 389-93, 2012 Apr.
Artículo en Inglés | MEDLINE | ID: mdl-22438149
6.
Surg Endosc ; 21(3): 439-44, 2007 Mar.
Artículo en Inglés | MEDLINE | ID: mdl-17180259

RESUMEN

BACKGROUND: The purpose of the present study was to assess the long-term safety and durability of effect for endoscopic full-thickness plication for the treatment of symptomatic gastroesophageal reflux disease (GERD). The Plicator (NDO Surgical, Inc., Mansfield, MA) used delivers a transmural suture through the gastric cardia to restructure the antireflux barrier. Published reports have shown the Plicator procedure to be effective in reducing GERD symptoms and medication use at 1 year post-plication. METHODS: Twenty-nine patients with chronic heartburn requiring maintenance daily anti-secretory therapy were treated at five sites. Patients received a single full-thickness plication in the gastric cardia 1cm below the gastroesophageal junction (GE) junction. Re-treatments were not permitted. Patients were evaluated at baseline for GERD symptoms and medication use. Intermediate (12 month) and long-term subject follow-up (median follow-up: 36.4 months; range, 31.2-43.9 months) were completed to evaluate procedure safety and durability of effect. RESULTS: Twenty-nine patients completed the 12-month and 36-month follow-up. All procedure-related adverse events occurred acutely, and no new events were observed during extended follow-up. At 36-months post-procedure, 57% (16/28) of baseline proton pump inhibitor (PPI)-dependent patients remained off daily PPI therapy. Treatment effect remained stable from 12- to 36-months, with 21/29 patients off daily PPI at 12 months compared to 17/29 patients at 36-months. Median GERD- Health Related Quality of Life (HRQL) scores remained significantly improved at 36 months versus baseline off-meds scores (8 versus 19, p < 0.001). In addition, the proportion of patients achieving > or = 50% improvement in GERD-HRQL score was consistent from 12 months (59%) to 36 months (55%). CONCLUSIONS: Endoscopic full-thickness plication can reduce GERD symptoms and medication use for at least 3-years post-procedure. Treatment effect is stable from 1 to 3 years, and there are no long-term procedural adverse effects.


Asunto(s)
Endoscopía Gastrointestinal/métodos , Fundoplicación/métodos , Reflujo Gastroesofágico/cirugía , Dolor Abdominal/etiología , Adulto , Anciano , Antiácidos/uso terapéutico , Dolor en el Pecho/etiología , Trastornos de Deglución/etiología , Disnea/etiología , Endoscopía Gastrointestinal/efectos adversos , Femenino , Estudios de Seguimiento , Fundoplicación/efectos adversos , Mucosa Gástrica/lesiones , Reflujo Gastroesofágico/tratamiento farmacológico , Antagonistas de los Receptores H2 de la Histamina/uso terapéutico , Humanos , Masculino , Persona de Mediana Edad , Faringitis/etiología , Inhibidores de la Bomba de Protones , Calidad de Vida , Resultado del Tratamiento
7.
Endoscopy ; 42(1): 62-7, 2010 Jan.
Artículo en Inglés | MEDLINE | ID: mdl-20066592
8.
Arch Intern Med ; 152(5): 1040-3, 1992 May.
Artículo en Inglés | MEDLINE | ID: mdl-1533759

