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OBJECTIVES: Iatrogenic perforations are the most common cause of esophageal perforation. We present our experience mainly based on a non-operative treatment approach as well as long-term outcome in these patients. MATERIALS AND METHODS: Twenty-one patients were treated for iatrogenic esophageal perforation at Oslo University Hospital, Ullevål from February 2007 to March 2014. The etiology of perforation was dilation of benign stricture in eight patients, either dilation, stenting or stent removal in four with malignant stenosis, during diagnostic endoscopy in four, removal of foreign body in two and by other causes in three patients, respectively. After median 82 months, 10 patients alive (47.6%) were sent questionnaires about dysphagia, HRQoL and fatigue. RESULTS: Median age at time of treatment was 66 years. Median in-hospital stay and mortality were 10.5 days and 4.8%, respectively. Initial treatment in 15 patients (71.4%) was non-surgical of whom one needed delayed debridement for pleural empyema. Initial treatment in six patients (28.6%) was surgical of whom three needed delayed stenting. Altogether 14 patients (66.7%) were stented. Eight (57.1%) had restenting. Median number of stents used was 1 (1-4). The stents were removed after median 36 days. The perforations healed after 2.5 months. After median 82 months, the patients reported reduced HRQoL. There was no significant difference regarding level of dysphagia and fatigue. CONCLUSIONS: We report satisfactorily short-term and long-term results of iatrogenic esophageal perforations. Mortality was low and HRQoL was deteriorated. Dysphagia and fatigue were comparable to a reference population.
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Perfuração Esofágica/terapia , Esofagoscopia/efeitos adversos , Esôfago/patologia , Corpos Estranhos/terapia , Adulto , Idoso , Idoso de 80 Anos ou mais , Transtornos de Deglutição/etiologia , Remoção de Dispositivo/efeitos adversos , Drenagem/efeitos adversos , Perfuração Esofágica/etiologia , Perfuração Esofágica/mortalidade , Fadiga/etiologia , Feminino , Corpos Estranhos/fisiopatologia , Humanos , Doença Iatrogênica , Tempo de Internação , Masculino , Pessoa de Meia-Idade , Noruega , Qualidade de Vida , Índice de Gravidade de Doença , Stents/efeitos adversos , Resultado do TratamentoRESUMO
OBJECTIVES: Food bolus-induced esophageal perforation is much more seldom than iatrogenic and emetic esophageal rupture. We present results from a non-operative treatment approach as well as long-term functional outcome. MATERIALS AND METHODS: Medical records of 10 consecutive patients with food bolus-induced esophageal perforation from October 2007 to May 2015 were retrospectively registered in a database. Six patients developed perforation related to endoscopic removal of impacted food, and four during esophageal passage of bone, meat or bread. Treatment was sealing the perforation by stenting (n = 7) with (n = 4) or without (n = 3) chest tube drainage, chest tube drainage (n = 1), observation (n = 1) and gastroesophageal resection (n = 1) because of concomitant emesis of gastric effluent. After median 51 months nine patients reported about dysphagia, fatigue and health-related quality of life. RESULTS: Ten patients aged median 62.5 years (range 30-85) stayed in our hospital for 12 days (5-68 days). There was no treatment-related mortality. Nine patients were alive 63 months (18-126) after perforation. Five needed restenting (leakage, migration, impacted stent), two had drainage of a mediastinal abscess, one patient developed a transient esophagobronchial fistula. Dysphagia score was 0 (0-1). One patient developed dysphagia for some solid food. Scores for fatigue and HRQoL was similar to a Norwegian reference population. CONCLUSION: Treatment mainly with a non-operative approach occurred without mortality. Complications were handled by restenting and abscess drainage. Functional result for dysphagia was excellent. Interesting results on fatigue and HRQoL must be interpreted with caution because of a limited patient material.
