Self-expandable metal stents versus endoscopic balloon dilation for the treatment of strictures in Crohn's disease (ProtDilat study): an open-label, multicentre, randomised trial.

BACKGROUND: Endoscopic balloon dilation (EBD) is the established endoscopic treatment for short strictures in Crohn's disease. Fully covered self-expandable metal stents (FCSEMS) have been used for endoscopic treatment of patients for whom EBD was unsuccessful. We aimed to determine the efficacy and safety of the two endoscopic treatments in patients with Crohn's disease with stenosis and compare the mean cost of both treatments. METHODS: This multicentre, open-label, randomised trial was done in 19 tertiary and secondary hospitals in Spain. Patients with Crohn's disease with obstructive symptoms and predominantly fibrotic strictures of less than 10 cm in length were eligible for inclusion. We excluded patients with stenosis treated with SEMS or EBD in the previous year and stenosis not accessible to a colonoscope. Patients were randomly assigned (1:1) to receive either EBD (EBD group) or FCSEMS (FCSEMS group) using a digital en-block randomisation system (block size of four). In the EBD group, dilation was done with a CRE Boston Scientific (Marlborough, MA, USA) pneumatic balloon with the diameter set at the discretion of the endoscopist; a maximum of two sessions of dilation were allowed with a minimum interval of 15-30 days between them. In the FCSEMS group, a 20 mm diameter Taewoong (Gimpo-si, South Korea) fully covered metal stent was placed; stent length was set at the discretion of the endoscopist. The primary outcome was to assess the efficacy of the endoscopic treatment, defined by the proportion of patients free of a new therapeutic intervention (EBD, FCSEMS, or surgery) due to symptomatic recurrence at 1 year of follow-up. Patients were analysed according to the intention-to-treat principle. Adverse events were recorded for all the patients; events were considered associated to be with the procedure when a causal association was possible, probable, or definite. This trial is registered with ClinicalTrials.gov, NCT02395354. FINDINGS: From Aug 28, 2013, to Oct 9, 2017, we assessed the eligibility of 99 patients, of whom 19 (19%) patients were excluded. Thus, 80 (81%) patients were randomly assigned to treatment: 39 (49%) patients to the FCSEMS group and 41 (51%) patients to the EBD group. 33 (80%) of 41 patients in the EBD group and 20 (51%) of 39 patients in the FCSEMS group were free of a new therapeutic intervention at 1 year (odds ratio [OR] 3·9 [95% CI 1·4-10·6]; p=0·0061). Two (3%) of 80 patients had severe adverse events (one [2%] patient in the EBD group and one [3%] patient in the FCSEMS group); both patients had perforations. INTERPRETATION: EBD is more effective than FCSEMS for Crohn's disease strictures, with a good safety profile for both treatments. FUNDING: Spanish National Institute of Health, Foundation of Spanish Society of Digestive Endoscopy, Catalan Society of Gastroenterology, and Taweoong.

[Impact of a registry on survival in familial adenomatous polyposis]. / Mejoría de la supervivencia de la poliposis adenomatosa familiar después del establecimiento de un registro.

BACKGROUND AND OBJECTIVE: Familial adenomatous polyposis (FAP) is an autosomal dominant inherited disease characterized by hundreds of adenomatous polyps in the large intestine. Almost all affected untreated patients will die from colorectal cancer (CRC) at the age of 40-50 years. The Balearic Islands Polyposis Registry was established in 1988. The aim of the present study was to evaluate changes in the prevalence of CRC and the prognosis of FAP, before and after the establishment of the registry. PATIENTS AND METHOD: The diagnosis of FAP was defined by history, clinical examination, histopathological assessment and/or genetic testing. In this study we compare the data of probands and call-up patients. To evaluate the impact of the registry, selected variables were calculated for the periods 1970-1987 and 1988-2005. RESULTS: At the end of 2005 the registry included information of 19 families with 52 affected members (19 probands, 33 call-up). Thirty-six patients were alive and 16 had died. The cumulative 15 years survival was 82% in call-up cases compared with 47% in probands (p < 0.05). The cumulative 15 years survival was 87% for the period 1988-2005, compared with 33% for the period 1970-1987 (p < 0.001). The frequency of CRC was 72% for the period 1970-1987 and 21% for the period 1988-2005 (p < 0.005). CONCLUSIONS: The survival of the call-up patients was significantly improved as compared to the probands. Since the establishment of the registry, the frequency of CRC has decreased considerably, and the prognosis has improved substantially in FAP patients.

[Ileal perforation secondary to intestinal endometriosis]. / Perforación ileal secundaria a endometriosis.

Endometriosis is defined as the presence of endometrial tissue outside the uterus. The bowel is not often affected. There are no specific clinical findings for intestinal endometriosis. It is typically asymptomatic, but sometimes can present with abdominal pain, diarrhoea, constipation or intestinal obstruction. Ileal perforation is a rare complication of intestinal endometriosis and only a few cases have been reported in the literature. Intestinal endometriosis can mimic many gastrointestinal diseases, such as irritable bowel syndrome, inflammatory bowel disease, infections and neoplasms. The diagnosis is made by laparoscopy or laparotomy. We present a case of a woman with intermittent abdominal pain and ileal perforation secondary to intestinal endometriosis.