RESUMEN

BACKGROUND: Laparoscopic cholecystectomy, introduced less than 2 years ago, is widely accepted by patients and physicians despite the lack of controlled trials comparing this technology with conventional cholecystectomy. Recent series have described a variable incidence of biliary tract injury with laparoscopic gallbladder removal. The primary interaction of endoscopic retrograde cholangiopancreatography with this technology is usually in the preoperative or postoperative diagnosis and treatment of common bile duct stones. METHODS: During a 12-month period, 597 patients underwent laparoscopic cholecystectomy by 20 general surgeons at six Puget Sound (Wash) hospitals. All patients with symptomatic postoperative biloma diagnosed by abdominal ultrasound or computed tomography with or without endoscopic retrograde cholangiopancreatography, as well as those who had acute bile duct injury diagnosed and repaired at the time of cholecystectomy, were retrospectively reviewed. RESULTS: Three bile duct transections were acutely recognized and treated with hepaticojejunostomy. Fourteen additional patients presented within 7 days with biloma, three of whom were treated with percutaneous drainage alone. Of the remaining 11 patients who underwent endoscopic retrograde cholangiopancreatography, six were noted to have common bile duct injuries; two, bile duct transections; and 3, cystic duct leaks that required a variety of endoscopic or surgical therapies. In all, 17 (2.9%) of 597 patients sustained a bile duct injury and, to date, seven (1.2%) of 597 patients required surgery for such injury. CONCLUSIONS: In a regional setting, laparoscopic cholecystectomy appears to be associated with a higher incidence of bile duct injury than previous reports of open cholecystectomy. Possible explanations include variant anatomy plus failure to obtain an operative cholangiogram, inadequate dissection, injudicious use of cautery or clip placement, inherent limitations of the procedure, or the learning curve associated with a new technology.


Asunto(s)
Conductos Biliares/lesiones , Bilis , Colangiopancreatografia Retrógrada Endoscópica , Colecistectomía/efectos adversos , Colecistectomía/métodos , Diagnóstico por Imagen , Humanos , Incidencia , Complicaciones Intraoperatorias/diagnóstico , Complicaciones Intraoperatorias/epidemiología , Complicaciones Intraoperatorias/terapia , Laparoscopía , Estudios Retrospectivos
9.
Aliment Pharmacol Ther ; 7(2): 117-23, 1993 Apr.
Artículo en Inglés | MEDLINE | ID: mdl-8485264

RESUMEN

Refractory inflammatory bowel disease can be treated by surgery or using nutritional supplementation or replacement. Immunosuppressive agents may also play a role for refractory disease; they have gained widespread acceptance, due not only to trials that demonstrate efficacy but also to the realization that these side-effects are minor compared to those associated with long-term, high-dose corticosteroids. To date, 6-mercaptopurine and azathioprine remain the drugs of choice based upon extensive clinical experience, but both methotrexate and cyclosporin are promising immunosuppressants for otherwise refractory disease.


Asunto(s)
Inmunosupresores/uso terapéutico , Enfermedades Inflamatorias del Intestino/terapia , Azatioprina/uso terapéutico , Ciclosporina/uso terapéutico , Humanos , Mercaptopurina/uso terapéutico , Metotrexato/uso terapéutico
10.
J Thorac Cardiovasc Surg ; 95(3): 415-22, 1988 Mar.
Artículo en Inglés | MEDLINE | ID: mdl-3343850

RESUMEN

Combined treatment with chemotherapy and radiation (chemoradiation) preceding surgical exploration for esophageal or gastroesophageal squamous cell carcinoma or adenocarcinoma was compared with surgical exploration alone to determine if there was an influence on tumor status at exploration, tumor resectability, disease recurrence, and patient survival. Preoperative chemoradiation resulted in significant tumor response as measured by decreased nodal involvement and 36% incidence of no residual tumor at resection (total response) and was reflected by an improvement in resectability. Local tumor recurrence was eliminated by preoperative chemoradiation preceding resection. Distant recurrence was not reduced and remained the major cause of death. The 2-year survival rate after tumor resection alone was 33% versus 66% after preoperative chemoradiation and resection (p = 0.13). Patient survival after resection alone was predicted by pathologic extent of local disease as measured by lymph node status. In contrast, survival after chemoradiation and resection was not predicted by pathologic extent of local disease. Surgical resection appears to have been an important component of therapy, primarily because survival was improved in patients after resection of residual local disease.


