Period of irreversible therapeutic intervention during sepsis correlates with phase of innate immune dysfunction.

Sepsis is a major health problem in the United States with high incidence and elevated patient care cost. Using an animal model of sepsis, cecum ligation, and puncture, we observed that mice became rapidly hypothermic reaching a threshold temperature of 28 °C within 5-10 h after initiation of the insult, resulting in a reliable predictor of mortality, which occurred within 30-72 h of the initial procedure. We also observed that the inflammatory gene expression in lung and liver developed early within 1-2 h of the insult, reaching maximum levels at 6 h, followed by a decline, approaching basal conditions within 20 h. This decrease in inflammatory gene expression at 20 h after cecal ligation and puncture was not due to resolution of the insult but rather was an immune dysfunction stage that was demonstrated by the inability of the animal to respond to a secondary external inflammatory stimulus. Removal of the injury source, ligated cecum, within 6 h of the initial insult resulted in increased survival, but not after 20 h of cecal ligation and puncture. We concluded that the therapeutic window for resolving sepsis is early after the initial insult and coincides with a stage of hyperinflammation that is followed by a condition of innate immune dysfunction in which reversion of the outcome is no longer possible.

[Complications in diagnostic and therapeutic endoscopic cholangiopancreatography. Prospective study]. / Complicaciones en colangiopancreatografía endoscópica diagnóstica y terapéutica. Estudio prospectivo.

BACKGROUND: Studies of ERCP-related morbidity seldom include a sufficient patient follow-up. The complication rate is variable. AIM: To characterize and to evaluate the frequency of complications in patients after Diagnostic and Therapeutic ERCP. PATIENTS AND METHODS: All patients undergoing ERCP during a 2-year period were included in this prospective study. Complications were assessed at time of ERCP and by personal or telephone contact at 1st, 7, 14 and 30-days after the procedure. RESULTS: A total of 897 ERCPs were included in the analysis, of which 93.9% were therapeutic procedures. 640 were female with age of 49.68 (+/-18.59) and 257 male with age 58.80 (+/-16.67). The 30-day complications rate was 3.19%; the procedure-related mortality rate was 0.11%. Mild hemorrhage occurred in 1.48% and moderate hemorrhage in 0.11%. Post-ERCP pancreatitis occurred in 0.79% and duodenal perforation in 0.45%. The 30-day procedure-no related mortality was 1.14%. CONCLUSION: This prospective study confirms the complications rate of ERCP including therapeutic procedures is low in our experience.

Increased insulin levels independent of gestational overweight in women with preeclampsia.

BACKGROUND: The etiology of preeclampsia is unknown. It is controversial whether insulin resistance (IR) is present in preeclamptic patients, and it is unclear if hyperinsulinemia is dependent upon being overweight during pregnancy or on preeclampsia per se. METHODS: We performed a cross-sectional study in 140 pregnant patients and compared serum insulin concentrations. These women, 18-40 years old, were classified into four groups: 1) overweight patients with mild preeclampsia (n = 21), 2) overweight patients without preeclampsia (n = 23), 3) non-overweight patients with mild preeclampsia (n = 48), and 4) non-overweight patients without preeclampsia (n = 48). An oral glucose tolerance test (OGTT) was performed in all patients between 29 and 40 weeks of gestation. Blood samples were taken at 0, 60, 120 and 180 min after 100 g oral glucose to measure serum glucose and insulin levels. RESULTS: Basal and postload OGTT glucose values and basal insulin levels were similar in all groups. However, insulin levels at 60, 120 and 180 min were significantly higher (p = 0.009, p = 0.009, p = 0.046, respectively) in overweight patients with preeclampsia than in those without. Insulin levels at 60 and 180 min were also higher (p = 0.024, p = 0.023, respectively) in non-overweight patients with preeclampsia than in those without. The area under the curve (AUC) for glucose was not significantly different between both groups of overweight patients or between non-overweight patients with or without preeclampsia. In contrast, the AUC of insulin was significantly higher in preeclamptic patients in both overweight (p = 0.004) and non-overweight (p = 0.024) groups than in overweight and non-overweight groups without preeclampsia, respectively. CONCLUSIONS: Increased insulin levels observed in mild preeclamptic patients were independent of overweight-related hyperinsulinemia.

[Endoscopic mechanical lithotripsy in choledocholithiasis of difficult extraction handling]. / Litotripsia mecánica vía endoscópica en el manejo de coledocolitiasis de difícil extracción.

