RESUMO
Background and aim: Among the Endoscopic retrograde cholangiopancreatography (ERCP) adverse events, an increasingly arising problem is the transmission of Multi Drug Resistant (MDR) Bacteria through duodenoscopes. The aim of this survey was to evaluate the current clinical practice of management of ERCP associated infections in Emilia-Romagna, Italy. Methods: An online survey was developed including 12 questions on management of ERCP associated infections risk. The survey was proposed to all 12 endoscopy centers in Emilia Romagna that perform at least > 200 ERCPs per year. Results: 11 centers completed the survey (92%). Among all risk factors of ERCP infections, hospitalization in intensive care units, immunosuppressant therapies, and previous MDR infections have achieved a 80 % minimum of concurrence by our respondents. The majority of them did not have a formalized document in their hospital describing categories and risk factors helpful in the detection of patients undergoing ERCP with an high-level infective risk (9/11, 82%). Most centers (8/11, 72%) do not perform screening in patients at risk of ERCP infections. Post procedural monitoring is performed by 6 of 11 centers (55%). Conclusion: Our survey showed that, at least at regional level, there is a lack of procedures and protocols related to the management of patients at risk of ERCP infections.
Assuntos
Colangiopancreatografia Retrógrada Endoscópica , Duodenoscópios , Humanos , Colangiopancreatografia Retrógrada Endoscópica/efeitos adversos , Duodenoscópios/microbiologia , Inquéritos e Questionários , Farmacorresistência Bacteriana Múltipla , Itália/epidemiologiaRESUMO
In patients with malignant esophageal strictures within 6 cm from the upper esophageal sphincter, self-expanding metal stents placement represents a challenge because there is an increased risk of complications. The aim of this study was to assess the safety and effectiveness of large-diameter WallFlex(®) fully covered self-expanding metal stents for palliation of patients with proximal malignant esophageal strictures. From March 2010 to December 2012, 12 patients with proximal strictures (4-6 cm from the upper esophageal sphincter) and six with very proximal strictures (<4 cm from the upper esophageal sphincter) were palliated with this fully covered self-expanding metal stent and included in the study. Technical success was 100% and clinical success was 94%. The mean baseline dysphagia score was 3.2, and 1 week after stenting it improved significantly to 1.3 (P < 0.001). Early complications occurred in four patients, more frequently in patients with very proximal strictures as compared with patients with proximal strictures (P = 0.02). Late complications occurred in five patients, and there were no differences between patients with very proximal strictures or proximal strictures (P = 0.245). The mean survival after stent placement was 119 days, and no differences between patients with very proximal strictures versus proximal strictures were found (P = 0.851). There was no stent-related mortality or 30-day mortality. Our results suggested that a large-diameter fully covered self-expanding metal stent is an effective and secure device for palliation of patients with proximal malignant esophageal strictures.
Assuntos
Neoplasias Esofágicas/cirurgia , Estenose Esofágica/cirurgia , Cuidados Paliativos/métodos , Stents Metálicos Autoexpansíveis/estatística & dados numéricos , Idoso , Idoso de 80 Anos ou mais , Transtornos de Deglutição/etiologia , Transtornos de Deglutição/cirurgia , Neoplasias Esofágicas/complicações , Neoplasias Esofágicas/patologia , Esfíncter Esofágico Superior/cirurgia , Estenose Esofágica/complicações , Estenose Esofágica/patologia , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Stents Metálicos Autoexpansíveis/efeitos adversos , Resultado do TratamentoRESUMO
We present an initial report regarding the clinical usefulness of peroral cholangioscopy, using a new type of cholangioscope, the Polyscope. Peroral cholangioscopy was performed in four patients with strictures after orthotopic liver transplantation (OLT) which were suspected of being ischemic biliary lesions, in three with indeterminate biliary strictures, in three with suspected retained bile duct stones, and in two for evaluation of the intraductal spread of adenomatous tissue after an ampullectomy. In all cases peroral cholangioscopy was performed successfully without complications. On the basis of direct viewing and/or tissue sampling a correct diagnosis was reached in all cases: in all patients who underwent OLT the strictures were not ischemic; the indeterminate strictures were all benign; and, in patients with suspected stones, complete clearance was confirmed. Intraductal spread was confirmed in one patient and excluded in the other. In our experience, peroral cholangioscopy using a Polyscope is a safe and effective method for diagnosing bile duct lesions.
