Evaluation of the efficacy of therapeutic endoscopy in gastrointestinal bleeding secondary to angiodysplasias. / Evaluación de la eficacia terapéutica endoscópica en hemorragia digestiva secundaria a angiodisplasias.

INTRODUCTION: Gastrointestinal angiodysplasias are defined as vascular dilations that communicate capillaries and veins in the walls of the digestive tract. The clinical presentation of these lesions varies from chronic occult bleeding to severe gastrointestinal hemorrhage. AIM: The primary aim of our study was to analyze lesion location, the efficacy of therapeutic endoscopy with argon plasma coagulation, and the factors associated with rebleeding in patients with gastrointestinal angiodysplasias. MATERIAL AND METHODS: A retrospective study of 32,042 endoscopies was carried out within the time frame of January 2012 and December 2013 at our hospital center. Gastrointestinal angiodysplasia was the diagnosis in 331 of the endoscopies. The procedures included upper gastrointestinal endoscopy, colonoscopy, sigmoidoscopy, and enteroscopy. RESULTS: The most frequent location of the angiodysplasias was the cecum (49%), followed by the ascending colon (17%) and the sigmoid colon (16%). They were most frequently found in the duodenum (60%) and gastric body (49%) at upper gastrointestinal endoscopy. Therapeutic endoscopy was performed in 163 cases (49.8%) and the most predominant methods were fulguration with argon (90%) and combination treatment (argon plasma coagulation and injection sclerotherapy) (6.7%). The macroscopic rebleeding rate after therapeutic endoscopy was 7.4%. Patients that had rebleeding presented with a lower hemoglobin concentration, higher mean age, and the presence of multiple angiodysplasias at endoscopy (P<.05). CONCLUSIONS: Therapeutic endoscopy was performed in 49.8% of the patients with angiodysplasias. The macroscopic rebleeding rate after treatment was 7.4%. There were statistically significant differences in the patients with rebleeding in relation to mean age, hemoglobin values, and the presence of multiple angiodysplasias.

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)

Ictericia por coledocolitiasis diagnosticada mediante una radiografía simple de abdomen / No disponible

No disponible

Hairy esophagus: una complicación de la cirugía reconstructiva faringoesofágica / 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.

Bile duct cannulation: success rates for various ERCP techniques and devices at a single institution.

BACKGROUND AND STUDY AIMS: Deep bile duct cannulation is the first step in carrying out ERCP biliary interventions. Although many special techniques have been described, there is a lack of reports that describe all methods employed to cannulate in a single series. This is a prospective study about the way in which cannulation was achieved in an ordinary ERCP workload. PATIENTS AND METHODS: From January 2002 to June 2004, all patients who underwent ERCP with accessible and intact papilla and no gastroduodenal surgical alterations were included. Cannulation either with a 5.5 french tapered, triple lumen sphincterotome (5.5 Fr-S), loaded with a 0.035 inch hydrophilic tip guidewire, or with a 3 french tapered, double lumen sphincterotome (3 Fr-S), plus a 0.025 inch guidewire, was considered standard cannulation (SC). Other methods and devices were considered to be alternative methods. RESULTS: Of the 199 patients, SC succeeded in 150 (75.4%). Initial cannulation was achieved in 78/100 with the 3 Fr-S, and in 59/96 (61.4%) with the 5.5 Fr-S, (p = 0.01). Alternative methods used to reach a final 98% success rate were any type of precut (23 patients, 11.5%), cannulation above a pancreatic placed guidewire (11, 5.5%), above a pancreatic stent (7, 3.5%), utilization of two devices at the same time (3, 1.5%), and papillectomy (1, 0.5%). In 4 (2%) patients, cannulation failed. CONCLUSIONS: In almost a quarter of the patients (45, 22.6%) in this series, cannulation had to be performed by alternative methods. A 3 Fr-S is a very useful tool for gaining access to the bile duct.

Congenital ocular motor apraxia associated with idiopathic generalized epilepsy in monozygotic twins.

Identical female twins (age 11 years) with congenital ocular motor apraxia and generalized idiopathic epilepsy are reported. Their presenting symptoms were a long history of abnormal head and eye movements. One twin developed partial sensory seizures. The patients underwent 16-channel EEG, electro-oculographic recordings, MRI of the brain, and genetic and metabolic investigations. EEG findings were consistent with idiopathic generalized epilepsy. Electrooculographic recordings of the saccades confirmed an inability to elicit horizontal saccades without preceding head movement; saccades to the left were better than saccades to the right. MR scans for one twin showed normal findings, however, for the twin who had meningitis they revealed asymmetry between the right and left temporal lobes but no specific abnormality. DNA analysis using a series of autosomal polymorphic markers confirmed the monozygocity of the twins. White blood cell enzyme analysis excluded Sandhoff disease, Tay-Sachs disease, GM1 gangliosidosis, metacromatic leucodystrophy, Gaucher disease, Niemann-Pick disease (A and B), and Krabbe leucodystrophy. Albumin and immunoglobulin (IgA, IgG, and IgM) levels were normal. It is concluded that autosomal recessive inheritance seems the most likely explanation here, as recent studies have found insertion and missense mutations of the aprataxin gene which have been related to an early onset form of ataxia with ocular motor apraxia and hypoalbuminaemia.

