Use of fully covered self-expanding metal stents for the management of benign biliary conditions.

BACKGROUND AND AIM: biliary self-expanding metal stents (SEMS) have the advantage of being inserted undeployed with very small sizes and provide, when fully opened, large diameters for biliary drainage. However, their use in benign conditions has been very limited, mainly because of difficulty in their extraction. We present our initial experience with a fully covered SEMS (Wallflex) for the management of benign problems of the bile duct. PATIENTS AND METHODS: in a prospective study, stents of 8 mm in diameter and 4, 6 or 8 cm long were inserted by means of ERCP. These SEMS were chosen when according to medical judgement it was thought that diameters greater than 10 French (3.3 mm) were needed for proper biliary drainage. Stents were extracted also endoscopically, several months later when deemed clinically appropriate. RESULTS: twenty biliary SEMS were inserted. Reasons for insertion were: large intrahepatic biliary fistula after hydatid cyst surgery (1), perforation of the papillary area following endoscopic sphincterotomy (2), coaxial insertion to achieve patency in obstructed uncovered stents inserted in benign conditions (3), benign strictures (7), multiple and large common bile duct stones that could not be extracted because of tapering and stricturing of the distal common bile duct (7). In all cases, successful biliary drainage was achieved and there were no complications from insertion. Stents were easily extracted after a mean time of 132 days (36-270) in place. Complete resolution of biliary problems was obtained in 14 patients (70%). CONCLUSIONS: in our initial experience, the fully covered Wallflex biliary stent was removed without any complication after being in place in the common bile duct for a mean time of over four months. Therefore, it could be used in the management of benign biliary conditions.

[Palliative management of malignant gastric outlet obstruction with endoscopically inserted self-expanding metal stents].

AIM AND BACKGROUND: the insertion of self-expanding metal stents to palliate malignant gastric outlet obstruction is a minimally invasive procedure that is being increasingly used. We discuss experience with this technique in a level-II hospital in the Spanish National Health System. PATIENTS AND METHODS: a retrospective five-year study (2003-2007) was conducted in 23 patients who underwent 27 procedures aimed at resolving malignant gastric outlet obstruction (mean, 0.45 procedures per month) using endoscopically inserted noncovered stents (Wallstent and Wallflex). RESULTS: insertion was technically feasible in all 27 (100%) attempts, with satisfactory clinical results in 25 cases (92.5%). Endoscopy alone was used 10 times (37%), and both endoscopy and fluoroscopy on 17 (63%) occasions. After stent insertion, one patient was intervened for treatment, and a patient with an unsuccessful prosthesis received a palliative surgical bypass. Four stents became obstructed by tumoral ingrowth, and patency was reestablished by inserting a new stent. Obstructive jaundice caused by stents covering the papilla of Vater occurred in three cases. There were no other complications or mortality due to the procedure. Mean survival was 104 days (range 28-400, SD +/- 94). CONCLUSIONS: in our experience endoscopic insertion of self-expanding metal stents appears to be a safe and efficient palliative method for malignant gastric outlet obstruction, and can be performed successfully in a center with our characteristics.

Outcomes of bile duct drainage by means of ERCP in geriatric patients / Resultados del drenaje de la vía biliar por CPRE en pacientes con edad geriátrica.

BACKGROUND AND OBJECTIVE: Endoscopic retrograde cholangiopancreatography (ERCP) is usually the procedure of choice for relieving bile duct obstruction. a large number of patients undergoing this intervention are geriatric population (aged 75 years of age and older). Our aim was to assess the efficacy of ERCP in this group of patients as compared to younger ones. PATIENTS AND METHODS: A retrospective study. All patients in whom a therapeutic biliary endoscopy had been performed over a four-year period of time (2002-2005) were included. RESULTS: 178 geriatric patients and 159 younger ones underwent ERCP. No differences were found in successful biliary drainage (97.7 vs. 98.7%), complication number (11.8 vs. 14.4%), or mortality rate (1.1 vs. 0.6%). On the other hand, more common bile duct stones were found in geriatric patients (57.3 vs. 39.6%, p = 0.004), and also more self-expanding metal stents were employed to drain malignant obstructive jaundice (47 vs. 8%, p = 0.0035). In the youngest group, more ERCPs were repeated in the same patients (4 vs. 10%, p = 0.001). CONCLUSIONS: The geriatric population showed similar success and morbidity and mortality rates when compared to younger patients in draining their bile duct by means of ERCP. Common bile duct stones were more frequently found in geriatric patients. No patients needing an ERCP should be excluded only because of their age.