Assuntos
Ductos Biliares/patologia , Doenças Biliares/diagnóstico , Endoscopia do Sistema Digestório/instrumentação , Adulto , Idoso , Idoso de 80 Anos ou mais , Constrição Patológica/diagnóstico , Endoscopia do Sistema Digestório/métodos , Feminino , Cálculos Biliares/diagnóstico , Humanos , Transplante de Fígado/efeitos adversos , Masculino , Pessoa de Meia-Idade , Duração da CirurgiaRESUMO
The Gastro-Laryngeal Tube (G-LT) is a modification of the laryngeal tube which provides a dedicated channel for the insertion of an endoscope while acting as a supraglottic airway for ventilation. The aim of this study was to assess the safety and effectiveness of this device in patients undergoing anesthesia for interventional endoscopic biliopancreatic procedures (IEBPPs).A total of 22 patients were included in the study. The G-LT was inserted successfully in all patients. Arterial oxygen saturation was stable; the mean value was 97.9%. The IEBPPs were performed successfully in all patients through the endoscopic channel, with a mean duration of 99 minutes. The maneuverability of the endoscope was considered good in all patients. There were two cases of sore throat after the procedures, two cases of asymptomatic erosion of the upper esophageal mucosa, one case of Mallory-Weiss syndrome, and one case of pancreatitis after endoscopic retrograde cholangiopancreatography.Our results suggest that the G-LT is an effective and secure device for airway management and for use during IEBPPs.
Assuntos
Anestesia Geral , Colangiopancreatografia Retrógrada Endoscópica/instrumentação , Intubação Intratraqueal/instrumentação , Idoso , Idoso de 80 Anos ou mais , Desenho de Equipamento , Feminino , Humanos , Masculino , Pessoa de Meia-IdadeRESUMO
Endoscopic ultrasound-guided transmural drainage (EUS-GTD) has become the standard procedure for treating symptomatic pancreatic fluid collections. The aim of this series was to evaluate the efficacy and safety of covered self-expanding metal stent (CSEMS) placement for treating infected pancreatic fluid collections. From January 2007 to May 2010, 22 patients (18 M/4F; mean age 56.9) with infected pancreatic fluid collections (mean size, 13.2 cm) at two Italian centers were evaluated for EUS-GTD. In 20 of the 22 patients, EUS-GTD with CSEMS placement was indicated. Early complications occurred in two patients: one patient developed a superinfection, which was managed conservatively, and one experienced stent migration and superinfection, and was managed surgically. The CSEMSs were removed without difficulty in 18 patients after a median of 26 days, while stent removal failed in one patient due to inflammatory tissue ingrowth; instead it was removed during surgery performed for renal cancer. Clinical success was achieved without additional intervention in 17 patients during a mean follow-up of 610 days; only one symptomatic recurrence was observed. In our experience, EUS-GTD with CSEMS placement appears safe for the treatment of infected pancreatic fluid collections.
Assuntos
Drenagem/instrumentação , Drenagem/métodos , Exsudatos e Transudatos/diagnóstico por imagem , Pseudocisto Pancreático/terapia , Pancreatite/complicações , Stents , Antibioticoprofilaxia , Remoção de Dispositivo , Endossonografia/métodos , Segurança de Equipamentos , Feminino , Seguimentos , Migração de Corpo Estranho/etiologia , Humanos , Masculino , Pessoa de Meia-Idade , Pseudocisto Pancreático/complicações , Stents/efeitos adversos , Superinfecção/etiologia , Terapia Assistida por Computador , Ultrassonografia DopplerRESUMO
Endoscopic ultrasonography-guided biliary drainage (EUS-BD) has been developed as an alternative drainage technique in patients with obstructive jaundice where endoscopic retrograde cholangiopancreatography (ERCP) has failed. Between July 2008 and December 2009, 16 patients (9 men; median age 79 years) with biliopancreatic malignancy, who were candidates for alternative techniques of biliary decompression because ERCP had been unsuccessful, underwent EUS-BD with placement of a transmural or transpapillary partially covered nitinol self-expandable metal stent (SEMS). EUS-assisted cholangiography was successful in all patients, with definition of the relevant anatomy, but biliary drainage was successfully performed in only 12 (75â%) of the 16 patients (9 choledochoduodenostomies with SEMS placement and 3 biliary rendezvous procedures with papillary SEMS placement), with regression of the cholestasis. No major complications and no procedure-related deaths occurred. There was one case of pneumoperitoneum which was managed conservatively. The median follow-up was 170 days. During the follow-up, eight patients of the 12 patients in whom biliary draining was successful died; four are currently alive. None of the patients required endoscopic reintervention. This series demonstrated that EUS-BD with a partially covered SEMS has a high rate of clinical success and low complication rates, and could represent an alternative choice for biliary decompression.