BACKGROUND: Large stones are difficult to remove in block through a small papillotomy, a relative narrowed distal bile duct, periampular diverticula or in those who have undergone only balloon sphincteroplasty prior to stone extraction. Extending the papillotomy is not always possible, and may carry, an increased risk of bleeding and perforation. Lithotripsy facilitates stone extraction and clearance of the common bile duct. AIM: This study investigated the predictors of successful or unsuccessful mechanical lithotripsy. PATIENTS AND METHODS: A series of 100 consecutive patients who underwent mechanical lithotripsy was evaluated retrospectively and a large number of variables tested for their association with successful outcome. RESULTS: The procedure was safe (morbidity rate 4.4%) and effective (68% stone clearance rate). The statistic analysis showed that lithotripter type was the only outcome predictor (p = 0.044). The other factors analyzed were not statistically significance. CONCLUSION: Mechanical lithotripsy is successful in about 70% of patients with difficult bile duct stones. The only significant factor that predicts failure of mechanical lithotripsy is lithotripter type.

[Endoscopic treatment of idiopathic recurrent chronic pancreatitis in children and adolescents]. / Tratamiento endoscópico de la pancreatitis crónica idiopática recidivante en niños y adolescentes.

BACKGROUND: The use of diagnostic and therapeutic endoscopic retrograde cholangiopancreatography (ERCP) is increasing in the management of pancreatobiliary diseases in children. AIM: Report our experience with ERCP in the management of chronic recurrent idiopathic pancreatitis in children. PATIENTS AND METHODS: Over a 12-year period we performed 56 ERCP for the treatment of chronic recurrent idiopathic pancreatitis in 20 patients which clinical status was assessed six months before the first ERCP and six months after the last ERCP. RESULTS: There were 12 girls and eight boys with a mean age of 11.36 in girls (range 4-17) and 12.77 in boys (range 9-16). Abdominal pain was the main presenting symptoms with hiperamylasemia. Clinical diagnoses included two pancreas divisum, chronic calcifying pancreatitis in two and 16 non-calcifying chronic pancreatitis with dilated and irregular pancreatic duct. The mean follow-up was 24 months. Twenty patients underwent a total of 56 therapeutic ERCP procedures included pancreatic and biliary sphincterotomy, pancreatic endoprosthesis placement, stone extraction and hydrostatic or mechanical dilation in pancreatic strictures. There were four complications of 56 procedures (7.14%), both being mild pancreatitis after endoprosthesis placement (n = 1), pancreatic sphincterotomy (n = 1) and hydrostatic dilation with endoprosthesis placement (n = 2). There were no deaths. There was a significant reduction in frequency and severity of pain after intervention (p < 0.001). One patient with calcifying pancreatitis required surgical intervention. CONCLUSION: ERCP is safety and useful diagnostic and therapeutic procedure in children and adolescents with chronic recurrent idiopathic pancreatitis.

[Transpapillary and transmural drainage of pancreatic pseudocysts]. / Drenaje de pseudoquistes pancreáticos por vía transpapilar o transmural.

BACKGROUND: Endoscopic treatment of pancreatic pseudocysts via cystoenterostomy or transpapillary stenting has been recognized as a successful treatment options in carefully selected patients. Transpapillary stenting is an option in patients with pancreatic pseudocysts directly communicating with the main duct. AIM: The aim of this study was to assess the safety and usefulness of transpapillary pancreatic endoprosthesis and transmural drainage in the treatment of symptomatic pancreatic pseudocysts. PATIENTS AND METHODS: After preliminary endoscopic retrograde pancreatography (ERCP) in 22 patients, transpapillary drainage was attempted in 8 patients with pseudocysts that communicated with the main pancreatic duct, transmural drainage of pseudocysts in contact with the stomach or duodenal wall was attempted in 12 patients and 2 patients were selected for combined transpapillary and transmural drainage. RESULTS: Endoscopic drainage was technically successful in 18 patients (81.8%) of whom 16 had complete pseudocyst resolution. Complications occurred in 9% and included bleeding (n = 1) after transmural drainage, and pancreatitis (n = 1) after transpapillary drainage. Mean follow-up was 12 months (range, 2 to 21); pseudocysts recurred in 2 patients (11%), whom required surgical intervention. No mortality was observed. CONCLUSION: Both transpapillary and transmural pseudocysts drainage are highly effective in patients with pseudocysts demonstrating suitable anatomy for these endoscopic techniques.