Success rate of complete extraction of common bile duct stones at first endoscopy attempt.

BACKGROUND AND AIM: ERCP with biliary sphincterotomy is the usual method to extract common bile duct stones. However, after sphincterotomy and by means of balloons and Dormia baskets not all stones may be extracted during the first endoscopy session. We present our experience regarding success rate after first ERCP. PATIENTS AND METHODS: 100 consecutive patients were included. All were diagnosed with choledocholitiasis by using ERCP. After biliary sphincterotomy, attempts to extract stones by means of balloons and Dormia baskets only were made. Billroth II gastrectomies and bile duct strictures of any origin were excluded. RESULTS: During the first attempt at ERCP, complete stone clearance was achieved in 73 patients. Of the remaining 27 patients: 3 underwent surgery for choledocholithiasis, 20 had a plastic stent inserted, and 4 needed another ERCP for stones having been left in place. Mean extracted stone size was 9.4 mm (+/- 3.8), and mean non-extracted stone size was 17 mm (+/- 7.3): p < 0.001. Male/female ratio was 35/38 in the extracted group and 6/21 in the non-extracted group (p < 0.05). There were 11 complications (one patient underwent surgery because of duodenal perforation not related to sphincterotomy). There was no mortality. CONCLUSIONS: In our experience, after endoscopic biliary sphincterotomy and by means of balloons and Dormia baskets a complete stone clearance has been achieved in 73% of patients at first endoscopy attempt. Failed extraction seems to be related to stone size and was more frequently found in women.

[Therapeutic biliary endoscopy in patients over 90 years of age]. / Terapéutica biliar endoscópica en pacientes con más de 90 años de edad.

Endoscopic retrograde cholangiopancreatography (ERCP) is an established method to treat bile duct obstruction. Besides, ERCP is one of the most stricking parts of interventional endoscopy and takes advantage of its minimal invasive condition to be applied to a wide variety of patients. We present five patients over 90 years of age who underwent successfully and without complications six therapeutic ERCPs. Endoscopic biliary sphincterotomy, common bile duct stone extraction and plastic stent insertion all were performed uneventfully and solving the biliary obstruction. Therapeutic ERCP is a safe and effective modality to treat bile duct obstruction in patients over 90 years of age.

Terapéutica biliar endoscópica en pacientes con más de 90 años de edad / Therapeutic biliary endoscopy in patients over 90 years of age

La colangiopancreatografía retrógrada endoscópica (CPRE) es un método consolidado para el tratamiento de la obstrucción de la vía biliar. Además, la CPRE ocupa un lugar importante en el intervencionismo endoscópico y por su condición mínimamente invasiva puede aplicarse a una gran variedad de pacientes. Presentamos cinco enfermos con más de 90 años de edad a los que se realizaron 6 CPRE terapéuticas. En todos ellos se drenó la vía biliar sin complicaciones relevantes. Según fuera preciso se realizaron: esfinterotomía biliar, extracción de cálculos coledocianos e inserción de prótesis plásticas. La CPRE terapéutica es una modalidad eficaz y segura de tratar la obstrucción biliar en pacientes por encima de los 90 años (AU)