Assuntos
Colestase/terapia , Drenagem/métodos , Endoscopia do Sistema Digestório/métodos , Stents , Idoso , Idoso de 80 Anos ou mais , Neoplasias dos Ductos Biliares/complicações , Cateterismo , Colestase/diagnóstico por imagem , Colestase/etiologia , Feminino , Seguimentos , Humanos , Masculino , Pessoa de Meia-Idade , Resultado do Tratamento , UltrassonografiaAssuntos
Colo/lesões , Colonoscopia/efeitos adversos , Perfuração Intestinal/etiologia , Colo/diagnóstico por imagem , Colo/cirurgia , Humanos , Perfuração Intestinal/diagnóstico por imagem , Perfuração Intestinal/cirurgia , Laparoscopia , Masculino , Pessoa de Meia-Idade , Procedimentos Cirúrgicos Minimamente Invasivos , Lavagem Peritoneal , Técnicas de Sutura , Tomografia Computadorizada por Raios XRESUMO
Since its development in the 1980s, endoscopic ultrasonography (EUS) has undergone a great deal of technological modifications. EUS has become an important tool in the evaluation of patients with various clinical disorders and is increasingly being utilized in many centers. EUS has been evolving over the years; EUS-guided fine needle aspiration (FNA) for cytological and/or histological diagnosis has become standard practice and a wide array of interventional and therapeutic procedures are performed under EUS guidance for diseases which otherwise would have needed surgery, with its associated morbidities. EUS shares the risks and complications of other endoscopic procedures. This article addresses the specific adverse effects and risks associated with EUS, EUS-FNA and interventional EUS, namely perforation, bleeding, pancreatitis and infection. Measures to help minimizing these risks will also be discussed.
Assuntos
Endossonografia/efeitos adversos , Ultrassonografia de Intervenção/efeitos adversos , Infecções Bacterianas/etiologia , Infecções Bacterianas/prevenção & controle , Biópsia por Agulha Fina/efeitos adversos , Endossonografia/métodos , Medicina Baseada em Evidências , Doenças da Vesícula Biliar/etiologia , Doenças da Vesícula Biliar/prevenção & controle , Hemorragia/etiologia , Hemorragia/prevenção & controle , Humanos , Perfuração Intestinal/etiologia , Perfuração Intestinal/prevenção & controle , Inoculação de Neoplasia , Ductos Pancreáticos/lesões , Pancreatite/etiologia , Pancreatite/prevenção & controle , Peritonite/etiologia , Peritonite/prevenção & controle , Prognóstico , Fatores de Risco , Ultrassonografia de Intervenção/métodosRESUMO
AIM: The aim of this paper was to evaluate the effect of carbon dioxide (CO2) vs. air insufflation on post-endoscopic retrograde cholangiopancreatography (ERCP) abdominal pain and distension. In addition, we investigated the changes in the partial pressure of end-tidal CO2 (PetCO2) and the partial pressure of arterial CO2 (PaCO2). METHODS: From October 2009 to January 2010, all patients admitted to our centre for ERCP were screened for enrollment; the patients recruited were randomised to CO2 or air insufflation. The patients were asked to rate their abdominal pain intensity and distension using a 100-mm Visual Analogue Scale (VAS) before, in the recovery room and at 1, 3, 6 and 24 hours after the ERCP. All anesthesiological and endoscopic details and complications were evaluated. RESULTS: We included 76 patients, 39 in the Air group and 37 in the CO2 group. The groups were similar for age, gender, indications and duration of the procedure. Post-procedure mean values of pain (in the recovery room and at 1, 3 and 6 hours) and distension (at recovery room, and at 1 and 3 hours) according to the VAS were significantly reduced in the CO2 group as compared to the Air group. At baseline, the PetCO2 values were similar between the two groups while, during the ERCP, they increased significantly in CO2 group as compared to the Air group; these values were reduced by simply increasing the ventilation. CONCLUSION: CO2 insufflation during ERCP significantly reduces post-procedural abdominal pain and distension. Increased PetCO2 and PaCO2 values remained within acceptable or readily controllable ranges.