[Self-expandable metallic biliary endoprosthesis in malignant obstructive jaundice]. / Endoprótesis metálicas biliares autoexpandibles en ictericia obstructiva maligna.

BACKGROUND: Implantation of metallic stents for malignant biliary strictures has been recognized to be effective alternatives. AIM: To show our experience in metallic stents for palliation of malignant biliary strictures. PATIENTS AND METHODS: Seventy three patients (38 males, 35 females, mean age 64.26) with malignant biliary strictures have been treated by implantation of metallic stents. Causes of obstruction were pancreatic carcinoma (23/73, 31.5%), bile duct carcinoma (31/73, 42.5%), carcinoma of ampula of Vater (11/73, 15%) and Klatskin tumor (3/73, 4.1%). RESULTS: Endoscopic procedure was successful in all cases. Neither procedure-related morbidity nor mortality was observed. Life surviving curve was 9 months and showed significant difference (p < 0.0071) in patients with carcinoma of ampula of Vater. CONCLUSION: Self-expanding metal endoprosthesis is a recognized method of palliation in malignant biliary obstruction. It efficiently relieves jaundice and generally improves comfort and nutritional status during the patient's remaining lifetime. The metallic stents are advantageous in patients surviving 6 months or less.

Relationship between insulin resistance and gonadotropin dissociation in obese and nonobese women with polycystic ovary syndrome.

OBJECTIVE: To test the interdependence between insulin resistance (IR) and gonadotropin dissociation (GD) in polycystic ovary syndrome (PCOS). DESIGN: Cross-sectional prospective study. SETTING: Clinical research center. PATIENT(S): Thirty-two PCOS patients aged 19-34 years; 16 obese (BMI > or = 27) and 16 nonobese (BMI < 27). INTERVENTION(S): A 75-g oral glucose tolerance test (OGTT) and a 100-microg i.v. GnRH test were performed on different days. Blood was taken at 0, 30, 60, 90, 120, and 180 minutes in each test. Serum glucose, insulin, LH, and FSH were measured. MAIN OUTCOME MEASURE(S): Area under the curve was calculated for glucose, insulin, and glucose-to-insulin ratio (GIR), and for LH, FSH, and LH-FSH ratio. RESULT(S): Glucose, insulin, and GIR were not modified significantly during the GnRH test, nor LH, FSH and LH-FSH ratio throughout the OGTT. There were no significant differences in GIR response of patients with and without GD, nor in LH-FSH ratio of patients with and without IR, after OGTT and GnRH test. However, obese patients with IR had a significantly larger (P<.04) area under the curve for LH-FSH ratio than those without IR after GnRH test, but not after OGTT test. CONCLUSION(S): Insulin resistance and GD do not appear to be related events in PCOS, suggesting that each one might be determined by different genetic disorders. However, IR can affect GD after chronic stimulation in obese patients.

[Conservative management of duodenal perforation following endoscopic sphincterotomy of papilla of Vater]. / Manejo conservador de la perforación duodenal secundaria a esfinterotomía endoscópica (EE) de la papila de vater.

BACKGROUND: Endoscopic sphincterotomy (ES) is an established procedure in treatment of diseases of the biliary tract; management of serious complications such as duodenal perforation remains controversial. Because mortality is high if sepsis is inadequately treated by no use of operative means, many surgeons advocate routine operative repair and drainage upon diagnosis. In surveys of large experiences, however, the majority patients initially were treated non-surgically, and the majority recovered. OBJECTIVE: To evaluate our experience with non-surgical management in patients with duodenal perforation after ES. PATIENTS AND METHODS: Retrospective chart review from January 1991 to December 2000 identified 12 instances of duodenal perforation. We reviewed endoscopic cholangiopancreatography (ERCP) findings, diagnostic methods, time to diagnosis, methods of management, length of patient stay, and outcome. RESULTS: Twelve patients with diagnosis of choledocholithiasis (5) papillary stenoses (4) and carcinoma of pancreas (3) had duodenal perforation among 1,510 ES performed (0.79%). In all cases during ES, retroperitoneal air on fluoroscopic examinations was observed and diagnosis was made. One patient was managed initially by surgery and death occurred due to pulmonary complications. Eleven patients were treated conservatively with nasogastric aspiration, none by mouth intravenous fluids, antibiotics, and somatostatin analog without mortality. Median length of stay was 6.7 days. CONCLUSIONS: Duodenal perforation after ES may be treated conservatively with success if identified during ES or early stage. Early diagnosis of duodenal perforation is essential for optimum outcome.

