Quistes de colédoco: un diagnóstico inadvertido. Serie de casos / Choledochal cysts: an inadvertent diagnosis. Case series

Las lesiones quísticas de vías biliares, constituyen una entidad, que rara vez se observa o diagnostica en el adulto. El motivo de este trabajo es mostrar la experiencia de un centro de referencia biliopancreática en el diagnóstico y tratamiento de quistes de colédoco. Usamos la clasificación de Todani para la descripción de los mismos. Fue un estudio Descriptivo y Retrospectivo con 502 colangiopancreatografías retrógradas endoscópicas y de ellas 20 casos de quistes de colédoco identificados mediante colangiografías de alta calidad.

Cystic lesions of the bile ducts constitute an entity that is rarely seen or diagnosed in adults. The purpose of this study is to show the experience of a biliopancreatic referral center in the diagnosis and treatment of choledochus cysts. The Todani classification was used to describe them. It was a retrospective, descriptive study of 502 endoscopic retrograde cholangiopancreatographies and of these 20 cases of choledochal cysts were identified by high-quality cholangiographies.

Hemorragia digestiva de origen oscuro: Enteroscopia de doble balón

Presentamos nuestra experiencia con el uso de Enteroscopia de Doble Balón (EDB) en el manejo de la hemorragia gastrointestinal de origen desconocido. Evaluamos 38 pacientes con sangrado digestivo y estudios endoscópicos convencionales normales. En 30 de estos pacientes (78,9 %) se logró precisar el sitio de sangramiento, siendo la ectasia vascular (66,6 %) la principal causa de hemorragia. Todas las lesiones fueron tratadas con esclerosis y electrocoagulación con Argón Plasma. No hubo complicaciones. En conclusión, el método de EDB es efectivo y seguro en el manejo de la hemorragia gastrointestinal de origen desconocido.

We present our experience with the use of Double Balloon Endoscopy in the management of gastrointestinal bleeding of unknown origin. We evaluated 38 patients with G.I. bleeding and previously normal upper and lower endoscopy studies; resulting in 30 patients with pathological findings (78,9%). The most common lesion was Vascular Ectasia (66,6 %). All lesions were treated with the injection of hypertonic solutions and Argon plasma coagulation. There were no complications. In conclusion, the Double Balloon Enteroscopy is a useful and safe method in the management of G.I. bleeding of obscure origin.

[Percutaneous endoscopic gastrostomy in patients with head and neck neoplasms. Evaluation of a new gastrostomy]. / Gastrostomia endoscopica percutanea en pacientes con tumores de cabeza y cuello. Evaluacion de un nuevo gastrostomo.

Since their aparition in 1980, percutaneus endoscopic gastrostomy (PEG), represented a dramatic impact in the enteral nutrition thecnics and their indication have expanded. The PEG have many advantages over the surgical gastrostomy. In this paper, we present our experience with the use of PEG in patients with head and neck cancer using a new home made gastrostome. Included were 61 patients 37 males (64.8%), 21 females (36.2%) with ages betwen 11 and 72 years. In 3 patients the PEG was not intended because tight esophageal stenoses. The PEG was completed in 56 cases (91.8%). In 5 patients (8.6%) there were minor complications (4 infections and 1 patient with pain). We have only one case of major complication which consisted in migration of gastrotome to the abdominal wall (Buried Bumper Syndrome). The gastrostome was patent between 15 and 312 days with a median of 125 days. The gastrostomies was made with siliconed 22Fr Foley catheter, crazy glue, and plastic tops. The Foley catheter is acid resistant and not deteriorate like other materials like latex. There was not adverse reaction at the ostomy site. The cost of the kit is about 11 US$ and the commercial kit is 125 US$, on the other hand the internal diameter is 15% wider than the commercial one.

[Transrectal ultrasonography in the preoperative staging of rectal adenocarcinoma. Cross-sectional study 1991-1994]. / Ultrasonido transrectal en la estadificación preoperatoria del adenocarcinoma de recto. Estudio transversal 1991-1994.