Asunto(s)
Adenocarcinoma/cirugía , Carcinoma de Células Escamosas/cirugía , Neoplasias Esofágicas/cirugía , Análisis Actuarial , Adenocarcinoma/tratamiento farmacológico , Adenocarcinoma/radioterapia , Adulto , Anciano , Anciano de 80 o más Años , Protocolos de Quimioterapia Combinada Antineoplásica/uso terapéutico , Carcinoma de Células Escamosas/tratamiento farmacológico , Carcinoma de Células Escamosas/radioterapia , Terapia Combinada , Neoplasias Esofágicas/tratamiento farmacológico , Neoplasias Esofágicas/radioterapia , Unión Esofagogástrica/cirugía , Femenino , Humanos , Masculino , Persona de Mediana Edad , Recurrencia Local de Neoplasia/prevención & control , Cuidados Preoperatorios , Estudios Retrospectivos
11.
J Am Geriatr Soc ; 29(2): 70-3, 1981 Feb.
Artículo en Inglés | MEDLINE | ID: mdl-7462544

RESUMEN

Biliary-tract disease is not only more common in the geriatric population but carries an increased surgical risk. Described is a series of 10 middle-aged and elderly patients who had stones in the common bile duct associated with significant underlying medical illness or peri-ampullary pathologic changes. They were successfully treated by endoscopic papillotomy. The 80 percent success rate in such critically ill patients suggests that endoscopic papillotomy might be used as the initial treatment modality in aging patients with amenable biliary-tract disease.


Asunto(s)
Ampolla Hepatopancreática/cirugía , Colangiopancreatografia Retrógrada Endoscópica , Cálculos Biliares/cirugía , Adulto , Anciano , Enfermedades de las Vías Biliares/complicaciones , Femenino , Cálculos Biliares/complicaciones , Cardiopatías/complicaciones , Humanos , Masculino , Métodos , Persona de Mediana Edad , Enfermedades Respiratorias/complicaciones
12.
Arch Surg ; 128(9): 1047-50; discussion 1051-3, 1993 Sep.
Artículo en Inglés | MEDLINE | ID: mdl-8368923

RESUMEN

OBJECTIVE: To analyze the clinical indications and long-term results for the Whipple procedure used for severe complications of chronic pancreatitis (CP). DESIGN: A series of 28 patients requiring the Whipple procedure for CP were reviewed by one surgeon between 1986 and 1993. SETTING: A multispecialty group practice hepatobiliary pancreatic referral center. PATIENTS: The referred patients with CP complications in the pancreatic head were anatomically defined by endoscopic retrograde cholangiopancreatographic and computed tomographic scans to include expanding pseudocysts, pancreatic duct disruption, arteriovenous fistula, or calcified obstructive fibrosis of bile duct, pancreatic duct, and/or duodenum. INTERVENTION: The Whipple procedure (pylorus-preserving [n = 25] or standard [n = 3]) was performed after preoperative assessment with a mesenteric arteriogram and, as necessary, percutaneous drainage or endoscopic stenting of pseudocyst, pancreatic duct, or bile duct were performed. MAIN OUTCOME MEASURES: Mortality, morbidity, length of hospital stay, and long-term results of the operation. RESULTS: There was no mortality. A 36% morbidity rate included adult respiratory distress syndrome (n = 3) secondary to a long operation time (average, 9.8 hours) or infected tissue and delayed gastric function (> 14 days) secondary to retrogastric amylase-rich fluid collections (n = 4). Long-term follow-up in 25 patients after 27 months (range, 3 to 84 months) showed that 88% were pain-free and 12% had improved. None had recurrent pancreas problems, but 28% had resumed drinking alcohol. Inability to gain weight was noted in 4% and a marginal ulcer in 4%. CONCLUSIONS: The Whipple procedure for severe complications of CP in the pancreatic head is a safe and effective operation leaving little gastrointestinal sequelae. Preoperative endoscopic and radiological assessment, drainage, and stenting procedures are key elements to achieving positive results.


