EFECTIVIDAD DE LA TOXINA BOTULÍNICA TIPO A EN EL MANEJO DE LA CADERA ESPÁSTICA DE NIÑOS CON PARÁLISIS CEREBRAL / EFFECTIVENESS OF THE TOXIN BOTULINUM TYPE A IN THE DRIVING OF THE HIP CHILDREN'S SPASTICS WITH CEREBRAL PALSY

La espasticidad es uno de los principales factores de riesgo que predispone a la luxación de cadera en los niños con parálisis cerebral (PC). La aplicación de toxina botulínica (BTX A) en los músculos aductores de caderas reduce este riesgo

Spasticity is one of the main risk factors predisposing to hip dislocation in children with cerebral palsy (CP), Botulinum toxin A (BTX A) injection in hip adductor muscles reduces this risk

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.

Utilización de prótesis metálicas autoexpandibles totalmente recubiertas en procesos biliares benignos / No disponible

Introducción y objetivo: las prótesis metálicas autoexpandibles biliares (PMAB) tienen la ventaja de introducirse plegadas con calibres muy pequeños y proporcionar, al abrirse completamente, diámetros grandes para el drenaje biliar. Su utilización en procesos benignos ha estado muy limitada, fundamentalmente por la dificultad en su extracción. Presentamos nuestra experiencia inicial con una PMAB totalmente recubierta (Wallflex) para tratar patología benigna de la vía biliar. Pacientes y métodos: en un estudio descriptivo prospectivo se insertaron por CPRE prótesis de 8 mm de diámetro y 4, 6 u 8 cm de longitud, cuando se consideró que para el drenaje biliar eran precisos diámetros superiores a 10 french (3,3 mm). Las prótesis se retiraron también por endoscopia varios meses después según se consideró oportuno clínicamente. Resultados: se insertaron 20 PMAB. Los motivos fueron: gran fístula biliar intrahepática tras cirugía de quiste hidatídico (1), perforación del área papilar por esfinterotomía endoscópica (2), recanalización de prótesis no recubiertas insertadas en procesos benignos (3), estenosis benignas (7), coledocolitiasis múltiples y de gran tamaño con afilamiento-estenosis del colédoco distal que no pudieron extraerse (7). En todos los casos se logró un drenaje biliar satisfactorio y no se produjeron complicaciones por la inserción. Las prótesis se extrajeron con facilidad a los 132 días de media (36-270). La resolución completa de los procesos se obtuvo en 14 pacientes (70%). Conclusiones: en nuestra experiencia inicial, la prótesis Wallflex biliar totalmente recubierta pudo extraerse sin complicaciones tras permanecer en el colédoco hasta una media de más de cuatro meses, por lo que podría utilizarse en el tratamiento de procesos biliares benignos(AU)

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(AU)

Biliary sphincterotomy dilation for the extraction of difficult common bile duct stones.

BACKGROUND AND AIM: Endoscopic retrograde cholangiopancreatography (ERCP) with biliary sphincterotomy (BS) is the usual method for extracting common bile duct stones. However, following BS and by means of extraction balloons and Dormia baskets a complete bile duct clearance cannot be achieved in all cases. We present a study on the impact that hydrostatic balloon dilation of a previous BS (BSD) may have in the extraction rate of choledocholithiasis. PATIENTS AND METHODS: A prospective study which included 91 consecutive patients diagnosed with choledocholithiasis who underwent ERCP. For stone removal, extraction balloons and Dormia baskets were used, and when necessary BSD was employed. RESULTS: Complete bile duct clearance was achieved in 86/91 (94.5%) patients. BSD was used in 30 (33%) cases. In these cases, extraction was complete in 29/30 (97%); 23 (76%) patients in the BSD group had anatomic difficulties or bleeding disorders. The most frequently used hydrostatic balloon diameter was 15 mm (60%). There were 7 (7.6%) complications: two self-limited hemorrhage episodes in the BSD group and one episode of cholangitis, one of pancreatitis, and three of bleeding in the group in which BSD was not used. CONCLUSIONS: BSD is a very valuable tool for extracting common bile duct stones. In our experience, there has been an increase in the extraction rate from 73% (Rev Esp Enferm Dig 2002; 94: 340-50) to 94.5% (p = 0.0001, OR 0.1, CI 0.05-0.45), with no increase in complications.

