Impact of endoscopic ultrasonography on the management of a prospective cohort of 700 consecutive patients referred for diagnostic endoscopic ultrasonography.

BACKGROUND: endoscopic ultrasonography (EUS) is a high accuracy technique for the study of many digestive diseases. The degree of knowledge about the impact of EUS on the management of these patients is inadequate. AIM: to determine the therapeutic impact of endoscopic ultrasonography (EUS) on a prospective cohort of patients. METHODS: all patients referred for EUS over a period of 2 years were prospectively evaluated in order to asses: 1. EUS provides new information not previously known; 2. theoretic impact of EUS on patient management; 3. real impact of EUS on final therapy; 4. changes in the aggressiveness of the therapeutic decision after EUS. RESULTS: 700 patients were included. Preoperative assessment of digestive tumors was the commonest indication. EUS provided "new information" in the 89% of the patients. With regard to endoscopist opinion, these findings should alter the management in 79% of patients ("theoretic impact"). However, EUS prompted a change in the management in 67% of patients ("real impact"). Final therapy post-EUS was less aggressive in 34% of patients. Changes in therapeutic decision were associated with EUS findings, alcohol intake and age ≥ 57 years old. CONCLUSIONS: 1) EUS findings, advanced age, and alcohol intake are associated with a change in the management in 2 out of every 3 patients referred for EUS. 2) Therapeutic decision (post-EUS) is less aggressive in a third of these patients, what should represent a significant economic saving.

Impacto de la ultrasonografía endoscópica en el manejo terapéutico de una cohorte prospectiva de 700 pacientes consecutivos referidos para USE diagnóstica / No disponible

Antecedentes: la ultrasonografía endoscópica (USE) es una técnica de gran precisión para el estudio de diferentes patologías digestivas. El grado de conocimiento sobre el impacto de la USE en el tratamiento de estos pacientes es escaso. Objetivo: determinar el impacto terapéutico de la USE en una cohorte prospectiva de pacientes. Material y métodos: estudio que evalúa de forma prospectiva a todos los pacientes remitidos para USE en un periodo de 2 años. Se analiza: a) si la USE aporta información no conocida previamente; b) el impacto teórico de la USE en el tratamiento; c) el impacto final/real de USE en el tratamiento; d) la variación en la decisión terapéutica tras realizar la USE. Resultados: se incluyeron 700 pacientes. La indicación más frecuente de USE era el estudio preoperatorio de tumores digestivos. La USE aportó “información nueva” en el 89% de los casos. En opinión del ecoendoscopista estos hallazgos deberían suponer un cambio terapéutico en el 79% de los pacientes (“impacto teórico”). Sin embargo, el tratamiento sólo se modificó en el 67% de los casos (“impacto real”). La estrategia terapéutica post-USE fue menos agresiva en el 34% de los casos. Los cambios en la actitud terapéutica se asociaban con los hallazgos de USE, ingesta de alcohol y edad > 57 años. Conclusiones: – Los hallazgos de la USE, la edad avanzada y el consumo de alcohol, se asocian con un cambio terapéutico en 2 de cada 3 pacientes remitidos a una unidad de USE. – La decisión terapéutica final (post-USE) es menos agresiva en un tercio de estos pacientes, lo que podría representar un ahorro económico significativo(AU)

Antecedents: endoscopic ultrasonography (EUS) is a high accuracy technique for the study of many digestive diseases. The degree of knowledge about the impact of EUS on the management of these patients is inadequate. Aim: to determine the therapeutic impact of endoscopic ultrasonography (EUS) on a prospective cohort of patients. Methods: all patients referred for EUS over a period of 2 years were prospectively evaluated in order to asses: 1. EUS provides new information not previously known; 2. theoretic impact of EUS on patient management; 3. real impact of EUS on final therapy; 4. changes in the aggressiveness of the therapeutic decision after EUS. Results: 700 patients were included. Preoperative assessment of digestive tumors was the commonest indication. EUS provided “new information” in the 89% of the patients. With regard to endoscopist opinion, these findings should alter the management in 79% of patients (“theoretic impact”). However, EUS prompted a change in the management in 67% of patients (“real impact”). Final therapy post-EUS was less aggressive in 34% of patients. Changes in therapeutic decision were associated with EUS findings, alcohol intake and age >= 57 years old. Conclusions: 1) EUS findings, advanced age, and alcohol intake are associated with a change in the management in 2 out of every 3 patients referred for EUS. 2) Therapeutic decision (post- EUS) is less aggressive in a third of these patients, what should represent a significant economic saving(AU)