Asunto(s)
Pancreatitis/cirugía , Adulto , Anciano , Anciano de 80 o más Años , Enfermedad Crónica , Femenino , Estudios de Seguimiento , Humanos , Masculino , Persona de Mediana Edad , Páncreas/cirugía , Pancreatitis/complicaciones , Pancreatitis/mortalidad , Complicaciones Posoperatorias , Reoperación , Índice de Severidad de la Enfermedad , Procedimientos Quirúrgicos Operativos/métodos , Factores de Tiempo
13.
Arch Surg ; 124(6): 684-8, 1989 Jun.
Artículo en Inglés | MEDLINE | ID: mdl-2786403

RESUMEN

Laser photoablative therapy has seen wide application in the esophagus, stomach, and rectum. Its use in the supraperitoneal colon has been less extensive because of fear of complications. One hundred fifteen patients who presented during a four-year period and underwent neodymium-YAG laser treatment on both sides of the peritoneal reflection (rectum, 47 patients; colon, 68 patients) were reviewed. The various lesions treated with laser therapy included 32 malignant tumors that presented with bleeding or obstruction, 44 large broad-based villous adenomas, six carcinoid tumors, and 33 patients with arteriovenous malformations or radiation proctitis who presented with acute hemorrhage or chronic blood loss. Overall treatment efficiency was 83% in the rectal group vs 87% in the colonic group. There was no significant difference in complication frequency or severity between the two groups, even though 45% of the colonic lesions were located in the thin-walled cecum. There was no laser-related mortality in this series. Laser photoablative therapy is safe and effective treatment for a wide variety of colorectal lesions. In experienced hands, it can be used on either side of the peritoneal reflection with equal efficiency and no increased risk of complications.


Asunto(s)
Adenoma/cirugía , Neoplasias del Colon/cirugía , Pólipos del Colon/cirugía , Terapia por Láser , Neoplasias del Recto/cirugía , Adulto , Anciano , Anciano de 80 o más Años , Femenino , Hemorragia Gastrointestinal/etiología , Humanos , Obstrucción Intestinal/etiología , Terapia por Láser/efectos adversos , Masculino , Persona de Mediana Edad , Neodimio
14.
Arch Surg ; 135(5): 564-8; discussion 568-9, 2000 May.
Artículo en Inglés | MEDLINE | ID: mdl-10807281

RESUMEN

HYPOTHESIS: Our experience with peristomal ulcers suggested that peristomal pyoderma gangrenosum (PPG) is an infrequent and usually unrecognized complication of inflammatory bowel disease. We hypothesized that a review of our experience with PPG would clarify the essentials of its diagnosis, evaluation, and treatment. DESIGN: A case series of 20 consecutive patients with PPG complicating inflammatory bowel disease were treated at our institution between 1986 and 1999. There were 15 women and 5 men. At the time of development of peristomal pyoderma, 10 of 20 patients had a diagnosis of Crohn disease (CD), while 9 had a diagnosis of ulcerative colitis (UC). One patient was diagnosed as having CD only after first developing PPG. MAIN OUTCOME MEASURE: Healing of PPG. INTERVENTIONS: All patients had failed local enterostomal care prior to referral. Debridements and/or stomal revisions were uniformly unsuccessful. Biopsies, when performed, did not provide clinically important information. Treatment was directed toward inflammatory bowel disease, with variable clinical responses to corticosteroids, metronidazole, cyclosporine, sulfasalazine, and infliximab. RESULTS: Ultimately, 13 patients had a diagnosis of CD. Of these patients, 12 (92%) of 13 developed PPG coincident with recurrent disease. Two patients had a remote history of proctocolectomy for UC and subsequent evaluation revealed CD. One patient developed PPG adjacent to a urinary Kock pouch after cystectomy; ultimately, a diagnosis of CD was made. No patients were lost to follow-up, but in 1 case of UC, no evaluation for latent CD was carried out. The final diagnosis was CD disease in 13 (65%) of 20 and UC in 7 (35%) of 20 patients. All PPG ulcers healed completely, within an average of 11.4 months (median, 8 months; range, 1-41 months). Ulcer resolution was achieved with medical therapy alone in 14 (70%) of 20 cases. Resection of active gastrointestinal CD resulted in healing in 5 (83%) of 6 cases. One case healed 2 months after conservative therapy only. CONCLUSIONS: This review of the largest reported series of PPG suggests the following: (1) PPG complicating inflammatory bowel disease is uncommon and often misdiagnosed by clinicians; (2) local wound care measures have little role in the healing of PPG; (3) PPG usually heralds active CD; (4) in patients with prior history of UC, PPG indicates CD until proven otherwise; (5) prolonged medical therapy (11 months), usually with immunosupression, is required for healing of PPG; and (6) if feasible, surgical resection of all active CD leads to the healing of PPG ulcers.