Biliary sphincterotomy dilation for the extraction of difficult common bile duct stones

Background and aim: endoscopic retrograde cholangiopancreatography(ERCP) with biliary sphincterotomy (BS) is the usualmethod for extracting common bile duct stones. However, followingBS and by means of extraction balloons and Dormia baskets acomplete bile duct clearance cannot be achieved in all cases. Wepresent a study on the impact that hydrostatic balloon dilation of aprevious BS (BSD) may have in the extraction rate of choledocholithiasis.Patients and methods: a prospective study which included 91consecutive patients diagnosed with choledocholithiasis who underwentERCP. For stone removal, extraction balloons and Dormia basketswere used, and when necessary BSD was employed.Results: complete bile duct clearance was achieved in 86/91(94.5%) patients. BSD was used in 30 (33%) cases. In these cases,extraction was complete in 29/30 (97%); 23 (76%) patients in theBSD group had anatomic difficulties or bleeding disorders. Themost frequently used hydrostatic balloon diameter was 15 mm(60%). There were 7 (7.6%) complications: two self-limited hemorrhageepisodes in the BSD group and one episode of cholangitis,one of pancreatitis, and three of bleeding in the group inwhich BSD was not used.Conclusions: BSD is a very valuable tool for extracting commonbile duct stones. In our experience, there has been an increasein the extraction rate from 73% (Rev Esp Enferm Dig2002; 94: 340-50) to 94.5% (p = 0.0001, OR 0.1, CI 0.05-0.45), with no increase in complications(AU)

[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.

Tratamiento paliativo de la obstrucción tumoral del vaciamiento gástrico con prótesis metálicas autoexpandibles insertadas endoscópicamente / No disponible

Antecedentes y objetivo: la inserción de prótesis metálicas autoexpandiblespara paliar la obstrucción tumoral del vaciamiento gástricoes un procedimiento mínimamente invasivo, que cada vez seutiliza con más frecuencia. Presentamos la experiencia de esta técnicaen un hospital de nivel II del Sistema Nacional de Salud.Pacientes y métodos: estudio retrospectivo de un periodo decinco años (2003-2007), en los que se trató de resolver la obstruccióntumoral del vaciamiento gástrico en 27 ocasiones a 23 pacientes(media de 0,45 procedimientos por mes), mediante la inserciónendoscópica de prótesis no recubiertas (Wallstent® y Wallflex®).Resultados: la inserción fue técnicamente posible en el 100%de los 27 intentos. Se obtuvo un buen resultado clínico en 25 ocasiones(92,5%). Se utilizó sólo endoscopia 10 (37%) veces y en lasotras 17 (63%) también fluoroscopia. Tras la inserción de la prótesisse intervino a un paciente con intención curativa y a otro, enel que la prótesis no funcionó, para realizar una derivación paliativa.Cuatro prótesis se obstruyeron por crecimiento tumoral, recanalizándosemediante la inserción de nuevas prótesis. En tres ocasionesse produjo ictericia obstructiva en prótesis que cubrían lapapila de Vater. No hubo otras complicaciones. Tampoco mortalidadderivada del procedimiento. La media de supervivencia fuede 104 días (rango 28-400, DE ± 94).Conclusiones: en nuestra experiencia, la inserción endoscópicade prótesis metálicas autoexpandibles parece un método seguroy eficaz en el tratamiento paliativo de la obstrucción tumoraldel vaciamiento gástrico y puede llevarse a cabo con éxito en uncentro de nuestras características

