Endoscopic mucosal resection with a multiband ligator for the treatment of Barrett s high-grade dysplasia and early gastric cancer.

AIM: Due to surgery s high mortality and morbidity, local therapeutic techniques are required for Barrett s high-grade dysplasia (BHGD) and early gastric cancer (EGC). Various techniques are available for endoscopic mucosal resection (EMR) in the GI tract. The " suck and cut technique, which uses a transparent cap or modified multiband variceal ligator, is usually the most practiced method. A multiband ligator (ML) allows sequential resection without the need for submucosal injection and endoscope withdrawal. The objective of this study was to evaluate the efficacy and safety of EMR with a ML device in the treatment of Barrett s high-grade dysplasia and early gastric cancer. PATIENTS AND METHODS: Prospective study. Eight consecutive patients (4 men; median age, 62 years; range 38-89 years) with BHGD (4) or EGC (4) were treated. EMR was performed with a multiband ligator in order to create a pseudopolyp and then permit snare polypectomy of flat mucosal lesions. The pseudopolyp was resected by using pure coagulating current. No submucosal saline injection was administered before resection. RESULTS: A total of 8 consecutive patients were treated with the multiband ligator (ML) technique. Barrett s esophagus (BE): one patient with long BE received 3 EMR sessions. Three patients presented with short BE and received 1 EMR session each. The histology of the EMR specimens confirmed a moderately differentiated adenocarcinoma with submucosal infiltration (1 patient) and BHGD (3 patients). Early gastric cancer (EGC): 3 patients had EGC (type IIa) and 1 patient had high-grade dysplasia. EMR was accomplished in 1 session for each patient. The histology of EMR specimens confirmed a mucinous adenocarcinoma with submucosal infiltration (1 patient), EGC (2 patients), and HGD (1 patient). Complications (mild esophageal stenosis, minor bleeding) occurred in 2 patients. CONCLUSIONS: EMR has diagnostic and therapeutic implications, and represents a superior diagnostic modality as compared to traditional biopsy. By means of EMR the resected mucosa is pathologically examined, and the lesion may be appropriately treated. EMR-ML is a safe and effective technique for the treatment of superficial lesions of the digestive tract, and is accepted as an alternative to surgical therapy for non-invasive lesions. Long-term follow-up is needed to determine the clinical impact of this method.

[Large balloon dilation for removal of bile duct stones]. / Dilatación de la papila de Vater con balón de gran diámetro para la extracción de coledocolitiasis.

AIM: To assess the efficacy and safety of dilatation of the papilla of Vater with large balloons for the treatment of choledocolithiasis in patients with difficult or risky extraction due to stone characteristics or peripapillary anatomy. DESIGN: Prospective. PATIENTS: This study includes 93 patients in whom large-balloon dilation was performed between June 2005 and January 2008. Patients had multiple large stones, tapered distal CBD (common bile duct), peri-/intra-diverticular papilla, and previous sphincterotomy or Billroth-II surgery. A controlled radial expansion (CRE) balloon with a diameter range of 12-20 mm was used. RESULTS: Stone removal was achieved in a single session in all patients (100 %). Most procedures (86%) did not require an extended exploration time. Mechanical lithotripsy was needed in 3.2 % of cases. There were two mild complications (2.1%). Hyperamilasemia was detected in 16% of patients. CONCLUSIONS: Papillary dilation with a large balloon is an effective, safe, and easy technique for the retrieval of difficult common bile-duct stones. The procedure neither adds time to the exploration, nor increases complications, and obviates the need for mechanical lithotripsy in a majority of patients.

[Large hydrostatic balloon for choledocolithiasis]. / Balón hidrostático de gran diámetro en coledocolitiasis.

AIM: To assess the efficacy and safety of hydrostatic dilatation with large balloons for the treatment of choledocolithiasis in patients with difficult or risky extraction due to stone characteristics or peripapillary anatomy. DESIGN: Prospective. PATIENTS: This study included 22 patients in whom a hydrostatic dilatation of the papilla with large balloons was performed between June 2005 and April 2006. Patients had multiple large stones, tapered distal common bile duct, peri-/intradiverticular papilla, previous sphincterotomy, or Billroth-II surgery. Esophageal, pyloric and colonic CRE dilatation balloons with diameters ranging from 12 to 20 mm (Boston Scientific Corporation) were used. RESULTS: Stone removal was achieved in a single session in all patients (100%). Most procedures (73%) did not require an extended exploration time. There were no complications. Hyperamilasemia was detected in 18% of patients. CONCLUSIONS: Hydrostatic papillary dilatation with large balloons is a simple, effective, and safe technique for the removal of difficult stones located in the distal common bile duct. It does not add to exploration time, nor increases complications, and reduces the need for lithotripsy. Further studies are needed to define the usefulness of this technique.

