Evaluation of the Quality of Semen and Sexual Function in Men with Inflammatory Bowel Disease.

BACKGROUND: Data on fertility rates and medication safety in men with inflammatory bowel disease (IBD) are limited. The aim of this study was to evaluate whether there is a seminal alteration in patients with IBD and, if so, to evaluate the mechanisms that may play a role according to what has been described in the literature. Its secondary aim was to evaluate the impact on male sexual function of IBD. METHODS: Multicenter, cross-sectional, case series study comparing men with IBD and control subjects. Semen analysis was performed according to the recommendations of World Health Organization. The impact on male sexual function was evaluated with the International Index of Erectile Function questionnaire. RESULTS: On multivariate analysis, patients with Crohn's disease had lower sperm concentrations compared with those with ulcerative colitis (median [interquartile range], 34.5 [19.2-48] versus 70 [34.5-127.5], P = 0.02) and lower seminal zinc levels (mean ± SD, 1475 ± 235 µmol/L versus 2221 ± 1123 µmol/L, P = 0.04). Patients with Crohn's disease on anti-tumor necrosis factor treatment had better progressive motility (mean ± SD, 56.7 ± 17.7 versus 35.1 ± 22.1, P = 0.01) and sperm morphology (14.4 ± 7.1 versus 7.6 ± 4.9, P = 0.04) than those who were not on anti-tumor necrosis factor. Regarding sexual function, no significant differences were found across patients with IBD and control subjects. CONCLUSIONS: Men with Crohn's disease showed a trend toward poorer semen quality than those with ulcerative colitis. Treatment with anti-tumor necrosis factor drugs does not seem to be associated with poor sperm quality. In patients in clinical remission, male sexual function is not affected by IBD.

Incidence, management, and course of cancer in patients with inflammatory bowel disease.

BACKGROUND AND AIMS: Patients with inflammatory bowel disease [IBD] are at increased risk for developing some types of neoplasia. Our aims were to determin the risk for cancer in patients with IBD and to describe the relationship with immunosuppressive therapies and clinical management after tumor diagnosis. METHODS: Retrospective, multicenter, observational, 5-year follow-up, cohort study. Relative risk [RR] of cancer in the IBD cohort and the background population, therapeutic strategies, and cancer evolution were analyzed. RESULTS: A total of 145 cancers were diagnosed in 133 of 9100 patients with IBD (global cumulative incidence 1.6% vs 2.4% in local population; RR = 0.67; 95% confidence interval [CI]: 0.57-0.78). Patients with IBD had a significantly increased RR of non-melanoma skin cancer [RR = 3.85; 2.53-5.80] and small bowel cancer [RR = 3.70; 1.23-11.13]. After cancer diagnosis, IBD treatment was maintained in 13 of 27 [48.1%] patients on thiopurines, in 2 of 3 on methotrexate [66.6%], none on anti-TNF-α monotherapy [n = 6] and 4 of 12 [33.3%] patients on combined therapy. Rate of death and cancer remission during follow-up did not differ [p > 0.05] between patients who maintained the treatment compared with patients who withdrew [5% vs 8% and 95% vs 74%, respectively]. An association between thiopurines [p = 0.20] or anti-TNF-α drugs [p = 0.77] and cancer was not found. CONCLUSIONS: Patients with IBD have an increased risk for non-melanoma skin cancer and small bowel cancer. Immunosuppresive therapy is not related to a higher overall risk for cancer or worse tumor evolution in patients who maintain these drugs after cancer diagnosis.

Induction of psoriasis with anti-TNF agents in patients with inflammatory bowel disease: a report of 21 cases.

