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BACKGROUND: The use of pancreatic prostheses in children with acute recurrent pancreatitis (ARP) and chronic pancreatitis (CP) has evolved. The main established indication is the treatment of persistent abdominal pain. This study aimed to evaluate the efficacy of pancreatic stenting for refractory abdominal pain in pediatric patients with ARP and CP. METHODS: We conducted a retrospective case series study. We included patients under 16 years of age diagnosed with ARP and CP in the study. Endoscopic retrograde cholangiopancreatography (ERCP) was performed with the insertion of one and later two pancreatic stents. We evaluated abdominal symptoms before and after treatment, number of changes, duration of treatment, and complications with follow-up at 24 months and after withdrawal. RESULTS: Nine patients with ARP and CP were included in the study: six with undetermined etiology and three with pancreas divisum. The mean age was 12.4 years. Prosthesis placement relieved abdominal pain in 100% of cases, with 3.2 replacement sessions every 6.2 months for 27.4 months, and mild complications (15.7%). One patient experienced pain on removal of the prosthesis and required bypass surgery. CONCLUSION: Pancreatic stent placement in patients with refractory abdominal pain with ARP and CP proved to be effective and safe, providing medium-term symptom relief and minimal complications.
INTRODUCCIÓN: El uso de prótesis pancreáticas en niños con pancreatitis aguda recurrente (PAR) y crónica (PC) ha evolucionado. La principal indicación establecida es el tratamiento del dolor abdominal persistente. El objetivo de este estudio fue evaluar la eficacia del uso prótesis pancreática para el dolor abdominal refractario en pacientes pediátricos con PAR y PC, sin respuesta a manejo conservador. MÉTODOS: Se llevó a cabo un estudio retrospectivo de serie de casos. Se incluyeron pacientes menores de 16 años con diagnóstico de PAR y PC. Se realizó una colangio pancreatografía retrograda endoscópica (CPRE) para introducir inicialmente una y posteriormente dos prótesis pancreáticas. Se evaluaron síntomas abdominales antes y después del tratamiento, número de recambios, duración del tratamiento y complicaciones con seguimiento a 24 meses y posterior a su retiro. RESULTADOS: Se incluyeron 9 pacientes con PAR y PC: seis de etiología no determinada y tres con páncreas divisum. La edad promedio fue de 12.4 años. La colocación de prótesis alivió el dolor abdominal en el 100%, con 3.2 sesiones de recambio cada 6.2 meses en 27.4 meses, y complicaciones leves (15.7%). Un paciente presentó dolor al retirar las prótesis y requirió cirugía derivativa. CONCLUSIONES: El uso de prótesis pancreática en pacientes con dolor abdominal refractario con PAR y PC demostró ser eficaz y seguro al aliviar los síntomas a mediano plazo con mínimas complicaciones.
Assuntos
Pancreatite Crônica , Humanos , Criança , Estudos Retrospectivos , Resultado do Tratamento , Pancreatite Crônica/complicações , Pancreatite Crônica/cirurgia , Dor Abdominal/etiologia , StentsRESUMO
Abstract Background: The use of pancreatic prostheses in children with acute recurrent pancreatitis (ARP) and chronic pancreatitis (CP) has evolved. The main established indication is the treatment of persistent abdominal pain. This study aimed to evaluate the efficacy of pancreatic stenting for refractory abdominal pain in pediatric patients with ARP and CP. Methods: We conducted a retrospective case series study. We included patients under 16 years of age diagnosed with ARP and CP in the study. Endoscopic retrograde cholangiopancreatography (ERCP) was performed with the insertion of one and later two pancreatic stents. We evaluated abdominal symptoms before and after treatment, number of changes, duration of treatment, and complications with follow-up at 24 months and after withdrawal. Results: Nine patients with ARP and CP were included in the study: six with undetermined etiology and three with pancreas divisum. The mean age was 12.4 years. Prosthesis placement relieved abdominal pain in 100% of cases, with 3.2 replacement sessions every 6.2 months for 27.4 months, and mild complications (15.7%). One patient experienced pain on removal of the prosthesis and required bypass surgery. Conclusion: Pancreatic stent placement in patients with refractory abdominal pain with ARP and CP proved to be effective and safe, providing medium-term symptom relief and minimal complications.