Assuntos
Dor Abdominal/prevenção & controle , Ar , Anestesia Geral , Dióxido de Carbono , Colangiopancreatografia Retrógrada Endoscópica/métodos , Dilatação Gástrica/prevenção & controle , Insuflação/métodos , Dor Abdominal/diagnóstico , Dor Abdominal/etiologia , Adulto , Idoso , Idoso de 80 Anos ou mais , Dióxido de Carbono/sangue , Dióxido de Carbono/metabolismo , Colangiopancreatografia Retrógrada Endoscópica/efeitos adversos , Feminino , Dilatação Gástrica/etiologia , Humanos , Insuflação/efeitos adversos , Masculino , Pessoa de Meia-Idade , Medição da Dor/métodos , Pressão Parcial , Fatores de TempoRESUMO
AIM: The aim of this study was to evaluate the short- and long-term outcomes of self-expanding metal stent (SEMS) insertion as a bridge to surgery (BTS) in patients presenting with acute left-sided colorectal cancer obstruction (LCCO). METHODS: All patients with acute LCCO who underwent endoscopic SEMS placement as a BTS between January 2005 and December 2010 were reviewed and included in the study. RESULTS: Thirty-six patients (19M and 17F; mean age 68.5) were included. The most frequent location was the sigmoid colon (47.2%). Technical success was achieved in 91.6% and clinical success in 88.9%. Technical failure was related to the location of the stricture at the rectosigmoid junction (P=0.03). There were four SEMS-related complications: one fecal obstruction, one haemorrhage treated with APC and two silent perforations which were noted during surgical resection. The mean time between SEMS insertion and surgical treatment was 19 days (range 6-80 days) and the most frequent intervention was a left hemicolectomy (46.9%). No intraoperative mortality and morbidity, or postoperative mortality were observed. The postoperative morbidity rate was 18.8% (two wound infections, one deep venous thrombosis, one case of pneumonia and one anastomotic dehiscence). Finally, after discharge from hospital, a total of 29 patients (90%) were stoma free. At the end of the follow-up period, 24 patients are still alive and the mean survival rate was 37.3±18 months (range 9-72). CONCLUSION: In our experience, SEMS placement as a BTS is a safe and effective strategy for the treatment of patients with acute LCCO.
Assuntos
Colectomia , Neoplasias Colorretais/complicações , Neoplasias Colorretais/cirurgia , Obstrução Intestinal/etiologia , Obstrução Intestinal/cirurgia , Stents , Doença Aguda , Idoso , Idoso de 80 Anos ou mais , Colectomia/métodos , Colonoscopia , Neoplasias Colorretais/mortalidade , Neoplasias Colorretais/patologia , Neoplasias Colorretais/terapia , Feminino , Seguimentos , Humanos , Obstrução Intestinal/terapia , Itália/epidemiologia , Masculino , Metais , Pessoa de Meia-Idade , Neoplasias Retais/complicações , Neoplasias Retais/cirurgia , Estudos Retrospectivos , Neoplasias do Colo Sigmoide/complicações , Neoplasias do Colo Sigmoide/cirurgia , Stents/efeitos adversos , Taxa de Sobrevida , Fatores de Tempo , Resultado do TratamentoRESUMO
BACKGROUND AND STUDY AIMS: Precut papillotomy is considered a risk factor for endoscopic retrograde cholangiopancreatography (ERCP)-related complications; however whether the complication risk is due to precut itself or to the prior prolonged attempts is still debated; therefore, early precut implementation has been suggested to reduce the complication rate. We conducted a meta-analysis of randomized controlled trials (RCTs) comparing cannulation and complication rates of early precut implementation with persistent attempts by the standard approach. METHODS: RCTs that compared cannulation and complication rates of the early precut implementation and of persistent attempts by the standard approach were included. Summary effect sizes were estimated by odds ratio (OR) with a random-effects model and by Peto OR. RESULTS: Six RCTs with a total of 966 subjects met the inclusion criteria. Overall cannulation rates were 90 % in both randomization groups (OR 1.20; 95 % confidence interval [CI] 0.54 - 2.69). Post-ERCP pancreatitis developed in 2.5 % of patients randomized to the early precut groups and in 5.3 % of patients from the persistent attempts groups (OR 0.47; 95 %CI 0.24 - 0.91). The overall complication rates, considering pancreatitis, bleeding, cholangitis, and perforation rates, were 5.0 % in the early precut groups and 6.3 % in the persistent attempts groups (OR 0.78; 95 %CI 0.44 - 1.37). CONCLUSIONS: RCTs that investigated the issue of timing of the precut procedure were limited. Current evidence suggests that in experienced hands the early implementation of precut and persistent cannulation attempts have similar overall cannulation rates; early precut implementation reduces post-ERCP pancreatitis risk but not the overall complication rate. Further studies are needed to confirm these findings.