Training model for teaching endoscopic submucosal dissection of gastric tumors

Introduction: the elevated risk of complications and technicalcomplexity of endoscopic submucosal dissection (ESD) has limitedits implementation in our medical system.Objective: to design and evaluate a training program forlearning the ESD technique.Methods: four endoscopists with no experience with ESD underwenta 4-step training program: 1) review of the existing literature,didactic material, and theoretical aspects of ESD; 2) ESDtraining in an ex-vivo animal model; 3) ESD training in an in-vivoanimal model (supervised by ESD expert); and 4) ESD performancein a patient. A standard gastroscope and an ESD knife (IT,Flex or Hook-knife Olympus®) were employed. The classical ESDtechnique was performed: rising of the lesion, circumferential incision,and submucosal dissection.Results: ex-vivo animal model: 6 x swine stomach/esophagus–cost < 100 euro; 6 x ESD: antrum (n = 2), body (n = 3) andfundus/cardia (n = 1)–; size of resected specimen: 4-10 cm; ESDduration: 105-240 minutes; therapeutic success: 100%; complications:perforation (1/6: 16%) sealed with clips. In-vivo animalmodel: 6 ESD (antrum/body of stomach: 4; esophagus: 2); size:2-5 cm; duration: 40-165 minutes; success: 100%; complications:0%. Patient: ESD of a gastric lesion located in theantrum/body; size: 3 cm; duration 210 minutes; a complete resectionwas achieved; no complications.Conclusions: the results of the present study support the usefulnessof this model for learning ESD in our system(AU)

Linear EUS: the clinical impact of N staging in esophageal carcinoma.

This review article focuses on nodal staging of esophageal cancer. Transesophageal endoscopic ultrasound (EUS) is the most accurate technique for preoperative local-regional staging of esophageal carcinoma (TN staging), once the CT and/or the PET scan have excluded the presence of distant metastasis. EUS guided fine needle aspiration (EUS-FNA) helps improve diagnostic accuracy in esophageal cancer lymph node staging. In certain subgroup of patients who present with a number of EUS lymph node criteria, EUS FNA may be avoided without affecting diagnostic accuracy. In tumors of the distal esophagus detection and biopsy of celiac lymph nodes may be successfully performed by EUS and EUS FNA, and important therapeutic decissions may be derived from such a practice.

Pancreatitis aguda como diagnóstico debut de un hiperparatiroidismo primario / Acute pancreatitis as clinical presentation of a primary hyperparatiroidism

No disponible

Effect of Helicobacter pylori eradication therapy in rosacea patients.

OBJECTIVE: The causal relation between rosacea and Helicobacter pylori infection is discussed. We evaluated the clinical evolution of rosacea after infection eradication. PATIENTS AND METHODS: We have prospectively studied 44 patients diagnosed with rosacea. Helicobacter pylori infection was determined, and infected patients were treated with eradication therapy. The evolution of dermatological symptoms in a subgroup of 29 infected patients in whom eradication had been achieved was followed during 16.8 (+/- 17.8) months. Median age was 50.6 (+/- 14.1) years for 22 women (75.9%) and 7 men (24.1%). Clinical response according to gender and clinical subtype of rosacea was evaluated. RESULTS: Complete improvement was observed in 10 patients (34.5%; 95% CI: 18.6-54.3%), relevant improvement in 9 (31.1%; 95% CI: 16-51%), poor improvement in 5 (17.2%; 95% CI: 6.5-36.4%), and absence of improvement in 5 cases (17.2%; 95% CI: 6.5-36.4%). No significant differences in dermatological evolution according to sex were observed. Regarding subtype of rosacea there was a relevant improvement in 83.3% (95% CI: 64.1-93.8%) of cases with papulopustular type as opposed to 36.5% (95% CI: 20-56.1%) of cases with erythematous predominance, p = 0.02. CONCLUSIONS: Based on these results, the relation between Helicobacter pylori and rosacea is supported, and infection should be investigated in these patients because an appreciable percentage of patients diagnosed with rosacea and Helicobacter pylori infection can benefit from eradication therapy, mainly in the papulopustular subtype.