Resumen Introducción: El uso de prótesis pancreáticas en niños con pancreatitis aguda recurrente (PAR) y crónica (PC) ha evolucionado. La principal indicación establecida es el tratamiento del dolor abdominal persistente. El objetivo de este estudio fue evaluar la eficacia del uso prótesis pancreática para el dolor abdominal refractario en pacientes pediátricos con PAR y PC, sin respuesta a manejo conservador. Métodos: Se llevó a cabo un estudio retrospectivo de serie de casos. Se incluyeron pacientes menores de 16 años con diagnóstico de PAR y PC. Se realizó una colangio pancreatografía retrograda endoscópica (CPRE) para introducir inicialmente una y posteriormente dos prótesis pancreáticas. Se evaluaron síntomas abdominales antes y después del tratamiento, número de recambios, duración del tratamiento y complicaciones con seguimiento a 24 meses y posterior a su retiro. Resultados: Se incluyeron 9 pacientes con PAR y PC: seis de etiología no determinada y tres con páncreas divisum. La edad promedio fue de 12.4 años. La colocación de prótesis alivió el dolor abdominal en el 100%, con 3.2 sesiones de recambio cada 6.2 meses en 27.4 meses, y complicaciones leves (15.7%). Un paciente presentó dolor al retirar las prótesis y requirió cirugía derivativa. Conclusiones: El uso de prótesis pancreática en pacientes con dolor abdominal refractario con PAR y PC demostró ser eficaz y seguro al aliviar los síntomas a mediano plazo con mínimas complicaciones.
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Introduction: The diagnostic yield (DY) of small-bowel capsule endoscopy (SBCE) varies considerably according to its indication. Some strategies have been used to increase DY with varying results. The intention of this study was to identify whether evaluation of the SBCE recordings by a second reviewer can increase DY and change patient management. Methods: One hundred SBCEs with different indications, already read by an endoscopist were read by a second blinded endoscopist. When the results of the 2 readings were different, the images were discussed by the endoscopists; if no consensus was reached, they took the opinion of a third endoscopist into account. All the participating endoscopists had experience in reading SBCEs (i.e., >50 per year). The SBCE findings were divided into positive (vascular lesions, ulcers, and tumors), equivocal (erosions or red spots), and negative. The interobserver agreement and the increase in DY were assessed as well as the percentage of false-negatives (FNs) in the first evaluation. Results: The indications for SBCE were small-bowel bleeding (SBB) in 48 cases, Crohn's disease (CD) in 30, and other causes (iron-deficiency anemia, small-bowel tumors, and diarrhea) in 22. There was substantial interobserver agreement between evaluations (κ = 0.79). The findings in the first evaluation were positive in 60%, equivocal in 20% and, negative in 20%. In the second evaluation, 66% were positive, 18% were equivocal, and 16% were negative. The increase in DY with the second reading was 6% (p = 0.380), i.e., 6.3% for SBB, 4.4% for CD and 9.2% for other indications, resulting in a change in management of 4% of the patients. FNs in the first SBCE reading were found in 4% of the SBCEs. Discussion: A second evaluation of the SBCE recordings identified significant pathology that the first evaluation had missed, resulting in a nonsignificant 6% increase in DY and a change in the management of 4% of the patients.