[Selection criteria for endoscopic cholangiopancreatography before laparoscopic cholecystectomy]. / Criterios de selección para la realización de colangiopancreatografía endoscópica previo a colecistectomía laparoscópica.

BACKGROUND: The unexpected detection of stones in common bile duct during laparoscopic cholecystectomy is a concern for laparoscopic surgeons. Immediate laparoscopic removal may not always be feasible due to inadequate operating facilities, surgeons, and assistants. Attempts have been made to identify clinical and biochemical predictor of common bile duct stones, the results of which have not been consistent. OBJECTIVE: The aim of this study was to define patients with risk for common bile duct stones based on history, abdominal ultrasound, and biochemical derangements, as well as to evaluate the role of endoscopic retrograde cholangiopancreatography (ERCP) and endoscopic sphincterotomy (ES) for diagnosis and duct clearance if necessary. PATIENTS AND METHODS: This is a prospective cross sectional analysis of 82 patients (66 females and 16 males) with gallstones on whom were performed clinical examination, laboratory test, and abdominal ultrasound to identify predictors of common bile duct stones. Preoperative ERCP was carried out and patients underwent ES for stone retrieval. RESULTS: Clinical evidence of jaundice or pancreatitis, elevated serum amylase, and ultrasonographic evidence of biliary tree dilation or common bile duct stone were considered risk factors. In 45 patients, common bile duct stones were identified at preoperative ERCP patients underwent ES, and stones were removed with 100% success. All patients were scheduled for laparoscopic cholecystectomy 24 h later. There was no mortality in this series. CONCLUSIONS: Clinical evidence of jaundice or pancreatitis, elevation of serum amylase and dilated common bile duct or presence of common bile duct stones were considered risk factors for choledocholithiasis. Use of such a model rather than individual criteria would improve selection of patients for preoperative ERCP, optimizing its role in the laparoscopic era.

[Postoperative biliary stenosis: long-term results of endoscopic treatment]. / Estenosis biliar postoperatoria: resultados del tratamiento endoscópico a largo plazo.

BACKGROUND: Endoscopic stent placement is often the initial therapy in symptomatic patients with postoperative strictures because patients are usually diagnosed at the time of ERCP. Although stent insertion rapidly relieves symptoms of biliary obstruction and can even be live-saving in patients with cholangitis, all stents eventually clog, necessitating regular stent changes every 3 to 4 months. Results from several groups suggested that placing multiple stents for months to years could dilate the stricture permanently and thus also treat patients with postoperative biliary strictures palliatively. OBJECTIVE: The outcome of temporary biliary stent placement for postoperative bile duct stenosis was retrospectively evaluated. This is a review of our experience with endoscopic dilation and stent placement in postoperative biliary strictures. PATIENTS AND METHODS: Thirty patients with postoperative strictures diagnosed with ERCP were treated with long-term endoscopic stent placement. One 10 Fr stent was placed at first whenever possible, and stents were exchanged every 3 months for a total of 18 months as median. RESULTS: Four men and 26 women with mean age 42 years (range 16-69 years), and laparoscopic cholecystectomy in six and cholecystectomy (open procedure) in 24; surgical history was reviewed retrospectively. Five patients were lost to follow-up and 25 patients were followed for a median of 18 months. In all 25 patients, previous to stent placement, 8.5 or 10 Fr, a mechanical or hydrostatic dilation was necessary. Stents were exchanged every 3 months to avoid cholangitis caused by clogging. Three 10 Fr stents were inserted in one patient, two 10 Fr stents in 14 patients, one 10 Fr and one 8.5 Fr stent in nine patients, and in one patient, one 10 Fr stent. Six patients (24%) developed recurrent stenosis and required surgery. CONCLUSIONS: Endoscopic treatment with mechanical or hydrostatic dilation and stent insertion may improve long-term results for patients with postoperative biliary strictures.

[Endoscopic sphincterotomy as an out-patient procedure: is it safe?]. / Esfinterotomía endoscópica (EE) como procedimiento ambulatorio: es seguro?