Preoperative evaluation of the depth of invasion in the rectal wall as well as the presence of regional metastatic nodes are considered important factors in order to decide surgical treatment as well as prognosis in cases of cancer of the rectum. This investigation was carried out in order to establish how usefull transrectal ultrasound was for the pre-operative evaluation of cancer of the rectum. We studied 78 patients with different ano rectal pathology, among them 40 patients with confirmed ADC of the rectum that were completely studied and had ultra sonographic as well as surgical and pathological staging using TNM classification. Confiability indicators of transrectal ultrasound when compared with pathology findings, showed a sensibility of 100% in T1-T2 and T4; in T3 lesions sensibility was 76%. Specificity was between 94% and 100% in all stages. We believe that trans-rectal ultrasound is a usefull, precise and reliable diagnostic tool, for staging purposes of rectal carcinoma.

[Endoscopic management of biliary fistula]. / Manejo endoscópico de las fístulas biliares.

From January 1991 to July 1993 we diagnosed 16 patients with biliary fistulas. Nine patients showed a fistula of the stump after cholecystectomy (two laparoscopic and the rest in a conventional form). In none was there any evidence of residual stones. Three patients that showed biliary fistula who had residual stones which was no diagnosed during surgery. Four patients had biliary fistulas at different levels after abdominal traumas due to bullet wounds. All the patients were treated endoscopically by means of endoscopic sphincterotomy and in one of them it was necessary to place a biliary stent due to the fact that there was a stricture under the level of the fistula. One patient who, in addition to the fistula had an abscess was drained guided by ultrasound after the sphincterotomy. The evolution of the patients was satisfactory. There were no complications because of the procedure.

[Colitis due to radiation: endoscopic management with heat probe]. / Colitis por radiación: manejo endoscópico con sonda caliente.

Rectal bleeding is a frequent symptom in radiation colitis, and is due to vascular lesions usually confined to the rectum. We present our preliminary experience with the use of the heater probe, in eight patients with radiation proctitis, whose main symptom was rectal bleeding. Six patients had radiation for carcinoma of the cervix and 2 had endometrial cancer. One to four sessions of coagulation were performed with an intensity of 200 to 400 Joules per session. In all patients a good response was obtained, bleeding diminished or stopped completely, with improvement of blood counts and the need for transfusions. We think that heater probe is a good therapeutic alternative, for the management of these difficult complication.

[Transrectal ultrasonography in the assessment of anal and rectal tumors]. / Ultrasonido transrectal en la evaluación de los tumores de ano y recto.

Transrectal ultrasonography was initially devised for prostatic evaluation but it has also been shown to be useful in the study of carcinoma of Rectum and Anus. 3 patients with carcinoma of the anal canal and 17 with carcinoma of the rectum were studied in order to define invasion of neighbouring organs and regional nodes. In 11 patients (55%) the extension of the tumor was to muscular layer. In 5 patients (25%) the study showed invasion to peri-rectal fat and presence of lymph nodes in 10 cases. In 4 patients (20%) the procedure showed invasion to neighbouring organs and preoperative radiation treatment was the indication.

[Heat probe: its use in the palliation of stenosing and bleeding tumors of the digestive tract. Preliminary report]. / Sonda caliente: su uso en paliación de tumores estenosantes y sangrantes del tubo digestivo. Comunicación preliminar.

We present our experience with the use of Heater Probe (H.P.) of the management of malignant stenoses of Gastrointestinal (G.I.) tract. We treated 6 patients: 4 with esophageal cancer, 1 cancer of rectum and 1 malignant infiltration of sigmoid colon. The symptoms were: dysphagia: 4 cases, rectal bleeding: 1 case and bleeding plus obstruction: 1 case. The symptoms were relieved in 5 of the 6 cases. In 1 case with dysphagia there were not response. The H.P. can represent a valid alternative in the palliation of malignant obstruction.

[Splenic focal lesion in oncologic patients diagnosed by ultrasound]. / Lesiones focales esplénicas en pacientes oncológicos diagnosticadas por ultrasonido.

Focal lesion of the spleen are infrequent, they appear in 2-4% of patients with malignancies, in our experience we found metastases in nineteen oncologic patients (0.54%) this fact modified the staging prognosis and therapeutic. All the cases were correlated with laparoscopy, fine needle biopsy guided by ultrasound, and or laparotomy. It is emphasized tha the spleen's size was normal in 47.4%. The usual appearance was multiple focal lesions in 89.5% and the sonography pattern of the lesion was variable: Hypoechoic in 63.2% hyperechoic an mixed in 15.8% respectively and cystic in 5.3%. We conclude that ultrasound is an excellent non invasive method to detect focal lesions of the spleen in oncologic patient, where is necessary to know the histology of this lesions, fine needle guided biopsies, can be done safely.