Malignant gastrointestinal obstruction: endoscopic stenting versus surgical palliation.

BACKGROUND: Malignant gastrointestinal obstruction is a secondary complication of cancers in an advanced state. Treatment has consisted of gastrojejunostomy. However, the endoscopic placement of metallic stents has provided positive results. This study aimed to compare the efficiency of both therapeutic options. METHODS: A total of 41 patients with gastrointestinal obstruction caused by inoperable neoplasm were treated endoscopically with enteral stent (24 patients) or gastrojejunostomy (17 patients). RESULTS: In the endoscopic group (EG) 24 patients (100%) achieved efficient gastric emptying, as compared with 82.3% in the surgical group (SG). The difference was not significant. The average time for initiating oral food tolerance was 2.4 days for the EG and 5 days for the SG (p < 0.001). The average inpatient time was 7.1 days for the EG and 11.5 days for the SG (p < 0.001). Mortality at 30 days was lower in the EG (16.6%) than in the SG (29.4%) (p < 0.05). The survival time was 20 weeks for the EG and 21.6 weeks for the SG. The difference was not significant. The rate of complications was 4% in the (EG) and 17.6% in the (SG), with the difference was not significant. CONCLUSION: Endoscopic treatment of malignant gastrointestinal obstruction provides an adequate palliation of the symptoms. It is less invasive, avoids the morbidity associated with open gastrojejunostomy, and achieves a faster start to oral food and a shorter hospital stay, leading to a higher quality of life.

Laparoscopic treatment of two patients with omental infarction mimicking acute appendicitis.

BACKGROUND: Omental infarction is a rare entity that usually causes symptoms similar to those of appendicitis. Ultrasound or computerized tomography scan can diagnose omental infarction preoperatively. METHODS: We treated two patients with omental infarction by performing a laparoscopic omentectomy in each one. RESULTS: The pathology verified the operative diagnosis, and both patients were discharged home on the first postoperative day. CONCLUSION: Omental infarction can be accurately diagnosed and safely treated with laparoscopy. Key Words: Laparoscopy, Omental infarction, Acute abdominal pain.

A three-dimensional virtual model of the head generated from digitalized CT or MR images for anatomical-radiological and neurosurgical evaluations.

A computer-generated virtual model has been developed that reconstructs the head in three dimensions from digitalized images obtained with magnetic resonance and computerized tomography. Through programming and the use of commercial graphic animation software, we have developed the whole process of the rotation of the head on different spatial planes. The procedure permits multidirectional anatomical sections to be made on the structure of the head, providing a true dynamic and user-friendly anatomical-radiological atlas. The system serves as a virtual model for the localization of an ideal surgical approach to any lesion thus avoiding possible neurological lesions.

C282Y and H63D mutations of the haemochromatosis gene in patients with iron overload.

OBJECTIVE: To determine the relevance of C282Y and H63D mutations of HEF gene in patients with iron overload. PATIENTS AND METHODS: Patients with iron overload referred to our Liver Unit were included in the study. The association of mutations to different diagnosis and their impact on the severity of the hepatopathy were explored. Sensitivity, specificity and positive and negative predictive values of mutations for the diagnosis of haemochromatosis were determined. RESULTS: The study included 78 patients with iron overload. The control group included 21 patients of similar age and sex ratio without iron overload nor hepatopathy. Twenty three patients had haemochromatosis, 22 alcoholic liver disease and 33 other diseases unrelated to iron metabolism. Seventy three per cent of patients with haemochromatosis were homozygous for the C282Y mutation. All the C282Y homozygous subjects had also haemochromatosis. Fifty three per cent of patients with alcoholic hepatopathy had some kind of mutation. This has been also observed in 70% of patients with iron-unrelated diseases. Such percentage was significantly greater than in the control group (24% with H63D mutation). C282Y homozygosity in patients with iron overload had a sensitivity of 73.9%, a specificity of 100%, a positive predictive value of 100% and a negative predictive value of 89.6%. CONCLUSIONS: In our population, as in all the Western countries, haemochromatosis is mainly associated to homozygous C282Y mutation. The high frequency of mutations in patients with iron overload and without haemochromatosis suggests the involvement of such mutations in iron overload.