AIM: Anti-tumor necrosis factor (TNF)-alpha agents are widely used for the treatment of both inflammatory bowel disease (IBD) and psoriasis. Psoriatic skin lesions induced by anti-TNF have been described in patients with IBD. We report a case series of psoriasis induced by anti-TNF agents in IBD patients. METHODS: Systematic analysis of cases of psoriasis induced by anti-TNF in an IBD patient cohort in tertiary hospitals of Madrid. RESULTS: A total of 21 of 1294 patients with IBD treated with anti-TNF-alpha agents developed drug-induced psoriasis (cumulative incidence 1.62%; 95% CI 1.06%-2.47%): 14 patients with infliximab and 7 with adalimumab; seventeen with Crohn's disease, 4 with ulcerative colitis. The onset of skin lesions varied in a wide range of time (after a mean 13±8 doses). The most frequent site of skin lesions was the limbs (62%) followed by the trunk (48%) and the scalp (43%). The psoriasis phenotypes were plaque psoriasis (57%), scalp (14%), palmoplantar pustulosis (14%), pustular generalized psoriasis (5%), guttate (5%) and inverse (5%). Four patients interrupted the anti-TNF treatment, and that led to the complete regression of lesions in 1 of them. The other 17 patients were maintained on anti-TNF therapy and managed with topical steroids. CONCLUSION: Psoriatic lesions can be induced by anti-TNF drugs. Plaque psoriasis on the extremities and trunk were the most frequent presentations in our series. Topical steroid treatment is effective in most patients. Anti-TNF discontinuance may be reserved for patients with severe psoriasis or patients without response to topical therapy.

Is the use of prophylactic hemoclips in the endoscopic resection of large pedunculated polyps useful? A prospective and randomized study.

BACKGROUND: The methods for preventing post-polypectomy bleeding (PPB) are not standardised and there are groups that use hemoclips for this purpose. OBJECTIVE: To study whether the use of hemoclips reduces PPB complications. MATERIALS AND METHODS: Prospective, randomised study of patients with pedunculated polyps larger than 10 mm. The patients were included in two groups (hemoclip before polypectomy -HC- and standard polypectomy -SP-). This study has been registered with the trial registration number NCT01565993. RESULTS: 105 polypectomies were performed (98 patients), 66 (62.9%) in the HC group. The total rate of complications was 10,6% in the HC group (4.5% early bleeding, 1.5% severe delayed bleeding, 4,5% mucosal burns, 1.5% perforation). In the SP group, the rate of total complications was 7,7%, (7,7% early bleeding, no significant differences). In view of the unexpected increase in the morbidity of the hemoclip group, the study was suspended without reaching the sample size. In an ad hoc analysis, which includes the standard polypectomy patients who refused to participate in the study (35 polyps), the total morbidity was 5,7% (no perforations and 2 patients with premature bleeding).When we compared the morbidity of the HC group to the morbidity of SP group plus R group (74 polyps), we also failed to detect any significant differences in terms of PPB, but did in terms of perforation. CONCLUSION: The prophylactic use of hemoclips in polypectomies of large pedunculated polyps leads to a further risk of mucosal burns and perforation that is not acceptable, and does not reduce the risk of PPB.

Is the use of prophylactic hemoclips in the endoscopic resection of large pedunculated polyps useful? A prospective and randomized study.

BACKGROUND: The methods for preventing post-polypectomy bleeding (PPB) are not standardised and there are groups that use hemoclips for this purpose. OBJECTIVE: To study whether the use of hemoclips reduces PPB complications. MATERIALS AND METHODS: Prospective, randomised study of patients with pedunculated polyps larger than 10 mm. The patients were included in two groups (hemoclip before polypectomy -HC- and standard polypectomy -SP-). This study has been registered with the trial registration number NCT01565993. RESULTS: 105 polypectomies were performed (98 patients), 66 (62.9%) in the HC group. The total rate of complications was 10,6% in the HC group (4.5% early bleeding, 1.5% severe delayed bleeding, 4,5% mucosal burns, 1.5% perforation). In the SP group, the rate of total complications was 7,7%, (7,7% early bleeding, no significant differences). In view of the unexpected increase in the morbidity of the hemoclip group, the study was suspended without reaching the sample size. In an ad hoc analysis, which includes the standard polypectomy patients who refused to participate in the study (35 polyps), the total morbidity was 5,7% (no perforations and 2 patients with premature bleeding).When we compared the morbidity of the HC group to the morbidity of SP group plus R group (74 polyps), we also failed to detect any significant differences in terms of PPB, but did in terms of perforation. CONCLUSION: The prophylactic use of hemoclips in polypectomies of large pedunculated polyps leads to a further risk of mucosal burns and perforation that is not acceptable, and does not reduce the risk of PPB.