Aim and background: the insertion of self-expanding metalstents to palliate malignant gastric outlet obstruction is a minimallyinvasive procedure that is being increasingly used. We discussexperience with this technique in a level-II hospital in the SpanishNational Health System.Patients and methods: a retrospective five-year study(2003-2007) was conducted in 23 patients who underwent 27procedures aimed at resolving malignant gastric outlet obstruction(mean, 0.45 procedures per month) using endoscopically insertednoncovered stents (Wallstent® and Wallflex®).Results: insertion was technically feasible in all 27 (100%) attempts,with satisfactory clinical results in 25 cases (92.5%). Endoscopyalone was used 10 times (37%), and both endoscopy andfluoroscopy on 17 (63%) occasions. After stent insertion, one patientwas intervened for treatment, and a patient with an unsuccessfulprosthesis received a palliative surgical bypass. Four stentsbecame obstructed by tumoral ingrowth, and patency was reestablishedby inserting a new stent. Obstructive jaundice caused bystents covering the papilla of Vater occurred in three cases. Therewere 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 selfexpandingmetal stents appears to be a safe and efficient palliativemethod for malignant gastric outlet obstruction, and can be performedsuccessfully in a center with our characteristics

Extracción de cálculo coledociano de gran tamaño con esfinterotomía biliar seguida de dilatación de la papila con balón hidrostático / No disponible

No disponible

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.

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

Antecedentes y objetivo: la colangiopancreatografía retrógradaendoscópica (CPRE) es habitualmente la técnica de elecciónpara desobstruir la vía biliar. Una gran parte de los pacientes a losque se realiza esta intervención están en edad geriátrica (mayoresde 75 años). Nuestro objetivo ha sido valorar la eficacia de laCPRE en este grupo de pacientes, comparado con los de menoredad.Pacientes y métodos: estudio retrospectivo en el que se hanincluido los pacientes a quienes se realizó terapéutica biliar endoscópicamediante CPRE en un periodo de cuatro años (2002-2005).Resultados: se realizó CPRE a 178 pacientes en edad geriátricay a 159 de menor edad. No hubo diferencias en el éxito deldrenaje biliar (97,7-98,7%), en el número de complicaciones(11,8-14,4%), ni en la mortalidad (1,1-0,6%). Por el contrario, enel grupo geriátrico hubo más coledocolitiasis (57,3-39,6%, p =0,004) y se utilizaron más prótesis metálicas autoexpandiblespara drenar la ictericia obstructiva tumoral (47-8%, p = 0,0035).En el grupo de menor edad se repitieron más CPRE a los mismospacientes (4-10%, p = 0,001).Conclusiones: el éxito y la morbimortalidad para drenar lavía biliar mediante CPRE son similares en los pacientes con edadgeriátrica y en los de edad inferior. La coledocolitiasis es más frecuenteen los pacientes mayores. No se debe excluir a ningún pacienteque precise de una CPRE sólo por la edad

Background and objective: endoscopic retrograde cholangiopancreatography(ERCP) is usually the procedure of choice forrelieving bile duct obstruction. A large number of patients undergoingthis intervention are geriatric population (aged 75 years ofage and older). Our aim was to assess the efficacy of ERCP in thisgroup of patients as compared to younger ones.Patients and methods: a retrospective study. All patients inwhom a therapeutic biliary endoscopy had been performed over afour-year period of time (2002-2005) were included.Results: 178 geriatric patients and 159 younger ones underwentERCP. No differences were found in successful biliarydrainage (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 metalstents were employed to drain malignant obstructive jaundice (47vs. 8%, p = 0.0035). In the youngest group, more ERCPs wererepeated in the same patients (4 vs. 10%, p = 0.001).Conclusions: the geriatric population showed similar successand morbidity & mortality rates when compared to younger patientsin draining their bile duct by means of ERCP. Common bileduct stones were more frequently found in geriatric patients. Nopatients needing an ERCP should be excluded only because oftheir age