Mejoría de la supervivencia de la poliposis adenomatosa familiar después del establecimiento de un registro / Impact of a registry on the survival familial adenomatous polyposis

Fundamento y objetivo: La poliposis adenomatosa familiar (PAF) es una enfermedad hereditaria, autosómica dominante, que se caracteriza por el desarrollo de centenares de pólipos adenomatosos en el colon. La mayoría de los afectados no tratados desarrollan cáncer colorrectal (CCR) a edades tempranas. El Registro de PAF de las Islas Baleares se estableció en 1988. El objetivo de este estudio es evaluar los cambios en la incidencia de CCR y en la supervivencia de los pacientes con PAF tras la creación del registro. Pacientes y método: El diagnóstico de PAF se establece a partir de la historia clínica, la exploración física, los datos histopatológicos y/o los resultados de los análisis genéticos. En el presente estudio se comparan los datos de los casos índice y de los casos secundarios. Asimismo, se han recogido los datos de los pacientes diagnosticados antes del establecimiento del registro (1970-1987) a fin de poder compararlos con los recabados durante su funcionamiento (1988-2005). Resultados: En 2005 el registro incluía información de 19 familias con 52 miembros afectados (19 casos índice y 33 casos secundarios). Del total, 36 pacientes siguen vivos y 16 han fallecido. La supervivencia acumulada a los 15 años es del 82% en los casos secundarios y del 47% en los casos índice (p < 0,05). La supervivencia a los 15 años fue del 87% en el período 1988-2005 y del 33% para el período 1970-1987 (p < 0,001). La frecuencia de CCR fue del 72% para el período 1970-1987 y del 21% para el período 1988-2005 (p < 0,005). Conclusiones: La supervivencia de los casos secundarios es significativamente mejor que la de los casos índice. Los pacientes con PAF han presentado una mejoría en la supervivencia y una disminución de la frecuencia de CCR tras el establecimiento del registro

Background and objective: Familial adenomatous polyposis (FAP) is an autosomal dominant inherited disease characterized by hundreds of adenomatous polyps in the large intestine. Almost all afected untreated patients will die from colorectal cancer (CRC) at the age of 40-50 years. The Balearic Islands Polyposis Registry was established in 1988. The aim of the present study was to evaluate changes in the prevalence of CRC and the prognosis of FAP, before and after the establishment of the registry. Patients and method: The diagnosis of FAP was defined by history, clinical examination, histopathological assessment and/or genetic testing. In this study we compare the data of probands and call-up patients. To evaluate the impact of the registry, selected variables were calculated for the periods 1970-1987 and 1988-2005. Results: At the end of 2005 the registry included information of 19 families with 52 affected members (19 probands, 33 call-up). Thirty-six patients were alive and 16 had died. The cumulative 15 years survival was 82% in call-up cases compared with 47% in probands (p < 0.05). The cumulative 15 years survival was 87% for the period 1988-2005, compared with 33% for the period 1970-1987 (p < 0.001). The frecuency of CRC was 72% for the period 1970-1987 and 21% for the period 1988-2005 (p < 0.005). Conclusions: The survival of the call-up patients was significantly improved as compared to the probands. Since the establishment of the registry, the frequency of CRC has decreased considerably, and the prognosis has improved substantially in FAP patients

Perforación ileal secundaria a endometriosis / Ileal perforation secondary to intestinal endometriosis

La endometriosis es la presencia de tejido endometrial fuera del útero. La afección del intestino por endometriosis es una entidad poco frecuente y suele ser asintomática o presentarse de forma inespecífica con dolor abdominal, diarrea, estreñimiento u obstrucción intestinal. La perforación intestinal es poco frecuente, y hay pocos casos publicados en la literatura médica. La endometriosis intestinal puede imitar a un gran número de enfermedades digestivas, como el síndrome del intestino irritable, la enfermedad inflamatoria intestinal, infecciones o neoplasias. El diagnóstico se suele realizar a través de laparoscopia o laparotomía. Presentamos el caso de una paciente con dolor abdominal recurrente y posterior perforación ileal, secundaria a endometriosis

Endometriosis is defined as the presence of endometrial tissue outside the uterus. The bowel is not often affected. There are no specific clinical findings for intestinal endometriosis. It is typically asymptomatic, but sometimes can present with abdominal pain, diarrhoea, constipation or intestinal obstruction. Ileal perforation is a rare complication of intestinal endometriosis and only a few cases have been reported in the literature. Intestinal endometriosis can mimic many gastrointestinal diseases, such as irritable bowel syndrome, inflammatory bowel disease, infections and neoplasms. The diagnosis is made by laparoscopy or laparotomy. We present a case of a woman with intermittent abdominal pain and ileal perforation secondary to intestinal endometriosis