Endoscopic retrograde cholangiopancreatography (ERCP) is an stablished method to treat bile duct obstruction. Besides, ERCP is one of the most stricking parts of interventional endoscopy and takes advantage of its minimal invasive condition to be applied to a wide variety of patients. We present five patients over 90 years of age who underwent succesfully and witout complications six therapeutic ERCPs. Endoscopic biliary sphincterotomy, common bile duct stone extraction and plastic stent insertion all were performed unventfully and solving the biliary obstruction. Therapeutic ERCP is a safe and effective modality to treat bile duct obstruction in patients over 90 years of age (AU)

Tasa de extracción completa de coledocolitiasis al primer intento endoscópico / Success rate of complete extraction of com monbile duct stones at first endoscopy attempt

Antecedentes y objetivo: la colangiopancreatografía retrógrada endoscópica (CPRE) con esfinterotomía biliar es el método habitual para extraer los cálculos coledocianos. Sin embargo, tras la esfinterotomía y con la ayuda de balones y cestas de Dormia no puede lograrse la limpieza completa del colédoco en todos los casos. Presentamos nuestra experiencia en la tasa de extracción completa al primer intento endoscópico. Pacientes y métodos: se han incluído 100 pacientes consecutivos diagnosticados de coledocolitiasis mediate CPRE en los que pudo realizarse una esfinterotomía biliar endoscópica. Se excluyeron gastrectomías Billroth II y estenosis coledocianas de cualquier origen. Para extraer los cálculos se utilizaron exclusivamente balones y cestas de Dormia. Resultados: en la primera sesión de CPRE pudieron extraerse todos los cálculos coledocianos en 73 pacientes. De los 27 restantes, en 20 se introdujo una prótesis biliar plástica para realizar después nuevos intentos endoscópicos de extracción, 3 pacientes fueron remitidos directamente para cirugía y en 4 pacientes los cálculos quedaron retenidos de forma inadvertida y fueron extraídos en nuevas sesiones de CPRE. El tamaño medio de los cálculos en el grupo de extracción completa fue 9,4 mm (ñ3,8) y en el de no extracción 17 mm (ñ7,3) -p<0,001-. La relación hombre/ mujer en el grupo de extracción fue 35/38 y en el de no extracción 6/21 -p<0,05-. Hubo 11 complicaciones (una peforación duodenal no relacionada con la esfinterotomía precisó cirugía) pero no hubo mortalidad. Conclusiones: en nuestra experiencia, tras esfinterotomía biliar endoscópica y por medio de balones y cestas de Dormia se logró la extracción del 73 por ciento de las coledocoliatiasis en la primera exploración. El fallo en la extracción se relacionó con el mayor tamaño de las coledocolitiasis y fue más frecuente en mujeres (AU)

[Nutritional status assessment in diabetes mellitus secondary to chronic alcoholic pancreatitis]. / Valoración del estado nutricional en la diabetes mellitus secundaria a pancreatitis crónica alcohólica.

BACKGROUND: Diabetes mellitus secondary to alcoholic chronic pancreatitis (DM-ACP) represents 0.5-2% of all cases of diabetes mellitus (DM) and shows predominantly symptoms related to malnutrition instead of cardinal clinical signs of diabetes. The aim of this study was to try to further characterize the features of the malnutrition in patients with pancreatic insufficiency. PATIENTS MATERIAL AND METHODS: We selected 40 patients (39 males and 1 female) meeting clinical, functional and morphological diagnostic criteria of DM-ACP which received a nutritional assessment that included estimation on fat and proteic body compartments being classified as caloric, proteic or mixed malnutrition. RESULTS: 29 patients (72.5%) showed some kind of malnutrition. The most frequent type was mixed (proteic-caloric) malnutrition found in 19 of them (47.5%). Caloric malnutrition was present in 6 (15%) and mainly proteic in 4 (10%). Only 11 patients with DM-ACP in our series showed a normal nourishment state. CONCLUSIONS: Large prevalence of mixed malnutrition in DM-ACP patients may be related to malabsorption of macronutrients (especially proteins and fat) due to exocrine insufficiency and misuse of nutrients as a result of the characteristic hypoinsulinemia showed by these patients.