Introdução: O rendimento diagnóstico (DY) da enteroscopia por cápsula (SBCE) varia consideravelmente de acordo com as suas indicações. Foram estudadas algumas estratégias para melhorar o DY, com resultados variados. O objetivo deste estudo é avaliar se uma segunda leitura de registos de enteroscopia por cápsula por um segundo endoscopista pode melhorar o DY e alterar o manejo dos doentes. Métodos: 100 SBCE realizadas por indicações variadas, previamente avaliadas por um endoscopista, foram reavaliadas por um segundo endoscopista cego para a primeira leitura. Na presença de resultados discordantes nas 2 leituras, as imagens foram discutidas pelos 2 endoscopistas, e por um terceiro na ausência de consenso entre os 2 primeiros. Todos os endoscopistas são experientes na leitura de SBCE (>50 SBCE/ano). Os achados foram categorizados em positivos (lesões vasculares, úlceras e tumores), equívocos (erosões e pontos vermelhos) e negativos. Foi avaliada a concordância inter-observador e o aumento do DY, bem como a percentagem de falsos negativos da primeira avaliação. Resultados: As indicações para SBCE foram hemorragia do intestino delgado (SBB) em 48 casos, doença de Crohn (CD) em 30 e outras causas (anemia por défice de ferro, pesquisa de tumores do intestino delgado e diarreia) em 22. A concordância inter-observador foi substancial (k = 0.79). Os achados da primeira avaliação foram positivos em 60%, equívocos em 20% e negativos em 20%, enquanto na segunda avaliação foram positivos em 66%, equívocos em 18% e negativos em 16%. O aumento de DY foi de 6% com a segunda leitura (p = 0.38), sendo 6.3% para SBB, 4.4% para CD e 9.2% para outras indicações, resultando numa alteração no manejo de 4% dos doentes. Foram identificados falsos negativos na primeira avaliação em 4% das SBCE. Conclusão: A segunda avaliação dos registos de SBCE identificou patologia significativa previamente não identificada, resultando num aumento não significativo de 6% do DY e numa alteração no manejo de 4% dos doentes.
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BACKGROUNDS AND AIMS: New mucosal resective and ablative endoscopic procedures based on gastric cardiac remodeling to prevent reflux have appeared. We aimed to evaluate the feasibility of a new ablative technique named antireflux ablation therapy (ARAT) for control of GERD in patients without hiatal hernia. METHODS: Patients with proton pump inhibitor (PPI)-refractory GERD without hiatal hernia underwent ARAT between January 2016 and October 2019. Gastroesophageal Reflux Disease-Health-Related Quality of Life (GERD-HRQL), upper endoscopy, 24-hour pH monitoring, and PPI use were documented at 3, 6, 12, 24, and 36 months after ARAT. RESULTS: One hundred eight patients were included (61 men [56.5%]; median age, 36.5 years; range, 18-78 years). ARAT was performed on all patients. At the 36-month evaluation, 84 patients had completed the protocol. Median ARAT time was 35.5 minutes (range, 22-51 minutes), and median circumference ablation was 300° (range, 270°-320°). No major adverse events occurred, and 14 of 108 patients (12.9%) presented with stenosis that was responsive to balloon dilation (<5 sessions). At the 3-month evaluation, the acid exposure time (AET), DeMeester score, and GERD-HRQL score had decreased from 18.8% to 2.8% (P = .001), 42.5 to 9.1 (P = .001), and 36.5 to 10 (P = .02), respectively, and these values were maintained up to 36 months. Success (AET <4%) was achieved in 89% and 72.2% at 3 and 36 months, respectively. Related factors at 36 months were as follows: pre-ARAT Hill type II (odds ratio [OR], 3.212; 95% confidence interval [CI], 1.431-5.951; P = .033), post-ARAT 3-month Hill type I (OR, 4.101; 95% CI, 1.812-9.121; P = .042), and AET <4% at 3 months (OR, 5.512; 95% CI, 1.451-7.621; P = .021). CONCLUSIONS: ARAT is a feasible, safe, and effective therapy for early and mid-term treatment of GERD in patients without a sliding hiatal hernia. However, longer follow-up evaluations and randomized comparative studies are needed to clarify its real role. (Clinical trial registration number: NCT03548298.).