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Perfuração Esofágica/terapia , Esôfago/patologia , Alimentos/efeitos adversos , Corpos Estranhos/terapia , Abscesso/etiologia , Abscesso/terapia , Adulto , Idoso , Idoso de 80 Anos ou mais , Transtornos de Deglutição/etiologia , Drenagem/efeitos adversos , Perfuração Esofágica/etiologia , Esofagoscopia , Feminino , Corpos Estranhos/fisiopatologia , Humanos , Masculino , Doenças do Mediastino/complicações , Pessoa de Meia-Idade , Noruega , Qualidade de Vida , Estudos Retrospectivos , Índice de Gravidade de Doença , Stents/efeitos adversos , Fístula Traqueoesofágica/etiologia , Resultado do TratamentoRESUMO
OBJECTIVES: Surgical repair has been the most common treatment of esophageal effort rupture (Boerhaave syndrome). Stent-induced sealing of the perforation has increasingly been used with promising results. We present our eight years´ experience with stent-based and organ-preserving treatment. MATERIALS AND METHODS: Medical records of 15 consecutive patients with Boerhaave syndrome from February 2007 to May 2015 were retrospectively registered in a database. Treatment was sealing of the perforation by stenting, chest tube drainage and débridement of the contaminated thorax. After median 25 months nine out of 10 patients responded to questions on fatigue and Ogilvie's dysphagia score. RESULTS: Fifteen patients, aged median 67.5 years (range 39-88), had a primary hospital stay of 20 days (range 1-80 days). Overall in-hospital mortality was 13%. Observation time was 44 months (range 0-87) and 10 patients were alive of August 2017. Ten patients (67%) needed surgical chest débridement. Five patients (33%) were restented for leakage, migration and for stent removal. Eleven patients (73%) had complications, which included pleural empyema (n = 4), fatal aortic bleeding, lung arterial bleeding, lung embolism, drain-induced lung laceration and respiratory failure. Dysphagia score was low (median 0.5) meaning that they were able to feed themselves. Total fatigue score (mean 14.6) was slightly increased (p = .05) compared with a reference population. CONCLUSIONS: The mortality rate after initial stenting of effort rupture seems to be comparable to standard surgical repair. Most patients required further intervention, either by restenting and/or surgical débridement. The functional result in these patients was satisfactory.
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Desbridamento , Perfuração Esofágica/terapia , Mortalidade Hospitalar , Doenças do Mediastino/terapia , Ruptura Espontânea/terapia , Stents , Adulto , Idoso , Idoso de 80 Anos ou mais , Bases de Dados como Assunto , Transtornos de Deglutição/etiologia , Drenagem/efeitos adversos , Perfuração Esofágica/mortalidade , Fadiga/etiologia , Feminino , Humanos , Tempo de Internação/estatística & dados numéricos , Masculino , Doenças do Mediastino/mortalidade , Pessoa de Meia-Idade , Noruega , Estudos Retrospectivos , Ruptura Espontânea/mortalidade , Índice de Gravidade de Doença , Stents/efeitos adversos , Resultado do TratamentoRESUMO
BACKGROUND: Following an episode of acute diverticulitis, surgical guidelines commonly advise routine colonic follow-up to rule out underlying malignancy. However, as a CT of the abdomen is frequently performed during clinical work-up, the routine need for colonic follow-up has become debated. PURPOSE: To evaluate the need for routine CT colonography after an episode of CT-verified uncomplicated sigmoid diverticulitis to rule out underlying colorectal malignancy. MATERIAL AND METHODS: This study retrospectively evaluated 312 patients routinely referred to colonic evaluation by CT colonography following an episode of acute diverticulitis. Patients were excluded if lacking diagnostic CT of the abdomen at time of diagnosis, if presenting with atypical colonic involvement, or if CT findings were suggestive of complicated disease (e.g., abscess or perforation). CT colonography exams were routinely reviewed by experienced abdominal radiology consultants on the day of the procedure. If significant polyps were detected, or if colorectal malignancy could not be excluded, patients were referred to same-day optical colonoscopy. For these patients, medical records were reviewed for optical colonoscopy results and histology reports if applicable. RESULTS: Among 223 patients with CT-verified uncomplicated sigmoid diverticulitis, no patients were found to have underlying colorectal malignancy. 27 patients were referred to optical colonoscopy based on CT colonography findings. 18 patients consequently underwent polypectomy, all with either hyperplastic or adenomatous histology. CONCLUSIONS: This study indicates that routine colonic evaluation by CT colonography following an episode of CT-verified uncomplicated sigmoid diverticulitis may be unwarranted, and should arguably be reserved for patients with protracted or atypical clinical course.