Asunto(s)
Colitis Ulcerosa/cirugía , Enfermedad de Crohn/cirugía , Enterostomía , Complicaciones Posoperatorias/cirugía , Piodermia Gangrenosa/cirugía , Adulto , Anciano , Colitis Ulcerosa/diagnóstico , Enfermedad de Crohn/diagnóstico , Desbridamiento , Femenino , Estudios de Seguimiento , Humanos , Masculino , Persona de Mediana Edad , Complicaciones Posoperatorias/diagnóstico , Piodermia Gangrenosa/diagnóstico , Recurrencia , Reoperación
15.
Arch Surg ; 134(3): 311-5, 1999 Mar.
Artículo en Inglés | MEDLINE | ID: mdl-10088575

RESUMEN

HYPOTHESIS: Pancreatitis arising from an obstructing ampullary neoplasm in patients with Gardner variant familial polyposis is an infrequently described clinical entity. We reviewed all patients with Gardner variant polyposis presenting with pancreatitis during a 12-year period in our institution, hoping to better define etiology and the appropriate diagnostic and interventional approach. METHODS: A retrospective record review (1986-1998) defined patient demographics, presenting features, initial and subsequent endoscopic retrograde cholangiopancreatography (ERCP) findings, subsequent treatments, and both immediate and long-term outcomes. Particular consideration was given to initial post-ERCP diagnosis and to endoscopic interventions undertaken at that time. We also looked at those patients who eventually required surgical intervention after long-term failure of medical and endoscopic therapy, the indications for surgery, final pathological characteristics, and follow-up results. RESULTS: Eight patients (6 women and 2 men), with a mean age of 42 years at initial presentation, were found. Each patient was known to have Gardner variant familial polyposis at the time of the initial bout of pancreatitis. All had undergone prior colectomy and 4 of 8 had undergone prior cholecystectomy. None were known to be taking medications or ingesting pancreatoxic substances. Five of 8 patients had obstructing focal or diffuse adenomatous disease involving the ampulla. Two of 8 patients had pancreatitis attributed to other causes (divisum, stones) and a single patient had no clear etiology. Three of 5 patients with ampullary adenomatous disease underwent pancreaticoduodenectomy for recurrent adenomatous encroachment and ampullary stenosis, despite repetitive snare resection and papillotomy. All of these patients had ampullary and other duodenal adenomas, and none had malignant disease. CONCLUSIONS: Patients presenting with pancreatitis in the setting of Gardner variant familial polyposis will frequently have an obstructing ampullary neoplasm, although additional etiologies should be sought. Initial endoscopic therapy affords transient relief but may not be definitive. The abnormal scarring and fibrosis (keloid formation, desmoid reaction) that characterize this disease likely play a large role in endoscopic or subsequent surgical failure. A significant number of these patients will go on to require surgical referral and intervention.


Asunto(s)
Síndrome de Gardner/complicaciones , Pancreatitis/etiología , Adulto , Colangiopancreatografia Retrógrada Endoscópica , Femenino , Humanos , Masculino , Pancreatitis/diagnóstico , Pancreatitis/terapia , Recurrencia , Estudios Retrospectivos
16.
Ann Thorac Surg ; 65(4): 919-23, 1998 Apr.
Artículo en Inglés | MEDLINE | ID: mdl-9564901

