EUS-guided gallbladder drainage as second option of biliary decompression after failed ERCP for the management of malignant distal biliary obstruction.

Endoscopic ultrasound-guided gallbladder drainage (EUS-GBD) is recommended as a rescue treatment of malignant distal biliary obstruction (MBDO) after failed ERCP and endoscopic ultrasound-guided biliary drainage (EUS-BD). A 64-year-old male was admitted for painless obstructive jaundice and anemia. For religious reasons, he refused any blood transfusions. Abdominal computed tomography scan showed a pancreatic tumor with dilation biliary tree and liver metastasis. ERCP failed and advanced biliary cannulation technique such as precut were avoided due to a high risk of bleeding. We avoided the two transmural EUS-BD approaches, which include EUS-guided choledochoduodenostomy and EUS-guided hepaticogastrostomy, due to smaller targets and considered riskier in this patient. Since the gallbladder was markedly distended and the cystic duct was patent, we performed a cholecystogastrostomy with a 15x10 mm electrocautery lumen-apposing metal stent (EC-LAMS) as a second option of biliary drainage. After a week, the serum bilirubin levels decreased to normal values and the patient was uneventfully discharged. At follow-up, he refused to receive chemotherapy and died six months later due to cancer progression.

Preoperative intragastric balloon in morbid obesity is unable to decrease early postoperative morbidity of bariatric surgery (sleeve gastrectomy and gastric bypass): a clinical assay.

INTRODUCTION: There are few studies that investigate the usefulness of the preoperative intragastric balloon (IGB). This study will evaluate if pre-surgical weight loss with IGB reduces morbidity and mortality after surgery. METHOD: Prospective randomised study of patients with morbid obesity treated with gastric bypass or vertical gastrectomy, with two arms: the balloon arm (B-arm), where an IGB was inserted within the 6 months before surgery, and the control arm (C-arm). RESULTS: The study included 66 patients: 65.6% women, 69.6% with bypass. Age: 43 years (SD 10.2) B-arm and 42.6 years (SD 9.2) in the C-arm. We found 34.4% therapeutic failures in IGB. The mean body weight loss, %EWL and BMI reduction before surgery was 16.2 kg (SD 9.84) B-arm versus 4.7 (SD 8.70) in the C-arm, 23.6% versus 4.7% (p < 0.001) and 6.04 versus 1 (p < 0.001), respectively. The hospital stay was 7 days (p25-75: 5-8) B-arm and 7 days (p25-75: 5-9) in the C-arm (p = 0.937). Post-surgical morbidity with IGB was 25% versus 29.5% in the C-arm, p = 0.689. The number needed to treat (NNT) to prevent of post-surgical morbidity was 23 patients. The B-arm presented 54.5% moderate-severe post-surgical adverse events (12.5%) versus 82.6% in the C-arm (23.5%), p = 0.111. The cost of placing a balloon was more than 4000 Euros each. CONCLUSIONS: The preoperative balloon does not achieve a reduction in the post-surgical morbidity, nor does it reduce the hospital stay or rate of re-operations. The balloon achieves a higher weight loss result when compared to a diet programme, its added cost must also be given due consideration. TRAIL REGISTRY: This study has been registered on ClinicalTrials.gov with the Identifier: NCT01998243 (November 28, 2013).

Prevalence of the need for sodium intake restriction and the use of laxatives in palliative patients.

BACKGROUND: palliative patients usually have diseases that require a restriction of dietary sodium, although the prevalence of this requirement is unknown. Such conditions, combined with constipation, may mean that the use of laxatives with electrolytes should be avoided. OBJECTIVES: to ascertain the prevalence of the need to restrict sodium intake in palliative patients and to analyze the prevalence of constipation and the use of laxatives, including those containing sodium. METHOD: this was a multicenter retrospective, descriptive, cross-sectional, epidemiological study of both inpatients and outpatients over 18 years of age treated at the palliative care clinic (June 2015-March 2016). Demographic and anthropometric characteristics, diseases associated with dietary sodium restriction and treatments administered were recorded. RESULTS: the study sample consisted of 400 palliative patients, with a mean age of 77.8 ± 13.0 years and 52.2% were male. Of these, 68.3% were inpatients and 31.8% were outpatients. Comorbidities requiring low sodium or a sodium-free diet were found in 87.0% (95% CI: 83.3-90.0) of cases. Only 46.5% (95% CI: 41.5-51.5) of patients had been prescribed a low salt diet. It should be noted that 50.5% (95% CI: 45.5-55.5) of patients required a low sodium diet and suffered from constipation. Laxatives (polyethylene glycol or lactulose-rich products [PEG] with electrolytes in 54% of cases) were taken by 53.8% (95% CI: 48.7-58.7) of patients, 52.1% due to constipation and 42.3% as a prevention due to opioid treatment. CONCLUSIONS: a high proportion of the study cohort (87%) had some condition that required dietary sodium restriction and at least half the patients had constipation. The use of laxatives to treat or prevent constipation is common in palliative patients. A sodium-free laxative is therefore preferred in these patients.