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BACKGROUND: Many drugs increase the risk for gastroduodenal ulcer bleeding. The aim of this study was to investigate Helicobacter pylori infection and drug use in patients who had gastroduodenal ulcer bleeding in 2002 or 2007, and possible differences between the periods. MATERIAL AND METHODS: Patients with gastroduodenal ulcer bleeding were prospectively included in the periods 1.1 - 31.12. 2002 and 1.1 - 31.12. 2007. Information was recorded about Helicobacter pylori infection and intake of NSAIDs (non steroidal anti-inflammatory drugs), acetylsalicylic acid, warfarin, clopidogrel, low-molecular heparine, SSRIs (selective serotonin reuptake inhibitors), corticosteroids, paracetamol and proton pump inhibitors. Inhabitants in Oslo age >or= 60 years in 2007, were used as a control for drug use. RESULTS: 78.2 % of patients in 2002 and 90.7 % of those in 2007 used at least one of the drugs (p = 0.01). In 2002, 25.7 % of patients used non-selective NSAIDs and in 2007 46.1 % used such drugs (p = 0.001). In 2002, 36.7 % of patients used more than one of the studied drugs, versus 50.9 % in 2007 (p = 0.02). Compared to controls, the patients used more NSAIDs, acetylsalicylic acid, clopidogrel, low- molecular heparine, SSRIs and corticosteroids. Helicobacter pylori infection was diagnosed in 51.0 % of patients in 2002, versus 41.1 % in 2007 (p = 0.11). INTERPRETATION: Most patients with gastroduodenal ulcer bleeding use drugs that have a known risk of adverse effects such as ulcer and/or gastrointestinal bleeding.
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Úlcera Duodenal , Úlcera Péptica Hemorrágica/etiologia , Úlcera Gástrica , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Anti-Inflamatórios não Esteroides/efeitos adversos , Anticoagulantes/efeitos adversos , Quimioterapia Combinada/efeitos adversos , Úlcera Duodenal/induzido quimicamente , Úlcera Duodenal/microbiologia , Feminino , Infecções por Helicobacter/complicações , Humanos , Masculino , Pessoa de Meia-Idade , Úlcera Péptica Hemorrágica/induzido quimicamente , Úlcera Péptica Hemorrágica/microbiologia , Inibidores da Agregação Plaquetária/efeitos adversos , Estudos Prospectivos , Inibidores da Bomba de Prótons/efeitos adversos , Fatores de Risco , Úlcera Gástrica/induzido quimicamente , Úlcera Gástrica/microbiologia , Adulto JovemRESUMO
BACKGROUND: Esophageal perforation is a serious condition with a high mortality. Treatment is both surgical and conservative. MATERIAL AND METHODS: Records were retrospectively reviewed for 22 patients (17 men), with median age 64 (30-85) years, that had been treated for esophageal perforation at Ullevaal University Hospital in the period 2000-2006. RESULTS: Perforation was cervical in two (9%) patients, thoracic in 19 (86%) and abdominal in 1 (5%) of the patient(s). The etiology was iatrogenic in 11 (50%) patients, emetic in 8 (36%) and caused by a foreign body in 3 (14%) patients. Five patients with an iatrogenic etiology had oesophageal cancer. Diagnosis after onset of symptoms was evident within 24 hours in 41% patients, during 24-72 hours in 14% and later than 72 hours in 45% of the patients. Half of the patients (11) were treated surgically, including two that had been initially treated conservatively. Five patients (23%) died of thoracic perforations during hospitalization and there were no other deaths. Median hospital stay was 54 (3-174) days. At the end of follow-up median survival was 113 (12-660) days and 10 of the 22 patients were dead (45%). INTERPRETATION: Our impression is that early surgery of oesophageal perforation in fit patients can improve the outcome.
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Perfuração Esofágica/terapia , Adulto , Idoso , Idoso de 80 Anos ou mais , Perfuração Esofágica/mortalidade , Perfuração Esofágica/cirurgia , Feminino , Seguimentos , Mortalidade Hospitalar , Humanos , Tempo de Internação , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Análise de Sobrevida , Resultado do TratamentoRESUMO
BACKGROUND: . In Norway, different attitudes prevail to discontinuation of antiplatelet agents, such as ASA, NSAID, ADP-receptor inhibitors (clopidogrel and ticlopidine) phosphodiestase inhibitors (dipyridamole) and glycoprotein IIb/IIIa receptor inhibitors (abciximab and eptifibatide), before endoscopic procedures. The Norwegian Association of Gastroenterology have appointed a group, consisting of a medical and a surgical gastroenterologist, a haematologist, a cardiologist and a pharmacologist, to review literature concerning the issue in order to give a recommendation. MATERIAL AND METHODS: Literature retrieved from a non-systematic search of Pubmed was critically reviewed by the study group. RESULTS: No randomised controlled studies were found to have addressed the problem. Two prospective and three retrospective studies have compared the frequency of bleeding complications for patients using or not using ASA/NSAID during endoscopic papillotomy or polypectomy. The studies showed either no differences in bleeding complications, or only an increase in mild, self-limiting haemorrhage for those using ASA/NSAID. INTERPRETATION: The group recommends that all gastroenterological procedures may be performed on patients taking ASA/NSAID provided there are no pre-existing bleeding disorders. As no clinical data are available for other antiplatelet agents, the group recommends to stop the treatment for 7 days before the procedure, but this will have to be balanced against the risk of thrombosis associated with the discontinuation.