RESUMEN

BACKGROUND: Patients who present with malignant esophagorespiratory fistula continue to provide a significant palliative challenge to gastroenterologists and surgeons. METHODS: This retrospective series reviewed 29 patients treated with conventional prostheses (13 patients), expandable wire mesh-coated prostheses (12 patients), and surgical bypass with esophageal exclusion (4 patients) between 1982 and 1995. RESULTS: Improvement in dysphagia scores were comparable in all three groups. Fistula occlusion was more successful with expandable prostheses (92%) compared conventional prostheses (77%); however, reinterventions were required more commonly with expandable prostheses, which were also significantly more expensive on a unit cost basis. In selected patients in whom prosthesis placement either was inappropriate or failed, surgical bypass and esophageal exclusion was undertaken. These patients demonstrated good palliation with minimal morbidity and no mortality. CONCLUSIONS: Both conventional and expandable prostheses are safe and reasonably straightforward treatment modalities for patients with esophagorespiratory fistulas. Because of ease of insertion and large luminal diameter, expandable metal prostheses will see increasing use in treatment of these difficult patients; however, conventional prostheses will remain a good alternative, especially in patients with extrinsic esophageal compression. When stent placement is either unsuccessful or inadvisable, physiologically fit patients can undergo surgical bypass and esophageal exclusion with good palliation and minimal morbidity and mortality.


Asunto(s)
Fístula Esofágica/cirugía , Implantación de Prótesis , Fístula del Sistema Respiratorio/cirugía , Stents , Mallas Quirúrgicas , Adenocarcinoma/complicaciones , Adulto , Anciano , Anciano de 80 o más Años , Carcinoma de Células Escamosas/complicaciones , Dolor en el Pecho/etiología , Colon/trasplante , Costos y Análisis de Costo , Trastornos de Deglución/cirugía , Femenino , Migración de Cuerpo Extraño/etiología , Humanos , Enfermedades Pulmonares/complicaciones , Masculino , Persona de Mediana Edad , Cuidados Paliativos , Neumonía por Aspiración/etiología , Diseño de Prótesis , Implantación de Prótesis/efectos adversos , Implantación de Prótesis/economía , Reoperación , Estudios Retrospectivos , Stents/efectos adversos , Stents/economía , Estómago/cirugía , Mallas Quirúrgicas/efectos adversos , Tasa de Supervivencia , Resultado del Tratamiento
17.
Pancreas ; 10(1): 22-30, 1995 Jan.
Artículo en Inglés | MEDLINE | ID: mdl-7899456

RESUMEN

A ruptured pseudoaneurysm is the most rapidly fatal complication encountered in patients with chronic pancreatitis, with a reported mortality rate of 12.5% in treated patients to > 90% in those untreated. Although reportedly a rare complication of chronic pancreatitis, a pseudoaneurysm is encountered in 6-9.5% of patients with chronic pancreatitis and as many as 17% of all patients operated on for chronic pancreatitis. Timely diagnosis and treatment seems to result in markedly reduced mortality. Four patients with bleeding pseudoaneurysms associated with chronic pancreatitis and pseudocysts were encountered recently at Virginia Mason Medical Center. These patients' charts, as well as the English literature, were reviewed in detail. All of our cases occurred in alcoholic males. Pseudocysts with pancreatic ductal or pseudocyst rupture were seen in three cases. All had a history of crescendo-decrescendo pain episodes and had evidence of bleeding or were bleeding at presentation. Splenic vein occlusion was identified in 50% of the cases. A pseudoaneurysm was documented by angiography in all patients. Embolization was successfully attempted without complication in two patients. Three patients were ultimately treated with a pylorus-sparing (2) or standard (1) pancreaticoduodenectomy. These three are alive and doing well at 16, 26, and 52 months from the time of their procedure. A fourth patient was treated nonoperatively, because of severe comorbid disease and aberrant anatomy, with successful embolization of the pseudoaneurysm and biliary and pancreatic stenting. The pseudocyst resolved and he is asymptomatic 12 months after therapy. We advocate preoperative arteriography in all patients with suspected or known arterial pseudoaneurysm.(ABSTRACT TRUNCATED AT 250 WORDS)


Asunto(s)
Aneurisma Falso/terapia , Aneurisma Roto/terapia , Hemorragia/terapia , Pancreatitis/complicaciones , Adulto , Anciano , Aneurisma Falso/complicaciones , Aneurisma Roto/complicaciones , Enfermedad Crónica , Hemorragia/etiología , Humanos , Masculino
18.
J Gastrointest Surg ; 1(4): 357-61, 1997.
Artículo en Inglés | MEDLINE | ID: mdl-9834370