Complications of endoscopic retrograde cholangiopancreatography. A study in a small ERCP unit.

BACKGROUNDS AND AIM: endoscopic retrograde cholangiopancreatography (ERCP) is an established procedure to drain the biliary and pancreatic ducts. Nevertheless, there are complications which seem to be more common in centers performing less than 200 ERCPs per year. Sometimes, however, due to the distribution of health resources, it is necessary to perform this technique in centers with a smaller number of procedures. We present the experience of ERCP-related complications in a small unit. MATERIAL AND METHODS: this is a retrospective study on prospective data recorded during six years (1997-2002). In this period, two endoscopists working together performed 507 ERCPs, which yields an approximately average of 84 procedures per year. RESULTS: in 507 ERCPs performed during this period of time, 55 complications arose (10.85%), and four patients died (0.79%) as a consequence of the procedure. There were 28 pancreatitis (5.5%), eight post-sphincterotomy bleeding events (1.6%), seven bilioduodenal perforations (1.4%), eight sepsis episodes of biliary origin (1.6%), and other 4 different complications. There were 418 (82.4%) successful ERCPs--either diagnostic or therapeutic--,which gave rise to 46 (11%) complications. There were 89 (17.6%) failed diagnostic or therapeutic ERCPs, which gave rise to 9 (10.11%) complications (p = 0.8 between both groups). Thirty five (7%) ERCPs were exclusively diagnostic and caused 6 (17%) complications. The 187 procedures performed for choledocholithiasis originated 14 (7.4%) complications, and represented the group with the lowest morbidity rate (p = 0.04). CONCLUSIONS: the complications rate in our center is within the range of reported figures. ERCPs performed for choledocholithiasis was associated with the lowest complications rate. The risk-benefit ratio in the anticipated, purely diagnostic ERCP must be carefully weighed due to its morbidity.

[Treatment of malignant colorectal obstruction by means of endoscopic insertion of self-expandable metallic stents]. / Tratamiento de la obstrucción neoplástica del colon meciante la inserción endoscópica de prótesis metálicas autoexpandibles.

BACKGROUND AND AIM: Self-expandable metallic stents are being used increasingly to treat the obstruction of different segments of the digestive tract and biliary tree. We present our centre experience on the initial resolution of malignant colorectal obstruction by means of this type of stents. PATIENTS AND METHODS: During a 18-month period, 13 patients patients suffering from malignant obstruction at the level of rectum, sigmoid or descending colon tried to be initially treated by means of endoscopic insertion of stents (non covered enteral Wallstents). Ten procedures were performed with both endoscopy and fluroscopy and three with only endoscopy. RESULTS: In 12 of the 13 patients (92,3%) the obstruction was solved by means of correct stent insertion. All the exclusively endoscopic procedures (without fluoroscopy) were successful. Six (50 %) patients with tumours at the rectosigmoid underwent later scheduled surgery. In the remaining six ones (a patient with an ovarian carcinoma and five with colonic adenocarcinoma) the stents were considered to be a palliative definitive treatment. Stent migration was observed in two of these patients and both were extracted endoscopically. Only one patient needed to have another stent inserted. A tumoural colo-vesical fistula developed in another patient in the palliative group, inside the previous inserted stent, and was treated by coaxial insertion of an esophageal Ultraflex. There were no other complications or mortality related to the endoscopic procedures. CONCLUSIONS: Self-expandable metallic stents might be considered, in general, as the initial treatment for the malignant obstruction at the level of rectum, sigmoid and descending colon

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)

[Endoscopic treatment of obstructive jaundice at a second level national health system hospital]. / Tratamiento endoscópico de la ictericia obstructiva en un hospital de nivel II del Sistema Nacional de Salud.

BACKGROUND AND AIMS: The difficulty of performing endoscopic retrograde cholangiopancreatography (ERCP) in our patients in the reference hospitals within a few days of diagnosis of obstructive jaundice led us to perform this technique in our center. We expected to perform a small number of ERCP annually. We analyzed the success rate of initial biliary drainage and the complications of this procedure. PATIENTS AND METHODS: We performed a retrospective study. From 1997-1999 we carried out 240 ERCP. In 128 patients, 140 ERCP were performed for obstructive jaundice (58,3%). The final diagnosis was choledocholithiasis in 69 patients (54%), tumors in 35 (27%), dilatation of the biliary tract without obstruction at cholangiography in 21 (17%) and benign stenosis of the biliary tract in 3 (2%). RESULTS: The mean procedure time for ERCP was 5.26 ( 2.8) days. Cholangiography was successfully performed in 117 patients (91.4%). Effective therapeutic endoscopy was performed in 111 patients (86.7%). Jaundice was resolved in 62 patients (90%) with choledocholithiasis, 55 (80%) by stone removal and in 7 (10%) by prosthesis. Resolution was also achieved in 25 (71.5%) tumors, mainly by prosthesis, and in 100% of patients with benign stenosis. In all patients with dilatation of the biliary tract without obstruction, biliary sphincterotomy was performed. Complications were found in 15 patients (11.7%) and two (1.56%) died. CONCLUSIONS: The majority of patients with obstructive jaundice can be satisfactorily treated in a center with our characteristics. However, in tumors, the figures for drainage were slightly lower than those reported in the medical literature.