[Needle sphincterotomy: a safe method]. / Esfinterotomía de aguja: un método seguro.

We performed needle papillotomy in 26 patients. When the biliary tract was not approach by conventional methods. We used an home made sphincterotomy and begin the incision at the papillar orifice and cut in cephalic direction to the 11-12 o'clock, and stop the cutting when we observe bile flow or choledochus mucosa. The only complication was bleeding in two patients and it stopped with epinephrine injection. There were not perforations or mortality. We conclude that needle papillotomy is a safe and useful method in selected cases.

[Colonoscopic dilator: a new instrument in the management of benign stenosis of the colon and rectum]. / Colonoscopio dilatador. Un nuevo instrumento en el manejo de las estenosis benignas de colon y recto.

Experience with a colonoscope with a distal segment that allows for the incorporation of dilating olives of the Eder Puestow type is presented. 15 patients with the diagnosis of benign stenosis of the colon or rectum who suffered of abdominal pain and constipation were treated. In 13 patients it was possible to eliminate the patients symptoms. There where no complications. The dilating colonoscope is a valid, alternative in the management of stenosis of the colon and rectum.

[Primary gastrointestinal lymphoma]. / Linfoma primario gastrointestinal.

20 patients were evaluated and found to have a radiologic-endoscopic diagnosis of primary gastrointestinal lymphoma, in the Digestive Tract Department of the "Padre Machado" Oncological Hospital in a 19 years period (1970-1989). In 17 patients diagnosis of non-Hodgkin's Lymphoma was made and the 3 other patients were diagnosed with the Hodgkin's Lymphoma. It was located more frequently in the stomach: 14 (70%). Through double contrast radiology, endoscopy and deep biopsy, the diagnosis was made in 12 (67%) patients. The most frequent hystological type was diffuse histiocytic lymphoma. Surgery was the most used treatment. The value of double contrast radiology, and deep biopsy stand out as adequate methods to obtained a positive diagnostic, avoiding unnecessary surgical procedures.

[Diagnostic accuracy of fine needle aspiration cytology guided by ultrasonography in intra-abdominal and retroperitoneal lesions]. / Exactitud diagnóstica dela citología por punción aspiración con aguja fina guiada por ultrasonido en lesiones intraabdominales y retroperitoneales.

UNLABELLED: Evaluation of the fine needle aspiration cytology guided by ultrasonography in the diagnosis of abdominal and retroperitoneal tumors. DESIGN: Transversal study of diagnostic standard-criterion test. PLACE: Ultrasonographic Unity Digestive Disease Department. Hospital Oncológico Padre Machado. SAMPLE: 98 patients with intraabdominal and retroperitoneal lesions. INTERVENTION: Fine needle aspiration cytology guided by Ultrasonography. INDICE TEST: Laparoscopy and/or laparotomy. MEASUREMENTS: Estimation of sensibility (S), Specificity (E), Efficacy (Ef), positive predictive value (VPP), negative predictive value (VPN), measure of false positives (TFP) and measure of false negatives (TFN) by diagnosis method. RESULTS: VP: 81%; VN: 12%; FP: 1%; FN: 6%; S: 93%; E: 92.3%; Ef.: 97%; VPP: 98.7%; VPN: 66%; TFP: 1.25%; Benign lesions: 22.5%; Malignancy lesions: 65.5%; non lesions: 12%; complications: severe: 1%, non significance: 5%. CONCLUSIONS: Fine needle aspiration cytology guided by ultrasound has high sensibility, specificity, efficacy, with low value of false positive. However, it has high incidence of false negatives and negative predictive value. We recommend diagnostic procedures when the suspicion of tumor is high did the cytology is negative.

[Ambulatory laparoscopy]. / Laparoscopia ambulatoria.