RESUMEN

Because transpapillary stents have been successfully placed to treat the ductal disruptions associated with pseudocysts, pancreatic ascites and pleural effusions, and pancreaticoenteric fistulas, we reviewed our experience with endoscopically placed prostheses in patients who had persistent pancreaticocutaneous fistulas but an otherwise intact duct. Nine patients who underwent endoscopic transpapillary stent placement for ongoing pancreaticocutaneous fistulas at our institution were retrospectively reviewed. Fistulas were present for a mean (+/-SEM) of 35 +/- 11 days and averaged 225 +/- 55 ml of output daily. Etiology of the fistulas included percutaneous pseudocyst drainage in four patients, pancreatic necrosis in two, complications of pancreatic surgery in two, and perforation of the duct of Santorini at the time of minor sphincterotomy in one. All patients had an otherwise intact duct at the time of endoscopic retrograde cholangiopancreatography. Six patients had transpapillary stents placed that did not bridge the area of leakage and three had prostheses placed across the ductal disruption. Eight of nine fistulas were successfully closed by means of this technique including five within 48 hours. There was one instance of stent migration and one patient developed prosthesis occlusion and an infected pseudocyst, which was treated with stent exchange. Stents were retrieved 10 to 14 days after fistula closure and no patient has had a recurrence at a median follow-up of 3 years. Transpapillary stents appear to effect closure of pancreaticocutaneous fistulas that fail to respond to conventional therapy.


Asunto(s)
Fístula Cutánea/terapia , Fístula Pancreática/terapia , Stents , Adulto , Anciano , Ampolla Hepatopancreática , Colangiopancreatografia Retrógrada Endoscópica , Remoción de Dispositivos , Endoscopía Gastrointestinal , Femenino , Humanos , Masculino , Persona de Mediana Edad , Fístula Pancreática/diagnóstico por imagen , Stents/efectos adversos
19.
Am J Surg ; 146(2): 250-3, 1983 Aug.
Artículo en Inglés | MEDLINE | ID: mdl-6881450

RESUMEN

The insertion of pancreaticobiliary drains at the time of endoscopic retrograde cholangiopancreatography can provide access to the bile or pancreatic duct, decompress an obstructed biliary tree, and allow infusion of solubilizing agents to effect gallstone dissolution. Twenty-six patients underwent 32 attempts at drain placement with 90 percent success and 6 percent minor complication rates. The use of pancreaticobiliary drains should supplement traditional diagnostic and therapeutic modalities in patients with surgical lesions of the pancreas or biliary tree.


Asunto(s)
Enfermedades de los Conductos Biliares/terapia , Colangiopancreatografia Retrógrada Endoscópica , Drenaje/métodos , Enfermedades Pancreáticas/terapia , Adulto , Neoplasias de los Conductos Biliares/terapia , Conductos Biliares Intrahepáticos , Colangitis/etiología , Colangitis/terapia , Drenaje/efectos adversos , Estudios de Evaluación como Asunto , Humanos , Masculino , Conductos Pancreáticos , Seudoquiste Pancreático/terapia
20.
Am J Surg ; 168(3): 223-6, 1994 Sep.
Artículo en Inglés | MEDLINE | ID: mdl-8080056

RESUMEN

Pancreatic ascites, etiologically related to a leaking pseudocyst or ductal disruption, has been treated medically with hyperalimentation, somatostatin analog, and large-volume paracentesis. Surgery is ultimately required in more than 50% of such patients. Mortality figures in patients with pancreatic ascites approximate 15% to 25% with either treatment modality. We describe 4 patients who were found to have ductal disruptions in conjunction with pancreatic ascites who responded to transpapillary pancreatic duct endoprosthesis placement. There has been no recurrence of ascites in these patients at a mean follow-up of 12 months following stent-retrieval. Further evaluation of endoscopic therapy for pancreatic ascites appears warranted.


Asunto(s)
Ascitis/terapia , Colangiopancreatografia Retrógrada Endoscópica , Enfermedades Pancreáticas/complicaciones , Adulto , Ascitis/etiología , Femenino , Humanos , Masculino , Persona de Mediana Edad , Stents
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