RESUMO
BACKGROUND AND AIMS: Postoperative esophageal strictures frequently recur. We assessed the efficacy of injecting triamcinolone after bougie dilation in comparison to dilation alone. METHODS: In a double-blind randomized fashion, 19 patients (68% male with mean age of 53-years old) with non-dilated esophagogastric complex strictures after esophagectomy with gastric pull-up were assigned to receive dilation alone (control) or 40 mg of triamcinolone at the borders of the wall lacerations caused by the bougienage in each dilation session during the study follow-up. Dysphagia and complications were assessed at 1, 2, and 6 months. Primary end-point was to be dysphagia-free. RESULTS: After 1 month of the beginning of therapy, 4 patients in the steroid group were without dysphagia, in comparison to 0 patient in the control group (P = 0.021). Six months after endoscopic therapy, 62% of the cases in the triamcinolone group versus none in the control group were dysphagia-free (P = 0.009). There was no perforation nor hemorrhage. CONCLUSIONS: Injecting triamcinolone after every dilation session next to or at the borders of the lacerations caused by the dilators, results in a significant improvement or resolution of dysphagia.
Assuntos
Dilatação/métodos , Estenose Esofágica/terapia , Esofagectomia/efeitos adversos , Junção Esofagogástrica/patologia , Glucocorticoides/administração & dosagem , Triancinolona/administração & dosagem , Adulto , Idoso , Transtornos de Deglutição/etiologia , Transtornos de Deglutição/terapia , Método Duplo-Cego , Estenose Esofágica/etiologia , Esofagoscopia , Feminino , Humanos , Injeções Intralesionais , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , RecidivaRESUMO
INTRODUCTION: The gold-standard treatment for autoimmune hepatitis (AIH) is a prednisone/azathioprine combination. However, subgroups of patients may be unresponsive to this treatment. The aim of this study is to evaluate the efficacy of second-line immunosuppressive therapies for AIH through a systematic review and meta-analysis in adult patients. PATIENTS AND METHODS: The systematic review was registered at the PROSPERO platform under number 42015019831. Databases MEDLINE (PubMed), Lilacs, Cochrane, and Scielo were searched. The keywords used were 'Hepatitis, Autoimmune' and descriptors terms (MeSH and DeCS). These terms were linked with each immunosuppressant of interest. RESULTS: A total of 1532 studies were identified. Of these, 1492 were excluded on the basis of title and abstract reading. Among the 40 studies retrieved for detailed full-text analysis, a total of 15 fulfilled the inclusion criteria for the analysis. The most studied second-line immunosuppressive was mycophenolate mofetil (MM). The mean reduction of aminotransferases was observed in 94.3% with tacrolimus/prednisone, 91.3% for cyclosporine/prednisone, 85.5% for budesonide, and 78.7% MM/prednisone. For MM/prednisone, the mean rate of histological remission was 88.6%, liver transplantation was indicated in 11.4%, and the mortality rate was 7.2%. Limitations were also present, such as the lack of randomized-controlled trials and prospective studies, the small number of patients, and the heterogeneity between remission criteria. CONCLUSION: This is the first systematic review and meta-analysis to compare the second-line imunossupressant therapy for AIH. The most studied second-line immunosuppressive is the MM, with a reasonable histological remission. The use of combined tacrolimus/prednisone was the most effective for the normalization of aminotransferases.
Assuntos
Ciclofosfamida/uso terapêutico , Hepatite Autoimune/tratamento farmacológico , Imunossupressores/uso terapêutico , Ácido Micofenólico/uso terapêutico , Tacrolimo/uso terapêutico , Anti-Inflamatórios/uso terapêutico , Budesonida/uso terapêutico , Quimioterapia Combinada , Hepatite Autoimune/patologia , Humanos , Prednisona/uso terapêutico , RetratamentoRESUMO
BACKGROUND AND STUDY AIMS: Buried bumper syndrome is an infrequent complication of percutaneous endoscopic gastrostomy (PEG) that can result in tube dysfunction, gastric perforation, bleeding, peritonitis or death. The aim of this study was to compare the efficacy of different PEG tube removal methods in the management of buried bumper syndrome in a large retrospective cohort. PATIENTS AND METHODS: From 2002 to 2013, 82 cases of buried bumper syndrome were identified from the databases of two endoscopy referral centers. We evaluated the interval between gastrostomy tube placement and diagnosis of buried bumper syndrome, type of treatment, success rate and complications. Four methods were analyzed: bougie, grasp, needle-knife and minimally invasive push method using a papillotome, which were selected based on the depth of the buried bumper. RESULTS: The buried bumper was cut free with a wire-guided papillotome in 35 patients (42.7â%) and with a needle-knife in 22 patients (26.8â%). It could be pushed into the stomach with a dilator without cutting in 10 patients (12.2â%), and was pulled into the stomach with a grasper in 12 patients (14.6â%). No adverse events (AEs) were registered in 70 cases (85.4â%). Bleeding occurred in 7 patients (31.8â%) after cutting with a needle-knife papillotome and in 1 patient (8.3â%) after grasping. No bleeding was recorded after using a standard papillotome or a bougie ( P â<â0.05). Ten of 22 patients (45.5â%) treated with the needle-knife had a serious AE and 1 patient died (4.5â%). CONCLUSIONS: We recommend that incomplete buried bumpers be removed with a bougie. In cases of complete buried bumper syndrome, the bumper should be cut with a wire-guided papillotome and pushed into the stomach.