BACKGROUND: Patients have been routinely admitted for observation for potential complications after therapeutic ERCP; however, in this era of cost containment it may be more cost-effective to perform these procedures on an out-patient basis. AIM: The purpose of this study was to determine safety and complication rates of endoscopic sphincterotomy in out-patients. MATERIALS AND PATIENTS: Over an 11-month period, 124 consecutive patient undergoing endoscopic sphincterotomy for biliary and pancreatic disease were enrolled in a prospective and randomized manner. Sixty patients (Group A) were observed 1-3 h post procedure before discharge with follow-up at 5 days. The other 62 patients (Group B) were admitted for observation. The statistical method was Fisher test and chi 2. RESULTS: Successful endoscopic sphincterotomy was achieved in 98.3% (122/124) of patients. Eighty five patients were female and 37 male. There were 60 outpatients and 62 in-patients; endoscopic sphincterotomy was performed by choledocholithiasis in 59.9% (70 cases) and papillary stenoses in 16.4% (20 cases). Complication rates were 3.27% (four patients): three pancreatitis and one bleeding. There were three in-patients and one outpatient (p. 313). We reduce costs $324,120.00 M.N. (Mexican pesos) without compromising patient safety and outcome. CONCLUSIONS: Endoscopic sphincterotomy may be performed safely on an outpatient basis, realizing significant savings in costs.

[Endoscopic management of choledocholithiasis during pregnancy]. / Manejo endoscópico de la coledocolitiasis durante el embarazo.

BACKGROUND: Gallstones and extrahepatic biliary obstruction is a difficult management problem during pregnancy. Choledocholithiasis may cause cholangitis or pancreatitis, potentially life-threatening conditions. As surgery may result in significant fetal mortality when performed on these patients. Endoscopic retrograde cholangiopancreatography (ERCP) and endoscopic sphincterotomy (ES) are preferred and could be performed safely in pregnant women provided suitable precautions are taken to minimize exposure to radiation. OBJECTIVE: To show our experience in ERCP and ES for symptomatic choledocholithiasis during pregnancy. MATERIAL AND PATIENTS: We described our experience in seven young women (mean age, 27.4 years) who presented with symptoms caused by choledocholithiasis, one in first trimester of pregnancy, four in second trimester, and two in third month. All had obstructive jaundice corroborated by abnormal liver function test and dilation of biliary tree on abdominal ultrasound. RESULTS: All had ERCP, ES, and stone extraction without complication and went on to deliver healthy babies at term. A lead apron was positioned over the abdomen of the mother to shield the fetus during roentgenographic fluoroscopy. Mean fluoroscopy time was 26 (range, 5-60 sec). CONCLUSIONS: Endoscopic management should be considered in women presenting with choledocholithiasis during pregnancy.

[Endoscopic diagnosis and treatment of non-traumatic bilhemia. A case report]. / Diagnóstico endoscópico y tratamiento de bilhemia de origen no traumática. Reporte de un caso.

Biliovascular fistulas are abnormal communications with two types of clinical manifestations depending on type of flow in fistulous tract: 1) hemorrhage into biliary tract known as hemobilia, or 2) bile into bloodstream, known as bilhemia. Historically, this complication has been treated with surgery; however, technological progress at present allows treatment with intervention techniques without surgery being mandatory. In 1975, Clemens and Wittrin introduced the term bilhemia, a rare complication of hepatic damage producing excessively high levels of serum bilirubin and moderate rise of hepatic enzymes secondary to post-traumatic intrahepatic biliovenous fistula. Although this pathology is rare, it is considered dangerous; of 50 patients reported in the literature, 25 died due to this problem. The main purpose of treatment is to release tract obstruction by endoscopic sphincterotomy of Vater's papilla or, if the process is localized in proximal areas of biliary tract, through percutaneous biliary drainage or preferably nasobiliary drainage with continuous suction. This procedure can at least produce temporary relief and occasionally fistula closure. A longer effect can be achieved with biliary stent placement. We describe what is, to our knowledge, the first case of diagnosis and successful treatment of non-traumatic bilhemia with endoscopic sphincterotomy and nasobiliary catheter placement.

Elevated expression of IL-23/IL-17 pathway-related mediators correlates with exacerbation of pulmonary inflammation during polymicrobial sepsis.