Assuntos
Colangiopancreatografia Retrógrada Endoscópica/efeitos adversos , Doenças do Ducto Colédoco/cirurgia , Pancreatite , Ensaios Clínicos Controlados Aleatórios como Assunto , Medição de Risco/métodos , Esfinterotomia Endoscópica/métodos , Humanos , Incidência , Pancreatite/epidemiologia , Pancreatite/etiologia , Pancreatite/prevenção & controle , Complicações Pós-Operatórias , Prognóstico , Fatores de Risco , Esfinterotomia Endoscópica/efeitos adversos , Fatores de TempoRESUMO
BACKGROUND AND AIM: Gastric antral vascular ectasia (GAVE) is a cause of bleeding in patients with liver cirrhosis. Argon plasma coagulation (APC) is the most used endoscopic treatment for GAVE-related bleeding. Treatment failures have been described in patients with haemorrhagic diathesis; post-procedure complications include haemorrhages and septicaemia. The aim of the study was to evaluate efficacy and safety of APC treatment of GAVE-related bleeding in patients with liver cirrhosis. METHODS: Patients included were suffering from GAVE-related bleeding and liver cirrhosis. APC treatment was performed until eradication. Resolution of transfusion-dependent anaemia and evaluation of complications were the primary outcomes. RESULTS: 20 patients (16 Child C and 4 Child B) were enrolled and prospectively followed for a mean period of 28 months. GAVE eradication was achieved in all patients after a median of 3 sessions (range 1-10). Resolution of anaemia was achieved in 18 patients. Six patients had relapse of GAVE after a mean of 7.7 months, successfully retreated by APC. Hyperplastic polyps developed in 3 patients causing active bleeding in 2 cases. Five patients had liver transplants and 1 had a relapse of GAVE after transplantation. CONCLUSION: APC is an effective and safe endoscopic treatment for GAVE in patients with liver cirrhosis.
Assuntos
Argônio/uso terapêutico , Eletrocoagulação , Ectasia Vascular Gástrica Antral/terapia , Hemorragia Gastrointestinal/terapia , Idoso , Idoso de 80 Anos ou mais , Feminino , Ectasia Vascular Gástrica Antral/complicações , Hemorragia Gastrointestinal/etiologia , Humanos , Cirrose Hepática/complicações , Masculino , Pessoa de Meia-Idade , Resultado do TratamentoAssuntos
Cálculos Biliares/terapia , Íleus/terapia , Obstrução Intestinal/terapia , Litotripsia , Doenças do Colo Sigmoide/terapia , Idoso de 80 Anos ou mais , Meios de Contraste , Feminino , Cálculos Biliares/complicações , Cálculos Biliares/diagnóstico por imagem , Humanos , Íleus/etiologia , Obstrução Intestinal/diagnóstico por imagem , Obstrução Intestinal/etiologia , Doenças do Colo Sigmoide/diagnóstico por imagem , Doenças do Colo Sigmoide/etiologia , Sigmoidoscopia , Tomografia Computadorizada por Raios XRESUMO
Endosonography is an imaging technique based on the unification of ultrasonography and edoscopy. EUS became part of clinical practice at the beginning of the 80s due to its superior capacity to study the pancreas with respect to abdominal ultrasound. In recent years, there is a growing interest in EUS as shown by the number of scientific articles and changing clinical practice regarding diagnostic and therapeutic algorithms (bile duct stones, cancer staging) and palliation.