Gastrectomía laparoscópica por adenocarcinoma gástrico. Resultados a largo plazo / Effect of Helicobacter pylori eradication therapy in rosacea patients

Objetivo: la relación causal entre la rosácea y la infección porHelicobacter pylori es discutida. Se propuso valorar la evoluciónde los síntomas cutáneos de la rosácea tras la erradicación de lainfección.Pacientes y métodos: se estudió prospectivamente a 44 pacientesdiagnosticados de rosácea. Se determinó la infección porHelicobacter pylori y se administró terapia erradicadora a los pacientesinfectados. Se siguió durante 16,8 (±17,8) meses la evoluciónde los síntomas dermatológicos del subgrupo de 29 pacientesinfectados en los que se había conseguido la erradicación. La edadmedia fue 50,6 (±14,1) años, siendo 22 mujeres (75,9%) y 7 varones(24,1%). Se valoró la respuesta clínica en función del sexo ydel subtipo clínico de rosácea.Resultados: se observó mejoría completa en 10 pacientes(34,5%; IC95%: 18,6-54,3%), mejoría importante en 9 (31,1%;IC95%: 16,5-51%), mejoría escasa en 5 (17,2%; IC95%: 6,5-36,4%) y ausencia de mejoría en 5 casos (17,2%; IC95%: 6,5-36,4%). No se observaron diferencias significativas en función delsexo. Con respecto al subtipo de rosácea experimentaron buenarespuesta el 83,3% (IC95%: 64,1-93,8%) de las rosáceas pápulopustulosasfrente al 36,5% (IC95%: 20-56,1%) de las rosáceas depredominio eritematoso, p = 0,02.Conclusiones: con estos datos se sigue apoyando la relaciónHelicobacter pylori-rosácea y se debería investigar la infección enlos pacientes con esta enfermedad, ya que un porcentaje apreciablede pacientes diagnosticados de rosácea e infectados con Helicobacterpylori pueden beneficiarse de la terapia erradicadora dela infección, sobre todo en el subtipo pápulo-pustuloso

Objective: the causal relation between rosacea and Helicobacterpylori infection is discussed. We evaluated the clinicalevolution of rosacea after infection eradication.Patients and methods: we have prospectively studied 44patients diagnosed with rosacea. Helicobacter pylori infectionwas determined, and infected patients were treated with eradicationtherapy. The evolution of dermatological symptoms in a subgroupof 29 infected patients in whom eradication had beenachieved was followed during 16.8 (± 17.8) months. Median agewas 50.6 (± 14.1) years for 22 women (75.9%) and 7 men(24.1%). Clinical response according to gender and clinical subtypeof rosacea was evaluated.Results: complete improvement was observed in 10 patients(34.5%; 95% CI: 18.6-54.3%), relevant improvement in 9(31.1%; 95% CI: 16-51%), poor improvement in 5 (17.2%; 95%CI: 6.5-36.4%), and absence of improvement in 5 cases (17.2%;95% CI: 6.5-36.4%). No significant differences in dermatologicalevolution according to sex were observed. Regarding subtype ofrosacea there was a relevant improvement in 83.3% (95% CI:64.1-93.8%) of cases with papulopustular type as opposed to36.5% (95% CI: 20-56.1%) of cases with erythematous predominance,p = 0.02.Conclusions: based on these results, the relation betweenHelicobacter pylori and rosacea is supported, and infectionshould be investigated in these patients because an appreciablepercentage of patients diagnosed with rosacea and Helicobacterpylori infection can benefit from eradication therapy, mainly inthe papulopustular subtype

[Cystic fibrosis presenting as acute recurrent pancreatitis]. / Pancreatitis aguda recidivante como forma de presentación de fibrosis quística.