Sepsis is a leading cause of death in the United States, claiming more than 215,000 lives every year. A primary condition observed in septic patients is the incidence of acute respiratory distress syndrome, which is characterized by the infiltration of neutrophils into the lung. Prior studies have shown differences in pulmonary neutrophil accumulation in C57BL/6J (B6) and A/J mice after endotoxic and septic shock. However, the mechanism by which neutrophils accumulate in the lung after polymicrobial sepsis induced by cecal ligation and puncture still remains to be fully elucidated. We show in this study that lung inflammation, characterized by neutrophil infiltration and expression of inflammatory cytokines, was aggravated in B6 as compared with A/J mice and correlated with a high expression of p19, the interleukin 23 (IL-23)-specific subunit. Furthermore, lipopolysaccharide stimulation of B6- and A/J-derived macrophages, one of the main producers of IL-23 and IL-12, revealed that B6 mice favored the production of IL-23, whereas A/J-derived macrophages expressed higher levels of IL-12. In addition, expression of IL-17, known to be upregulated by IL-23, was also more elevated in the lung of B6 mice when compared with that in the lung of A/J mice. In contrast, pulmonary expression of interferon-γ was much more pronounced in A/J than that in B6 mice, which was most likely a result of a higher production of IL-12. The expression of the IL-17-dependent neutrophil recruitment factors chemokine (CXC motif) ligand 2 and granulocyte colony-stimulating factor was also higher in B6 mice. Altogether, these results suggest that increased activation of the IL-23/IL-17 pathway has detrimental effects on sepsis-induced lung inflammation, whereas activation of the IL-12/interferon-γ pathway may lead, in contrast, to less pronounced inflammatory events. These two pathways may become possible therapeutic targets for the treatment of sepsis-induced acute respiratory distress syndrome.

Obesity differentially affects serum levels of androstenedione and testosterone in polycystic ovary syndrome.

OBJECTIVE: To assess androstenedione (A) and T levels in obese and nonobese patients with polycystic ovary syndrome (PCOS) after GnRH and oral glucose tolerance tests (OGTT). DESIGN: Cross sectional study. SETTING: Clinical research center. PATIENT(S): Thirty patients with PCOS, of whom 15 were obese and 15 were nonobese, and 7 women without PCOS were included in the study. INTERVENTION(S): The GnRH test and OGTT were performed in all subjects. MAIN OUTCOME MEASURE(S): Basal and stimulated levels of LH, FSH, insulin, A, and total T were measured. Areas under the curve (AUCs) and AUC change after stimulation for these hormones were calculated. RESULT(S): The basal T levels were significantly higher in obese than in nonobese patients with PCOS. In contrast, the basal levels of A were similar in obese and nonobese patients with PCOS. The T(AUC) after GnRH was significantly greater in obese than in nonobese patients with PCOS but was not significantly different after OGTT. The A(AUC) after GnRH and OGTT was significantly greater in nonobese than in obese patients with PCOS. However, there were no significant differences in T(AUC) and A(AUC) changes after GnRH and OGTT. CONCLUSION(S): A different pattern in the levels of T and A with respect to obesity in PCOS was observed, suggesting a shift in ovarian enzymatic function.

Incidencia y relación de esfinterotomía endoscópica en la migración proximal de prótesis biliares / Incidence and relationship of endoscopic sphincterotomy in proximal biliary stent migrations

Antecedentes: las endoprótesis son frecuentemente utilizadas para el tratamiento de patologías de la vía biliar, sin embargo la frecuencia y los factores potenciales de riesgo para determinar su migración proximal, permanecen poco estudiados. Objetivo: analizar la incidencia de migración proximal de endoprótesis biliares, así como su relación con la práctica de esfinterotomía endoscópica (EE) en un Hospital de Concentración considerado como centro endoscópico de referencia. Pacientes, método y resultados: de enero de 1995 a diciembre de 1998, en nuestro Departamento, se valoraron 410 prótesis biliares instaladas por diversas patologías de origen benigno o maligno. En 272 casos se realizó EE y en los 138 restantes se colocaron sin necesidad de la EE. Se observó migración proximal global en 4.4 por ciento. Las estenosis iatrogénicas en protocolo de dilatación se asociaron significativamente con migración proximal. La relación con EE no fue estadísticamente significativa. Conclusiones: nuestros resultados indican que las estenosis iatrogénicas son un factor de riesgo que se asocian con migración proximal de prótesis biliares, mientras que la EE no tiene significancia estadística para tal evento.