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Endoscopia Gastrointestinal , Inibidores da Agregação Plaquetária/administração & dosagem , Aspirina/administração & dosagem , Aspirina/efeitos adversos , Endoscopia Gastrointestinal/efeitos adversos , Medicina Baseada em Evidências , Humanos , Inibidores da Agregação Plaquetária/efeitos adversos , Hemorragia Pós-Operatória/etiologia , Hemorragia Pós-Operatória/prevenção & controle , Guias de Prática Clínica como Assunto , Fatores de Risco , Trombose/etiologia , Trombose/prevenção & controleRESUMO
The article describes a case of gas explosion during diathermy snare resection of a polyp in the rectum, after cleansing with a sorbitol enema. Proximity to anus prevented perforation or other complications. The patient was shown to be a methane producer by a hydrogen-methane breath test. Gas explosion is a rare complication during use of diathermy in lower endoscopy, and usually occurs in patients with sub-optimal bowel cleansing. CO2 insufflation will prevent this and should be the method of choice; first of all because it reduces patient discomfort in the period after colonoscopy.
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Diatermia , Explosões , Gases , Pólipos Intestinais/terapia , Doenças Retais/terapia , Idoso , Colonoscopia , Diatermia/efeitos adversos , Feminino , Humanos , SorbitolRESUMO
BACKGROUND: Colorectal polyps are common, but there is a large geographical variation--and Norway has one of the highest incidences. There is circumstantial evidence that most cancers develop from polyps; so detection, eradication and follow-up stategies for polyps are important. The article provides an update on these topics. MATERIAL AND METHODS: The article is based on the authors' own research and clinical experience, and on literature retrieved through a non-systematic search of Pubmed. RESULTS AND INTERPRETATION: Classification of polyps is based on morphology and histology, and the risk of malignancy depends on both. Colonoscopy is the primary method for detection of polyps; biopsies can be taken and treatment initiated during the procedure. CT colography (virtual colonoscopy) may be on the verge of becoming a diagnostic tool. Pedunculated polyps are usually removed by endoscopical snare resection, which is sufficient even when cancer has developed in the head of the polyp. Large sessile polyps, with considerable risk of malignancy, may be removed by transanal endoscopic microsurgery in the rectum, while surgical localised resection will often be required in the colon. Between these extremes, many polyps may be removed by more advanced endoscopic techniques, and at times with supplementary ablation.
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Pólipos do Colo , Neoplasias Colorretais , Pólipos Intestinais , Polipose Adenomatosa do Colo/complicações , Polipose Adenomatosa do Colo/cirurgia , Pólipos do Colo/complicações , Pólipos do Colo/diagnóstico , Pólipos do Colo/patologia , Pólipos do Colo/cirurgia , Colonoscopia , Neoplasias Colorretais/diagnóstico , Neoplasias Colorretais/etiologia , Neoplasias Colorretais/patologia , Neoplasias Colorretais/cirurgia , Medicina Baseada em Evidências , Seguimentos , Predisposição Genética para Doença , Humanos , Pólipos Intestinais/complicações , Pólipos Intestinais/diagnóstico , Pólipos Intestinais/patologia , Pólipos Intestinais/cirurgia , Guias de Prática Clínica como Assunto , Fatores de RiscoRESUMO
INTRODUCTION: Myotonic dystrophies are inherited multisystemic diseases characterized by musculopathy, cardiac arrythmias and cognitive disorders. These patients are at increased risk for fatal post-surgical complications from pulmonary hypoventilation. We present a case with myotonic dystrophy and esophageal cancer who had a minimally invasive esophagectomy complicated with gastrobronchial fistulisation. PRESENTATION OF CASE: A 44-year-old male with myotonic dystrophy type 1 and esophageal cancer had a minimally invasive esophagectomy performed instead of open surgery in order to reduce the risk for pulmonary complications. At day 15 respiratory failure occurred from a gastrobronchial fistula between the right intermediary bronchus (defect 7-8mm) and the esophagogastric anastomosis (defect 10mm). In order to minimize large leakage of air into the gastric conduit the anastomosis was stented and ventilation maintained at low airway pressures. His general condition improved and allowed extubation at day 29 and stent removal at day 35. Bronchoscopy confirmed that the fistula was healed. The patient was discharged from hospital at day 37 without further complications. DISCUSSION: The fistula was probably caused by bronchial necrosis from thermal injury during close dissection using the Ligasure instrument. Fistula treatment by non-surgical intervention was considered safer than surgery which could be followed by potentially life-threatening respiratory complications. Indications for stenting of gastrobronchial fistulas will be discussed. CONCLUSIONS: Minimally invasive esophagectomy was performed instead of open surgery in a myotonic dystrophy patient as these patients are particularly vulnerable to respiratory complications. Gastrobronchial fistula, a major complication, was safely treated by stenting and low airway pressure ventilation.