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Técnicas de Ablação , Fundoplicatura , Refluxo Gastroesofágico , Hérnia Hiatal , Técnicas de Ablação/métodos , Adolescente , Adulto , Idoso , Endoscopia Gastrointestinal , Monitoramento do pH Esofágico , Estudos de Viabilidade , Feminino , Refluxo Gastroesofágico/tratamento farmacológico , Refluxo Gastroesofágico/cirurgia , Hérnia Hiatal/tratamento farmacológico , Hérnia Hiatal/cirurgia , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Inibidores da Bomba de Prótons/uso terapêutico , Qualidade de Vida , Resultado do Tratamento , Adulto JovemRESUMO
BACKGROUND: new alternatives for entry site closure (ESC) in per-oral endoscopy myotomy (POEM) and gastric peroral endoscopy myotomy (G-POEM) have appeared. OBJECTIVE: to compare the over-the-scope-clip (OTSC®) and conventional clips (CC) for ESC in POEM and G-POEM. MATERIAL AND METHODS: a retrospective review of a prospective POEM and G-POEM database was performed between January 2015 and August 2019. A description was made of outcomes, using either OTSC® or CC for submucosal tunnel closure. RESULTS: forty-six POEM and 26 G-POEM were included in the study (23/13 per group [CC/OTSC®]). There were no clinical or procedure differences. ESC was performed with 1 OTSC® vs 5 CC and 1 vs 6 (p = 0.01) for POEM and G-POEM, respectively. Adverse events associated with clips were 21.7% vs 13% (p = 0.01) and 7.7% vs 0% (p = 0.02) for CC and OTSC® in POEM and G-POEM, respectively. CONCLUSION: OTSC® represents a safe and effective alternative for entry site closure in POEM and G-POEM cases. Further studies are needed to recommend OTSC® as the first option for submucosal tunnel closure in these procedures.
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Acalasia Esofágica , Cirurgia Endoscópica por Orifício Natural , Piloromiotomia , Acalasia Esofágica/cirurgia , Esfíncter Esofágico Inferior , Humanos , Estudos Prospectivos , Estudos Retrospectivos , Instrumentos Cirúrgicos , Resultado do TratamentoAssuntos
Angiodisplasia , Coagulação com Plasma de Argônio/métodos , Endoscopia por Cápsula/métodos , Enteroscopia de Duplo Balão , Íleo , Jejuno , Angiodisplasia/diagnóstico , Angiodisplasia/fisiopatologia , Angiodisplasia/cirurgia , Enteroscopia de Duplo Balão/instrumentação , Enteroscopia de Duplo Balão/métodos , Humanos , Íleo/irrigação sanguínea , Íleo/diagnóstico por imagem , Jejuno/irrigação sanguínea , Jejuno/diagnóstico por imagem , Masculino , Melena/diagnóstico , Pessoa de Meia-Idade , Resultado do TratamentoAssuntos
Endoscopia por Cápsula , Hemorragia Gastrointestinal/etiologia , Infecções por Uncinaria/diagnóstico , Albendazol/uso terapêutico , Anti-Helmínticos/uso terapêutico , Hemorragia Gastrointestinal/diagnóstico por imagem , Infecções por Uncinaria/tratamento farmacológico , Humanos , Masculino , Pessoa de Meia-IdadeRESUMO
Background and study aims Peroral endoscopic myotomy (POEM) is an excellent endoscopic treatment for achalasia. Clinical and manometric parameters are used for evaluation and follow-up.âHowever, clinical success does not guarantee high quality of life (QoL) scores, generating doubts about their direct relationship.âWe aimed to evaluate QoL scores before and after POEM at medium and long term, to evaluate differences between achalasia subtypes and find which factors related to low QoL scores. Patients and methods Achalasia-confirmed patients undergoing POEM between February 2012 and November 2016. and completing at least 1 year of follow-up, were included. Assessment before and at 1, 6, 12, 24, 36 and 48 months after POEM employed manometry, barium series, Eckardt score, and the AE-18 health-related QoL scale. Demographic, clinical, and procedure characteristics were documented, with comparisons between subgroups. Multiple logistic regression analysis was done. Results 65 of 88 patients were included (38 women, 27 men; median age 47 years, interquartile range [IQR] 20â-â81), and 50 (76.9â%) completed 4 years of follow-up.âEckardt score improved (median, preprocedure 10 vs. post-procedure 2; Pâ=â0.002) and this persisted. There was initial improvement in median integrated relaxation pressure (IRP) (29.4âmmHg [16â-â55] vs. 10.3âmmHg [3â-â18]; Pâ=â0.000) and median QoL scores (40 vs. 68âat 1 month; Pâ=â0.002); however IRP increased and QoL scores decreased. Men with confirmed type III achalasia had low QoL scores. Conclusions All patients had significant clinical improvement after POEM, with medium- to long-term persistence. Though quality of life and IRP initially improved, they deteriorated in the long term. Male sex and type III achalasia seem to be associated with low QoL scores.