We present our experience with laparoscopy in 600 outpatients with several diseases in seven years (1982-1988). We performed 707 studies in 594 patients (99%), in six cases (1%) the examination was not feasible because of intra-abdominal adhesions. In 235 patients (39.16%) previous abdominal surgery was not considered a contraindication for the examination. We performed 295 hepatic biopsies, 69 adhesions cuts, 9 laparoscopic placement of Tenckhoff catheter and other procedures. The incidence of complications was 5.23%, related to laparoscopy 3.67% and to procedures 1.55%. Major complications occurred in four patients (0.56%), surgical intervention was required in one patient (0.14%). We neither had infectious complications, nor mortality. We conclude that laparoscopy can be an ambulatory procedure, because it has a low incidence of complications in skilled hands and is well tolerated.

[Ultrasound, computed tomography and laparoscopy. Efficacy in the detection of primary and metastatic hepatic tumors. Comparative study]. / Ultrasonido, tomografía computarizada y laparoscopia. Eficacia en la detección de tumores hepáticos primarios y metastásicos. Estudio comparativo.

OBJECT: To compare ultrasound, computed tomography and peritoneoscopy in the diagnosis of primary and metastatic hepatic tumors. DESIGN: Prospective trial of a cohort patients during a year. PLACE: Digestive Disease Department in a National referral Cancer Center. PATIENTS: Forty five patients with intraabdominal tumors for pretreatment evaluation. Intervention; Ultrasonography, computed tomography and peritoneoscopy performed in a period of ten days. MEASUREMENTS: sensibility, specificity and efficiency comparison of results by Chi square test, with Yates correction (X2 Yates), measure of pre test and post test probabilities using Bayes theorem. RESULTS: In hepatic humors, peritoneoscopy was the most sensitive, specificity was similar for the three procedures (p greater than 0.1), in the detection of hepatic metastases peritoneoscopy was the most sensitive 91.6% vs 50% (p less than 0.05) similar specificity and high positive predictive value for the three procedures, comparable with the post test probabilities. CONCLUSIONS: In the detection of focal hepatic lesions, peritoneoscopy was the best method; in case of doubt, failure of non invasive procedures or the need of biopsy samples must be considered the procedure of choice.

[Cancer of the ampullar region]. / Cáncer de la región ampular.

The clinical-pathological spectrum of ampullary cancer in 18 patients studied at the Department of Gastroenterology (Hospital Oncológico Padre Machado) during the last decade (1980-88) is presented. Involvement of the extrahepatic bile ducts was due to cancer of the ampullary region. In all cases diagnosis was confirmed by pathology. The value of ERCP is presented and the need to set apart this tumors from carcinoma of the head of the pancreas is emphasized. None of the nine cases treated with radical resection (Whipple) had operative mortality, and although follow-up for all cases is not long enough, two patients are alive and free of disease, five years after surgery. The value of prosthesis and biliary drainage for palliation is commented upon. Emphasis is placed on the need of using the term ampullary cancer in its proper connotation. Criteria for differentiating periampullary tumors (specially cancer of the head of the pancreas) are presented.

[Colonoscopy as primary procedure in the diagnosis of colonic neoplasms]. / Colonoscopia como exploración primaria en el diagnóstico de las neoplasias del colon.

Experience with colonoscopy as an initial procedure in the study of the colon is presented. 3.450 colonoscopies in patients with GI symptoms were performed by trained endoscopists using the intermediate length scopes (130cm) without fluoroscopy. In 90% of the cases the whole colon was studied in a mean time of 20 minutes. 382 neoplasms (11.07%) were diagnosed. Polips represented 90% of the lesions and 34.3% of them were adenomas. 30% of the adenomas and 34.4% of the malignant tumors were localized in the right colon. We emphasise that 82.7% of the polips found in the right colon were adenomas. As a side effect we had a sigmoid perforation, it represents 0.03%. Colonoscopies performed by a trained endoscopist is a highly diagnostic method with low degree of complications, making it the procedure of choice in the study of the colon in specialized centers.

[Colitis caused by radiation: 20 years' experience]. / Colitis por radiación: 20 años de experiencia.

The 20 year experience with diagnosis and management of radiation colitis at the Gastroenterology Department of the Hospital Oncológico "Padre Machado" is presented. Of 404 cases, 98% were treated for carcinoma of the cervix. The most frequent symptoms were rectal bleeding (71%) and changes in the intestinal habitus (27.2%). Symptoms were present from one month to one year prior to radiation. Flexible sigmoidoscopy in 77.5% of patients showed Grade I and II actinic disease, and X Ray studies sowed Grade II and III in 80%. Thirty eight patients required surgical treatment.