Intraoperative ERCP: What role does it have in the era of laparoscopic cholecystectomy?

In the treatment of patients with symptomatic cholelithiasis and choledocholithiasis (CBDS) detected during intraoperative cholangiography (IOC), or when the preoperative study of a patient at intermediate risk for CBDS cannot be completed due to the lack of imaging techniques required for confirmation, or if they are available and yield contradictory radiological and clinical results, patients can be treated using intraoperative endoscopic retrograde cholangiopancreatography (ERCP) during the laparoscopic treatment or postoperative ERCP if the IOC finds CBDS. The choice of treatment depends on the level of experience and availability of each option at each hospital. Intraoperative ERCP has the advantage of being a single-stage treatment and has a significant success rate, an easy learning curve, low morbidity involving a shorter hospital stay and lower costs than the two-stage treatments (postoperative and preoperative ERCP). Intraoperative ERCP is also a good salvage treatment when preoperative ERCP fails or when total laparoscopic management also fails.

Is outpatient ERCP suitable, feasible, and safe? The experience of a Spanish community hospital.

BACKGROUND: We wanted to evaluate the safety of outpatient endoscopic retrograde cholangiopancreatography (ERCP). The follow-up of an ERCP outpatient during a short observation period could be a feasible and safe approach. METHODS: To evaluate the safety of outpatient ERCP, we assessed the rate of post-ERCP complications found and missed during a 6-h observation period after therapeutic ERCP. RESULTS: We performed 236 ERCPs on an outpatient basis, with a failure rate of 3.7% but with an overall completion rate for the intended treatment of 90.7%. Seventy-eight percent of the ERCPs were primarily therapeutic. The age of the patients was 63.9 years and 61.9% were females. One hundred seventy-seven (74.5%) patients were discharged from the hospital after the observation period. Thirty-three (14.1%) patients were admitted without further delay due to unexpected ERCP findings or for early detection of complications. Twenty-seven (11.4%) patients had a prolonged hospital stay because of complications during the observation period. Just two patients previously discharged developed later complications: cholangitis and pancreatitis (0.84% of the ERCPs and 7.4% of the overall complications). There were 27 ERCP complications (12.1%). Of the overall complications, 29.6% were diagnosed very early after the procedure and 62.9% were diagnosed during the observation period. 8.9% out of the 12.1% of the ERCP complications were mild to moderate. There was no mortality. CONCLUSION: Twenty-five (92.6%) of ERCP complications occurred during the first 6 h, making the use of this short observation period safe for an early discharge. The evolution of the patients who developed delayed complications was unremarkable. Whenever outpatient ERCP is feasible, it should be done to help cut costs.

Ectopic papilla of Vater in the pylorus.

The major papilla of Vater is usually located in the second portion of the duodenum, to the posterior medial wall. Sometimes the mouth of the biliary duct is located in other areas. Drainage of the common bile duct into the pylorus is extremely rare. A 73-year old man, with a history of duodenal ulcer, was admitted to hospital with the diagnosis of cholangitis. Dilatation of the extrahepatic biliary duct was observed by abdominal ultrasonography, and endoscopic retrograde cholangiopancreatography (ERCP) was performed. No area suggesting the presence of the papilla of Vater was found within the second duodenal portion. Finally the major papilla was located in the theoretical pyloric duct. Cholangiography was performed and choledocholithiasis was found in the biliary tree. The patient underwent dilatation of the papilla with a balloon tyre and removal of a 7 mm stone using a Dormia basket, which solved the problem without further complications. This anomaly increased the difficulty of performing therapeutic interventions during ERCP. This alteration in anatomy may increase the risk of complications during papillotomy, with a theoretically higher risk of perforation. Dilatation using a balloon was the chosen therapeutic technique both in our case and in the literature, due to its low rate of complications.

