Esophageal stents in malignant and benign disorders.

Endoscopic stent placement is an effective palliative treatment for malignant dysphagia and fistula, leading to rapid symptom relief. However, recurrent dysphagia and other stent-related complications are common, for which reason continuously new design modifications are implemented. Although some of these changes facilitate stent placement, complications remain and occur at similar rates. Recently, stents have also been used in benign esophageal disorders. Covered stents have the ability to effectively seal esophageal perforations and leaks, reducing the need for invasive surgery. This benefit does not pertain to patients with refractory benign esophageal strictures, in whom stents have limited long-term effect and are associated with a high complication rate. The initial results of fully covered metal stents in refractory esophageal variceal bleeding are encouraging, but their definite role remains to be further elucidated. This review provides an overview of indications, techniques, and management of complications of stents in malignant and benign esophageal disease.

New developments in endoscopic treatment of chronic pancreatitis.

The aim of endoscopic therapy of chronic pancreatitis (CP) is to treat pain by draining the pancreatic duct or managing loco-regional complications. Recent decennia were characterized by continuous improvement of endoscopic techniques and devices, resulting in a better clinical outcome. Novel developments now also provide the opportunity to endoscopically treat refractory CP-related complications. Especially suboptimal surgical candidates could potentially benefit from these new developments, consequently avoiding invasive surgery. The use of fully covered self-expandable metal stents (SEMS) has been explored in pancreatic and CP-related biliary duct strictures, resistant to conventional treatment with plastic endoprotheses. Furthermore, endosonography-guided transmural drainage of the main pancreatic duct via duct-gastrostomy is an alternative treatment option in selected cases. Pancreatic pseudocysts represent an excellent indication for endoscopic therapy with some recent case series demonstrating effective drainage with the use of a fully covered SEMS. Although results of these new endoscopic developments are promising, high quality randomized trials are required to determine their definite role in the management of chronic pancreatitis.

Guilty as charged: unmeasured urinary anions in a case of pyroglutamic acidosis.

A patient developed an unexplained metabolic acidosis with the characteristics of renal tubular acidosis. By correcting the serum anion gap for hypoalbuminaemia and analysing the urinary anions and cations, the presence of unmeasured anions was revealed. The diagnosis of pyroglutamic acidosis, caused by a combination of flucloxacillin and acetaminophen, was established. Strategies for solving complex cases of metabolic acidosis are discussed.

Octreotide therapy in dumping syndrome: Analysis of long-term results.

BACKGROUND: Octreotide therapy is effective in controlling severe dumping symptoms during short-term follow-up but little is known about long-term results. AIM: To report on the long-term results of patients with severe dumping syndrome treated at the Leiden University Medical Center with subcutaneous or depot intramuscular (long-acting release) octreotide. METHODS: Follow-up of 34 patients with severe dumping syndrome refractory to other therapeutic measures treated between 1987 and 2005 with octreotide subcutaneous/long-acting release. At regular intervals symptoms, quality of life, weight, faecal fat excretion and gallstone formation were evaluated. RESULTS: All patients had excellent initial relief of symptoms during octreotide subcutaneous therapy. However, during follow-up 16 patients stopped therapy because of side effects (n = 9) or loss of efficacy (n = 7). Four patients died. Fourteen patients (41%) remain using octreotide (follow-up 93 +/- 15 months), seven are on octreotide subcutaneous and seven on octreotide long-acting release. Patients with severe dumping (both early and late) do better on subcutaneous than long-acting release despite the inconvenience of frequent injections. Dumping symptoms are reduced by 50% even in long-term users. Body weight continues to increase during therapy despite more pronounced steatorrhoea. CONCLUSION: The long-term the efficacy of octreotide is much less favourable compared with short-term treatment.