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Acalasia Esofágica/cirurgia , Esfíncter Esofágico Inferior/fisiopatologia , Esfíncter Esofágico Inferior/cirurgia , Miotomia de Heller , Qualidade de Vida , Adulto , Idoso , Idoso de 80 Anos ou mais , Sulfato de Bário , Meios de Contraste , Endoscopia Gastrointestinal , Acalasia Esofágica/diagnóstico por imagem , Acalasia Esofágica/fisiopatologia , Feminino , Miotomia de Heller/métodos , Humanos , Masculino , Manometria , Pessoa de Meia-Idade , Relaxamento Muscular , Período Pós-Operatório , Período Pré-Operatório , Pressão , Radiografia , Fatores Sexuais , Fatores de Tempo , Adulto JovemAssuntos
Anastomose em-Y de Roux/métodos , Doenças Biliares , Colangiopancreatografia Retrógrada Endoscópica/métodos , Colecistectomia/efeitos adversos , Colecistite/cirurgia , Enteroscopia de Duplo Balão/métodos , Complicações Pós-Operatórias , Idoso , Ductos Biliares/diagnóstico por imagem , Ductos Biliares/patologia , Ductos Biliares/fisiopatologia , Doenças Biliares/diagnóstico , Doenças Biliares/etiologia , Doenças Biliares/cirurgia , Colecistectomia/métodos , Colecistite/diagnóstico , Colecistite/fisiopatologia , Drenagem/métodos , Gastrectomia/métodos , Humanos , Masculino , Complicações Pós-Operatórias/diagnóstico , Complicações Pós-Operatórias/cirurgia , Estenose Pilórica/cirurgia , Resultado do TratamentoRESUMO
BACKGROUND AND STUDY AIM: Per oral endoscopic myotomy (POEM) is a complex technique used in achalasia. Preclinical training is essential but little is known about the number of procedures needed. The aim of this study was to determine the number of procedures required to master POEM in an animal model. PATIENTS AND METHODS: This prospective comparative study was conducted in two swine models at a single institution in Mexico City between November 2012 and October 2014: Group 1 (G1)â=â30 ex vivo and Group 2 (G2)â=â20 live swine models. POEM was mastered after finishing the five steps without complications. Time, characteristics, and complications were recorded. Velocity of tunnelization and myotomy (VTM) was determined. Ex vivo analysis was done in G1 immediately after finishing POEM and at day 30 in G2. RESULTS: A total of 50 POEM were done in both groups (G1â=â30, G2â=â20). The mean times were 90.17âmin (G1) and 89.50âmin (G2) (Pâ=â0.92). Myotomy was faster in G2 (21.10 vs 27.97 min; Pâ=â0.009) with a slightly slower tunnelization (40.35 vs 41.13âmin; Pâ=â0.86). Myotomy was longer in G2 (9.25 vs 8.83 cm; Pâ=â0.26). VTM between the groups was similar (G1â=â0.159 vs G2â=â0.157âcm/min; Pâ=â0.925). Complications were: mucosotomy (G1â=â18â%, G2â=â8â%; Pâ=â0.430), mediastinal perforation (G1â=â12â%, G2â=â8â%; Pâ=â1.0), and perforation at the gastroesophageal junction (GEJ) level (G1â=â16â%, G2â=â4â%; Pâ=â0.149). Seven models in G2 presented minor bleeding and there was one death not attributed to the procedure. Mastery was obtained after 26 cases. CONCLUSIONS: We suggest that centers interested in learning POEM consider 26 procedures in animal models to master it before performing it in patients with achalasia.