[Gastric pneumatosis]. / Neumatosis gástrica.

Gastric pneumatosis is an infrequent entity. The clinical course may oscillate from an asymptomatic or mild condition (gastric emphysema) to a severe disorder with high mortality (emphysematous gastritis). Diagnosis with imaging techniques is based on radiological evidence of air in the gastric wall.

[Helical CT compared to ERCP in obstructive biliary pathology]. / TC helicoidal frente a CPRE en la patología biliar obstructiva.

BACKGROUND: Endoscopic retrograde cholangiopancreatography (ERCP) is the examination of choice in the diagnosis of biliary tract pathology although newer, less invasive techniques with high diagnostic sensitivity should be evaluated. The aim of this study was to evaluate the diagnostic efficacy of helical computed tomography (CT) in bile duct obstruction, particularly in choledocholithiasis. PATIENTS AND METHODS: Forty-four patients with suspected bile duct obstruction were prospectively evaluated. Helical TC was carried out 12 hours before ERCP and patients were grouped according to risk of choledocholithiasis. RESULTS: Choledocholithiasis was found in 20 patients (45.4%). Helical TC identified this pathology in 17 and correctly ruled it out in 18 of 24 patients (S: 85%, E: 75%, positive predictive value 74%, negative predictive value 85.7%. Of the patients with choledocholithiasis, bile duct dilatation was found in 18. Helical TC correctly diagnosed this pathology in 16 of the 18 patients (88.8%). Helical TC correctly diagnosed one of two patients (50%) with choledocholithiasis and normal bile ducts. CONCLUSIONS: Helical TC is effective in the diagnosis of choledocholithiasis but is not sufficiently accurate to be used in the screening of this entity.

[Dilatation of the papilla of Vater in the treatment of choledocholithiasis in selected patients]. / Dilatación de la papila de Vater en el tratamiento de la coledocolitiasis en pacientes seleccionados.

OBJECTIVE: To prospectively analyze the results obtained with papillary balloon dilatation (PBD) in the treatment of common bile duct stones in patients at risk of complications if endoscopic sphincterotomy (ES) were performed. PATIENTS AND METHOD: Thirty-three patients were included between January 2001 and June 2003 (mean age 76.2 years). The criteria for PBD were: choledocholithiasis < or =10 mm in patients with peripapillary diverticula, hemostatic alterations, Billroth-II, and preservation of Oddi's sphincter. In 79% of the patients sedation was performed by an anesthetist. PBD was performed with a balloon catheter dilator with a diameter of 8 or 10 mm for 2 minutes. The efficacy and duration of the procedure as well as complications at 30 days and patient satisfaction were evaluated. RESULTS: Stone extraction was achieved in all patients (100%). The mean duration of the procedure was 26 minutes. Two patients (6%) presented mild pancreatitis. Serum amylase was elevated in 16 patients (48%): > or =3 times (post-PBD hyperamylasemia) in 11 (33%). The procedure caused no discomfort in 25/26 (96%) of the patients sedated by an anesthetist vs 2/5 patients (49%) who underwent endoscopic sedation. CONCLUSIONS: PBD is an effective and simple therapeutic option in the treatment of small common bile duct stones (< or =10 mm) and in patients at high risk. The duration of endoscopic retrograde cholangiopancreatography is not prolonged. Complications are infrequent (6%) and mild. Post-PBD hyperamylasemia is frequent and generally without clinical importance. Sedation by an anesthetist improves patient satisfaction.

[Toxic hepatitis caused by nimesulide, presentation of a new case and review of the literature]. / Hepatitis tóxica por nimesulida, presentación de un nuevo caso y revisión de la bibliografía.

Nimesulide is a potent non-steroidal anti-inflammatory drug. It is a new, selective cyclooxygenase-2 inhibitor with few adverse effects on the gastrointestinal system. We present a case of hepatotoxicity in which other possible causes of liver damage were excluded. A biochemical pattern of cholestasis was predominant. Evolution was favorable after the drug was stopped and enzymatic alterations progressively returned to normal. The cases reported to date are reviewed. The precise mechanism by which nimesulide produces liver damage is not known but it is probably caused by an idiosyncratic reaction. Because of the severity of the hepatitis described in some cases, treatment should be stopped when liver dysfunction is detected and the patients should be closely monitored.