Insertion of fully covered self-expanding metal stents in benign biliary diseases.

INTRODUCTION: Benign biliary diseases are traditionally treated using plastic stents. However, fully covered self-expanding metal stents are currently gaining acceptance for the treatment of these pathologies. OBJECTIVE: To assess the effectiveness and complications associated with the placement of temporary endoscopic fully covered self-expanding metal stents for the treatment of benign biliary diseases. MATERIALS AND METHODS: This was a retrospective and observational study using a prospective database from a tertiary care center from March 2012 to May 2016. Some patients that had a fully covered metal stent due to a benign biliary disease were also included. The indications, resolution, technical success rates and adverse events were documented. RESULTS: 31 patients were included with a total of 34 stents inserted. The indications were as follows: 8 (25%) post cholecystectomy biliary stenoses, 11 (31%) large or multiple choledocholithiasis, 3 (8.3%) biliary fistulas, 2 (6%) post-liver transplant stenoses, 2 (8.3%) papillary stenoses, 2 (6%) perforations and 2 (6%) bleeds. The global resolution success rate of the stents for all pathologies was 88%, this included 87.5% (7/8) in post cholecystectomy stenoses, 73% (8/11) in large choledocholithiasis and 100% for the remaining indications. Thirty-three of 34 stents were removed after an average of 133 days (ranging from 10 to 180 days). No complications were registered. CONCLUSION: Fully covered self-expanding metal stents are an effective and reliable alternative for the resolution of benign biliary diseases.

Post-ERCP pancreatitis: early precut or pancreatic duct stent? A multicenter, randomized-controlled trial and cost-effectiveness analysis.

BACKGROUND: Pancreatitis is the most frequent complication due to ERCP. Pancreatic duct stent placement has been described as a preventive measure. There is also evidence pointing towards the preventive effect that early precut may provide. AIM: To determine and compare the cost-effectiveness of an early precut approach versus pancreatic duct stent placement for the prevention of post-ERCP pancreatitis. METHODS: This was a multicenter, randomized-controlled pilot study with a cost-effectiveness analysis performed between early precut (group A) and pancreatic duct stent (group B) for the prevention of pancreatitis in high-risk patients. Patients with a difficult biliary cannulation and at least one other risk factor for post-ERCP pancreatitis were enrolled and randomized to one of the treatment arms. Both effectiveness and costs of the procedures and their complications were analyzed and compared. RESULTS: From November 2011 to November 2013, 101 patients were enrolled; 50 subjects were assigned to group A and 51 to group B. There were no significant differences in terms of baseline characteristics of patients between groups. Two cases of mild pancreatitis were observed in each group. The overall costs were U$ 1,242.6 per patient in group A and U$ 1,606.5 per patient in group B. The cost in group B was 29.3% higher (p < 0.0001). CONCLUSION: Early precut showed a better cost-effectiveness profile when compared to pancreatic duct stent placement.

Early precut is as efficient as pancreatic stent in preventing post-ERCP pancreatitis in high-risk subjects - A randomized study.

BACKGROUND: The most common adverse event of endoscopic retrograde cholangiopancreatography is pancreatitis. Precut sphincterotomy has been regarded as a risk factor. Some authors have stated that early precut may actually reduce post-ERCP pancreatitis risk. However, early precut as a preventive measure has not been compared to other preventive measures, such as pancreatic duct stent placement. AIM: To compare the efficacy of early precut sphincterotomy versus pancreatic duct stent placement in high-risk subjects undergoing endoscopic retrograde cholangiopancreatography for the prevention of post-endoscopic cholangiopancreatography. MATERIALS AND METHODS: This was a single-blinded, randomized trial that took place in two tertiary referral centers in Buenos Aires, from November 2011 to December 2013. ERCP subjects presented at least one of the following risk factors: female sex, age less than 40 years, clinical suspicion of sphincter of Oddi dysfunction, previous pancreatitis, and/or common bile duct diameter of less than 8 mm. Only those who presented a difficult biliary cannulation were randomized into two groups: those who received early precut sphincterotomy and those in whom persistency of biliary cannulation was intended, with subsequent pancreatic duct stent placement after cholangiography was achieved. The incidence of post-ERCP pancreatitis, as well as other adverse events incidence, was compared. RESULTS: Overall, 101 patients were enrolled, 51 in the pancreatic duct stent group and 50 in the early precut group. Pancreatitis rate was similar in both groups (3.92% vs 4%, p NS). In all cases, pancreatitis was classified as mild. There were no deaths registered. CONCLUSION: Early precut was associated with an incidence of adverse events similar to pancreatic duct stent placement.