[Endoscopic treatment of gastrointestinal fistulas with biological fibrin glue]. / Tratamiento endoscópico de fístulas gastrointestinales con un pegamento biológico tisular.

OBJECTIVE: We summarize our experience of endoscopic treatment of gastrointestinal fistulas with fibrin glue. PATIENTS AND METHOD: We retrospectively reviewed the outcome of 30 patients with gastrointestinal fistulas (9 internal and 21 external) refractory to standard conservative treatment for at least 10 days. Once the fistula was endoscopically located, 4 to 8 ml of reconstituted fibrin glue (Tissucol 2.0) at 37 degrees C was injected through a Duplocath catheter on a weekly basis. RESULTS: The mean age was 59 years (32-87) and 63% were men. A total of 21.9% of the patients had high output fistulas. We were able to find all fistular orifices what were located close to the surgical anastomosis. Healing time was 17 days (4-90); 2.8 sessions were required per patient (1-5) but only 2.3 sessions were required in responders. Complete sealing of fistulas was achieved in 75%; (80% in low-output, 25% in high-output and 55.5% in internal fistulas). The frequency of fistula recurrence was 3.3%. No complications related to the sealing procedure were found. Overall mortality was 10%, but only 6.6% was related to persistence of the fistula. CONCLUSIONS: Endoscopic treatment of fistulas with biological glue has a high success rate in sealing without complications, helping to speed up the healing process and reduce costs, particularly in low-output enterocutaneous fistulas.

Tratamiento endoscópico de fístulas gastrointestinales con un pegamento biológico tisular / Endoscopic treatment of gastrointestinal fistulas with biological fibrin glue

Objetivo: En este estudio resumimos nuestra experiencia en el tratamiento endoscópico de las fístulas gastrointestinales con pegamento de fibrina. Pacientes y método: Revisamos retrospectivamente la evolución de 30 pacientes con fístulas (9 internas y 21 externas) resistentes al tratamiento estándar conservador al menos durante 10 días. Una vez la fístula era localizada endoscopicamente, se inyectaban de 4 a 8 ml de Tissucol® 2,0 a 37 °C por un catéter Duplocath®. Resultados: La edad media fue de 59 años (32-87) con un 63% de varones. El 21,9% de los pacientes tuvieron fístulas de alto débito. Se pudo localizar todos los orificios fistulosos, muy próximos a las anastomosis quirúrgicas. El tiempo para conseguir el cierre de los orificios fistulosos fue de 17 (4-90) días, con 2,8 (1-5) sesiones por paciente, pero sólo 2,3 en los pacientes en quienes el sellado fue un éxito. La cicatrización completa se obtuvo en el 75% (el 80% en fístulas de bajo débito, el 25% en las de alto débito y el 55,5% en las fístulas internas). La frecuencia de recurrencia fue del 3,3%. No hubo complicaciones en relación con el sellado. La mortalidad global fue del 10%, pero sólo el 6,6% se relacionó con mantener abierta la fístula. Conclusiones: El tratamiento endoscópico de las fístulas con Tissucol® tiene una alta tasa de éxitos sin complicaciones y contribuye a acelerar el proceso de cicatrización de las fístulas, lo que disminuye los costes, particularmente en las fístulas enterocutáneas de bajo débito