Heterogeneity of late-onset adrenal 3ß-ol-hidroxysteroid dehydrogenase deficiency in patients with hirsutism and polycystic ovaries

Nine women clinical features of polycystic ovarian syndrome (PCOS) were studied in order to establish the differential diagnosis with late-onset adrenal hyperplasia (LOAH). Their hirsutism was classified as moderate in five patients and severe in the remainig four cases. All patients had bilateral polycystic ovarian enlargement by ultrasound examination. As a control group five women with normal ovarian function without hirsutism were submitted to the same protocol of study. The patients studied as well as the women of the control group had basal serum determinations of pregnenolone (P5), 17 hydroxypregnenolone (17-OHP5), dehydroepiandrosterone (DHEA), pregesterone (P), 17-hydroxyprogesterone (17-OHP), androstenedione (A), testosterone and cortisol by radioimmunoassay techniques. The basal serum levels of androgens showed no correlation with the severity of hirsutism or with the ultrasound finding. An adrenal stimulation with synthetic adrenocorticotropic hormone (ACTH) to all women performed in order to assess their adrenal responsiveness. The analysis of the ratios between delta 5 and delta 4 steroids demonstrated a partial enzymatic blockade at the level of 3ß-o1-hydroxysteroid dehydrogenase (3-HDS) in three patients. The blockade was particulary in the conversion of P5 to P and 17-OHP5 to 17- OHP. The lack of delta 4 steroid secretion in the presence of normal increase of delta 5 precursors following ACTH was noted. These findings confirm the clinical use of the ACTH stimulation test to reveal the presence of enzymatic alterations in adrenal steroidogenesis in some patients previously considered to have PCOS. Since it was demonstrated that the conversion steps were affected in variable degrees, the presence of different isoenzymes of 3-HSD is suggested

Colangiopancreatografía endoscópica diagnóstica y terapéutica en fuga biliar posterior a trasplante hepático. Reporte de dos casos / Diagnostic and therapeutic endoscopic cholangiopancreatography in post liver-transplantrelated biliary leak. Report of two cases

Antecedentes: en el ámbito de vía biliar, las estenosis anastomóticas y las fugas biliares son las complicaciones más frecuentes después del transplante de hígado, y son causas importantes de morbilidad, exploración quirúrgica y/o drenaje biliar. Objetivo: dar a conocer nuestra experiencia en el uso de colangiopancreatografía transendoscópica (CPE) en el diagnóstico y manejo de dos pacientes trasplantados de hígado que presentaron fuga biliar como complicación tardía. Pacientes-método y resultados: se presentan dos pacientes, un hombre y una mujer, con edades de 50 y 34 años respectivamente, con trasplante ortotópico de hígado que tardíamente desarrollan ascitis secundaria a fuga biliar confirmada por CPE y se someten a tratamiento endoscópico mediante esfinterotomía de papila de Vater y colocación de drenaje biliar interno, mediante endoprótesis tipo Amsterdam. Después de 20 semanas se retira la endoprótesis y se observa integridad de la vía biliar. Conclusiones: la CPE diagnóstica y terapéutica es de utilidad en la fuga biliar que se presenta como complicación en el paciente con trasplante ortotópico de hígado.

Colocación de endoprótesis biliares como procedimiento ambulatorio / lBiliary endoprosthesis placement as an outpatient procedure

Antecedentes: debido a las posibles complicaciones, la gran mayoría de los procedimientos terapéuticos de colangiopancreatografía endoscópica (CPE), se realiza en pacientes hospitalizados. Actualmente algunos departamentos de endoscopia los realizan en pacientes catalogados como ambulatorios con resultados satisfactorios. Objetivo: analizar la seguridad e índice de complicaciones en la colocación de endoprótesis biliares en pacientes ambulatorios y hospitalizados en un Hospital de Concentración considerado como centro endoscópico de referencia. Pacientes-método y resultados: de enero de 1998 a diciembre de 1999, se colocaron 140 endoprótesis biliares como método de drenaje en patología benigna o maligna de árbol biliar. El procedimiento se realizó en 72 pacientes externos en condiciones estables y en 68 pacientes hospitalizados. No existió diferencia significativa entre los grupos con relación a edad, sexo, necesidad de esfinterotomía endoscópica (EE) o tasa de complicaciones. Un paciente hospitalizado y cuatro externos presentaron complicaciones. No hubo mortalidad relacionada al procedimiento en ningún grupo. Conclusión: la colocación endoscópica de prótesis biliares con método de drenaje en patología benigna o maligna de la vía biliar puede realizarse con alto grado de seguridad y exitosamente en pacientes externos en condiciones estables. Esto reduce considerablemente los costos.