Cystic fibrosis is a multiorgan autosomal recessive disease resulting from mutations in a gene located on the long arm of chromosome 7. The disease is usually diagnosed in the first few years of life when it typically presents with severe pulmonary manifestations and pancreatic insufficiency; however, a small percentage of patients with less dramatic symptoms is not diagnosed until adolescence or even adulthood. The genotype of each patient seems to influence the various forms of clinical presentation. Although uncommon, acute recurrent pancreatitis can be one of the forms of delayed presentation of cystic fibrosis. We report the case of an 17-year-old man who was diagnosed with cystic fibrosis after presenting 2 episodes of acute pancreatitis without associated pancreatic insufficiency. Subsequent study also revealed nasal polyps.

Pancreatitis aguda recidivante como forma de presentación de fibrosis quística / Cystic fibrosis presenting as acute recurrent pancreatitis

La fibrosis quística (FQ) es una enfermedad multiorgánica autosómica recesiva consecuencia de mutaciones existentes en un gen del brazo largo del cromosoma 7. La mayor parte de los casos se diagnostica durante los primeros años de vida, cuando la enfermedad se presenta de forma típica con manifestaciones pulmonares graves e insuficiencia pancreática, pero un pequeño porcentaje de pacientes no se diagnostica hasta la adolescencia e incluso la edad adulta, por presentar cuadros clínicos menos floridos. El genotipo de cada paciente parece influir en las diferentes formas clínicas de presentación de la enfermedad. La pancreatitis aguda recidivante, aunque poco frecuente, puede ser una de las formas de presentación tardía de la FQ. Presentamos el caso de un varón de 17 años que fue diagnosticado de FQ tras presentar 2 episodios de pancreatitis aguda, sin insuficiencia pancreática asociada. También se detectaron en el estudio posterior pólipos nasales

Cystic fibrosis is a multiorgan autosomal recessive disease resulting from mutations in a gene located on the long arm of chromosome 7. The disease is usually diagnosed in the first few years of life when it typically presents with severe pulmonary manifestations and pancreatic insufficiency; however, a small percentage of patients with less dramatic symptoms is not diagnosed until adolescence or even adulthood. The genotype of each patient seems to influence the various forms of clinical presentation. Although uncommon, acute recurrent pancreatitis can be one of the forms of delayed presentation of cystic fibrosis. We report the case of an 17-year-old man who was diagnosed with cystic fibrosis after presenting 2 episodes of acute pancreatitis without associated pancreatic insufficiency. Subsequent study also revealed nasal polyps

Fibrin-glue sealed liver biopsy in patients with a liver transplantation or in liver transplantation waiting list: preliminary results.

Liver biopsy is frequently necessary for candidate evaluation or histologic follow-up of transplanted livers. Although generally considered to be safe, it carries a risk of complications in up to 0.5% of cases; hemorrhage being the most important. It can present as an asymptomatic intra- or perihepatic hematoma or result in overt hemorrhage of variable intensity. Patients with deranged hemostasis or on antiaggregant therapy are at high-risk for hemorrhagic complications. Percutaneous liver biopsy may be contraindicated if hemostasis is profoundly disordered. Safety values are not well defined: arbitrary limits are 60% prothrombin activity and 60,000 platelets per mm3. Patients with more altered values are candidates for alternative techniques, such as transjugular biopsy. Another option is the so-called plugged percutaneous liver biopsy, which uses direct injection of a plugging material into the biopsy tract. Different materials have been used: Tissucol, absorbable gelatin sponge, or hemostasis coils. We communicate our experience with Tissucol (fibrin glue) plugging in 30 percutaneous liver biopsies on 16 patients after liver transplantation with prothrombin activity <60%, platelet count <60,000 per mm3, or both. Only two complications were observed. Plugged liver biopsy is an efficient and relatively safe procedure in patients with impaired hemostasis; it can be performed even when transjugular biopsy is not available.