Objective: We summarize our experience of endoscopic treatment of gastrointestinal fistulas with fibrin glue. Patients and method: We retrospectively reviewed the outcome of 30 patients with gastrointestinal fistulas (9 internal and 21 external) refractory to standard conservative treatment for at least 10 days. Once the fistula was endoscopically located, 4 to 8 ml of reconstituted fibrin glue (Tissucol® 2.0) at 37 ºC was injected through a Duplocath® catheter on a weekly basis. Results: The mean age was 59 years (32-87) and 63% were men. A total of 21.9% of the patients had high output fistulas. We were able to find all fistular orifices what were located close to the surgical anastomosis. Healing time was 17 days (4-90); 2.8 sessions were required per patient (1-5) but only 2.3 sessions were required in responders. Complete sealing of fistulas was achieved in 75%; (80% in low-output, 25% in high-output and 55.5% in internal fistulas). The frequency of fistula recurrence was 3.3%. No complications related to the sealing procedure were found. Overall mortality was 10%, but only 6.6% was related to persistence of the fistula. Conclusions: Endoscopic treatment of fistulas with biological glue has a high success rate in sealing without complications, helping to speed up the healing process and reduce costs, particularly in low-output enterocutaneous fistulas

Tratamiento endoscópico de fístulas gastrointestinales con un pegamento biológico tisular / Endoscopic treatment of gastrointestinal fistulas with biological fibrin glue

Objetivo: En este estudio resumimos nuestra experiencia en el tratamiento endoscópico de las fístulas gastrointestinales con pegamento de fibrina. Pacientes y método: Revisamos retrospectivamente la evolución de 30 pacientes con fístulas (9 internas y 21 externas) resistentes al tratamiento estándar conservador al menos durante 10 días. Una vez la fístula era localizada endoscopicamente, se inyectaban de 4 a 8 ml de Tissucol® 2,0 a 37 °C por un catéter Duplocath®. Resultados: La edad media fue de 59 años (32-87) con un 63% de varones. El 21,9% de los pacientes tuvieron fístulas de alto débito. Se pudo localizar todos los orificios fistulosos, muy próximos a las anastomosis quirúrgicas. El tiempo para conseguir el cierre de los orificios fistulosos fue de 17 (4-90) días, con 2,8 (1-5) sesiones por paciente, pero sólo 2,3 en los pacientes en quienes el sellado fue un éxito. La cicatrización completa se obtuvo en el 75% (el 80% en fístulas de bajo débito, el 25% en las de alto débito y el 55,5% en las fístulas internas). La frecuencia de recurrencia fue del 3,3%. No hubo complicaciones en relación con el sellado. La mortalidad global fue del 10%, pero sólo el 6,6% se relacionó con mantener abierta la fístula. Conclusiones: El tratamiento endoscópico de las fístulas con Tissucol® tiene una alta tasa de éxitos sin complicaciones y contribuye a acelerar el proceso de cicatrización de las fístulas, lo que disminuye los costes, particularmente en las fístulas enterocutáneas de bajo débito

Objective: We summarize our experience of endoscopic treatment of gastrointestinal fistulas with fibrin glue. Patients and method: We retrospectively reviewed the outcome of 30 patients with gastrointestinal fistulas (9 internal and 21 external) refractory to standard conservative treatment for at least 10 days. Once the fistula was endoscopically located, 4 to 8 ml of reconstituted fibrin glue (Tissucol® 2.0) at 37 ºC was injected through a Duplocath® catheter on a weekly basis. Results: The mean age was 59 years (32-87) and 63% were men. A total of 21.9% of the patients had high output fistulas. We were able to find all fistular orifices what were located close to the surgical anastomosis. Healing time was 17 days (4-90); 2.8 sessions were required per patient (1-5) but only 2.3 sessions were required in responders. Complete sealing of fistulas was achieved in 75%; (80% in low-output, 25% in high-output and 55.5% in internal fistulas). The frequency of fistula recurrence was 3.3%. No complications related to the sealing procedure were found. Overall mortality was 10%, but only 6.6% was related to persistence of the fistula. Conclusions: Endoscopic treatment of fistulas with biological glue has a high success rate in sealing without complications, helping to speed up the healing process and reduce costs, particularly in low-output enterocutaneous fistulas