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BACKGROUND: Endoscopic colorectal cancer (CRC) screening is currently implemented in many countries. Since endoscopes cannot be sterilised, the transmission of infectious agents through endoscopes has been a matter of concern. We report on a continuous quality control programme in a large-scale randomised controlled trial on flexible sigmoidoscopy screening of an average-risk population. Continuously, throughout a two-year screening period, series of microbiological samples were taken from cleaned ready-to-use endoscopes and cultured for bacterial growth. RESULTS: 8573 endoscopies were performed during the trial period. Altogether, 178 microbiological samples (2%) were taken from the biopsy channels and surfaces from the endoscopes. One sample (0.5%) showed faecal contamination (Enterobacter cloacae), and 25 samples (14%) showed growth of environmental bacteria. CONCLUSIONS: Growth of bacteria occurs in a clinical significant number of samples from ready-to-use endoscopes. Pathogenic bacteria, however, were found only in one sample. Improvement of equipment design and cleaning procedures are desirable and continuous microbiological surveillance of endoscopes used in CRC screening is recommended.
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Bactérias/isolamento & purificação , Colonoscópios/microbiologia , Neoplasias Colorretais/prevenção & controle , Humanos , Noruega , Controle de Qualidade , Ensaios Clínicos Controlados Aleatórios como Assunto , Sigmoidoscópios/microbiologiaRESUMO
Esophageo-tracheal fistula is a rare condition, and in most cases such fistulas are caused by malignant disease or emergency endotracheal intubation. A case where a wrapped tablet produced a fistula between the esophagus and trachea is described. The patient is a male born in 1938 who swallowed a tablet without unwrapping it. The patient was treated with self-expanding metal stents (SEMS), but closure of the fistula was not achieved. Different examinations and treatment options are discussed. Surgical treatment for this condition has demonstrated considerable mortality and morbidity. In some cases closure of the fistula can be achieved by use of SEMS. Although we advise treatment of such cases with SEMS, in some cases treatment with stents will prove troublesome and the risk/benefit analysis will have to be reevaluated.
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Embalagem de Medicamentos , Fístula Esofágica , Esofagoscopia/instrumentação , Corpos Estranhos , Doença Iatrogênica , Fístula do Sistema Respiratório , Stents , Doenças da Traqueia , Idoso , Broncoscopia , Deglutição , Fístula Esofágica/diagnóstico , Fístula Esofágica/etiologia , Fístula Esofágica/terapia , Humanos , Masculino , Valor Preditivo dos Testes , Fístula do Sistema Respiratório/diagnóstico , Fístula do Sistema Respiratório/etiologia , Fístula do Sistema Respiratório/terapia , Tomografia Computadorizada por Raios X , Doenças da Traqueia/diagnóstico , Doenças da Traqueia/etiologia , Doenças da Traqueia/terapia , Resultado do TratamentoRESUMO
Diet has been associated with sporadic colorectal cancer (CRC) risk. The relationship to the growth rate of adenomas is largely unknown. Previous analyses of our cohort of polyp cases have shown 1) indicators of a healthy diet were inversely associated with adenoma occurrence, 2) diet was related to the fecal profile, 3) obesity was positively associated with adenoma growth, 4) familial predisposition of CRC was positively associated with adenoma growth, and 5) intervention with calcium and antioxidants was not associated with adenoma growth. The present aim was to study the effects of diet on growth and recurrence of adenomas. Data were collected from a 3-yr polyp growth and intervention study. Polyps larger than 9 mm were removed, whereas the remainder and newly discovered polyps smaller than 10 mm were left in situ for 3 yr. Diet was assessed by a 5-day dietary record by weighing (DR) and food-frequency questionnaire (FFQ). Weak inverse associations were found only between adenoma growth and fruits and berries (adjusted odds ratio, aOR = 0.3; 95% CI = 0.1-0.9) and carbohydrates (aOR = 0.1; 95% CI = 0.1-0.6; both only DR data) and between adenoma recurrence and vegetables (crude odds ratio, cOR = 0.4; 95% CI = 0.1-0.9; only FFQ data). Taken together, the present and previous findings from this cohort may indicate an early role for dietary factors in CRC development.