Assuntos
Endoscopia Gastrointestinal/métodos , Endossonografia/métodos , Endossonografia/instrumentação , Trato Gastrointestinal/anatomia & histologiaRESUMO
Intrahepatic cholangiocarcinoma (ICC) is a rare malignant tumor of the biliary tract with growing incidence and dismal prognosis. It is responsible for 10-20% of primary liver cancer worldwide, but early diagnosis is still a challenge and few treatment options are available. Aim of this review is to summarize the current knowledge about biological features and arising molecular patterns of this disease. The identification of emerging biomarkers and early detection of precursor lesions shall play a key role in the perspective of future tailored targeted therapies.
Assuntos
Neoplasias dos Ductos Biliares/patologia , Ductos Biliares Intra-Hepáticos/patologia , Colangiocarcinoma/patologia , Detecção Precoce de Câncer , Neoplasias Hepáticas/patologia , Neoplasias dos Ductos Biliares/diagnóstico , Biomarcadores Tumorais , Colangiocarcinoma/diagnóstico , Humanos , Neoplasias Hepáticas/diagnósticoAssuntos
Doenças dos Ductos Biliares/terapia , Carcinoma Hepatocelular/terapia , Quimioembolização Terapêutica/efeitos adversos , Endoscopia do Sistema Digestório/métodos , Adesivo Tecidual de Fibrina/uso terapêutico , Fístula/terapia , Neoplasias Hepáticas/terapia , Antineoplásicos/administração & dosagem , Doenças dos Ductos Biliares/etiologia , Fístula/etiologia , Humanos , Transplante de Fígado , Masculino , Pessoa de Meia-IdadeAssuntos
Cateterismo/métodos , Colangiopancreatografia Retrógrada Endoscópica , Esfinterotomia Endoscópica/instrumentação , Ductos Biliares , Cateterismo/instrumentação , Colangiopancreatografia Retrógrada Endoscópica/efeitos adversos , Humanos , Metanálise como Assunto , Ductos Pancreáticos , Pancreatite/etiologia , Pancreatite/prevenção & controle , Esfinterotomia Endoscópica/métodosRESUMO
BACKGROUND/AIMS: Endoscopic variceal banding ligation (EVL), first described by Stiegmann in 1988, is now an accepted alternative to sclerotherapy (EVS) for esophageal varices with previous bleeding. However, results are conflicting in terms of complications, eradication, recurrence, rebleeding and mortality rate. We aimed to compare EVL with EVS in a prospective randomized trial in patients with previous esophageal bleeding proved by endoscopy. End points were rebleeding rate and death during a short (eradication period) or long-term follow-up (> 1 year). METHODOLOGY: One hundred patients (50 EVL, 50 EVS) were enrolled. Eradication rate, number of treatments needed to achieve eradication, recurrence of varices, rebleeding and complications were recorded and analyzed. RESULTS: No differences were observed between the two groups regarding age, sex and Child class. One patient dropped out in the EVL group and 6 in the EVS group. Eradication was obtained in 44 (88%) with EVL and 41 (82%) with EVS with a mean of 3.41 and 5.29 treatments (p<0.001), respectively. Rebleeding occurred during eradication in 6 patients (12%) in the EVL group and 21 (42%) in the EVS group (p=0.001); after eradication, 7 patients (14%) rebled in the EVL group and 4 (8%) in the EVS group (not significant). Non-variceal bleeding was observed in 5 patients (2 EVL and 3 EVS) during follow-up. Two patients in the EVL group died after variceal rebleeding; 3 died of gastric bleeding; and, 15 from non-hemorrhagic events (8 EVL and 7 EVS). In the EVL group 14 patients had recurrent varices and 7 rebled; in the EVS group 11 recurred, with rebleeding in 5. Major complications were fewer in the EVL group (1 stenosis, 4 chronic ulcers) compared to 18 patients in the EVS group (9 stenosis and 9 chronic ulcers) (p<0.005). CONCLUSIONS: EVL might be preferable to EVS for faster reduction and obliteration of varices, with a lower rate of complications and rebleeding before eradication. No differences were observed in recurrence.