[Sphincterotomy plus large balloon dilation versus sphincterotomy alone for the extraction of complex lithiasis: A prospective analysis]. / Esfinterotomía más dilatación con balones de grandes volúmenes versusesfinterotomía en la extracción de litiasis complejas: análisis prospective.

BACKGROUND AND PURPOSE: Mid-size sphincterotomy associated with large balloon dilation is an alternative to wide sphincterotomy to remove complex lithiases. However, which of the two techniques is most effective remains unclear. Hence, we conducted this study to compare both methods prospectively. METHOD: Since January 2012 until March 2014, 133 consecutive patients with complex stones were included. Group A underwent mid-size sphincterotomy associated with large balloon dilation and group B underwent wide sphincterotomy alone. Success rates were assessed for: Extraction of stones, ductal patency rate, the use of mechanical lithotripsy, dose, time and dose per radioscopy area as well as procedure-related complications. RESULTS: Group A comprised 44 patients and group B comprised 69 patients. Overall success rate for extraction was 86.4% in group A and 70% in group B (p = 0.069). In giant lithiasis, effective extraction was 89.3% in group A and 58.6% in group B (p = 0.019). Use of mechanical lithotripsy was 15.9% and 30.4%, respectively (p = 0.142). Total radiotherapy dose was 39.8 mGy vs. 26.2 mGy, respectively (p = 0.134). Complications occurred in 6.8% and 5.5% of the procedures in each group, without significant differences among them (p = 0.856). CONCLUSION: Sphincterotomy plus large balloon dilation is more effective and equally safe than conventional sphincterotomy for the management of giant main bile duct lithiasis.

[Hilar bile duct tumors: Endoscopic or percutaneous drainage? A prospective analysis]. / Tumores hiliares biliares: ¿drenaje endoscópico o percutáneo?Análisis prospective.

BACKGROUND AND OBJECTIVE: Both the endoscopic and the percutaneous approach are widely accepted for the drainage of hilar tumors. Our primary objective was to report on the effectiveness and complications of these procedures. METHODS: Prospective observational analysis of the endoscopic and/or percutaneous management of all hilar tumors treated at a referral hospital from October 2011 until October 2014. Group A included patients treated endoscopically and group B included patients treated with percutaneous drainage. The following variables were assessed: Effective biliary drainage rate, survival time and complications. RESULTS: Group A comprised 40 patients and group B, 22 patients. Overall success rate in achieving effective biliary drainage was 85% in group A and 90.9% in group B (p = 0.78). Five patients required a combined approach. In group A, the rate of effective drainage in patients with Bismuth IV-type tumors was 58.3%, while it was 81.8% in patients in group B (p = 0.44). There was no difference in mean survival between both groups. For group A, complication rate was 11.5%, whereas it was 2.94% for group B (p = 0.41). CONCLUSIONS: Endoscopic and percutaneous biliary drainage are both effective methods for the palliative treatment of patients with hilar tumors. However, for Bismuth IV-type strictures, percutaneous drainage proved to be safer and more effective.

[Endoscopic ultrasound-guided choledocho-duodenostomy in advanced pancreatic cancer with duodenal obstruction]. / Colédoco-duodenostomía guiada por ecoendoscopía en cáncer de páncreas avanzado con obstrucción duodenal.

Endoscopic retrograde cholangiopancreatography (ERCP) is considered the first-approach for biliary drainage. In cases of ERCP failure, patients are usually referred for percutaneous transhepatic biliary drainage or surgical biliary bypass. In the last decade, the indications of endoscopic ultrasound (EUS) in the management of patients with pancreatic cancer have increased, and numerous cases of EUS-guided biliary drainage have been reported in patients with failures during the ERCP. Our goal is to report a patient with locally advanced pancreatic cancer who presented with painless jaundice and cholestasis with biliary and duodenal obstruction. A EUS-guided choledochoduodenostomy was performed by placement of a self-expanding metal stent.

[Quality and competence in endoscopic cholangiography. Towards certainty]. / Calidad y competencia en colangiografía endoscópica. Rumbo a lo seguro.

INTRODUCTION: The American Society of Gastroenterology (ASGE) and the American College of Gastroenterolog (ACG) have established indicators to recognize high-quality studies in endoscopic retrograde cholagiopancreatography (ERCP). The indicators were: a) Pre-procedure: adequate indication, informed consent, assessment of the degree of difficulty of the procedure and antibiotic prophylaxis. b) Intraprocedure: cannulation, choledocholithiasis extraction and stents placement rates. c) Postprocedure: full documentation and complications rates. METHODS: Between October 2010 and October 2012 we performed a retrospective, descriptive, observational and self-evaluative study to assess the compliance with ERCP quality indicators proposed by the ASGE. RESULTS: Preprocedural indicators were evaluated in 734 studies. Cannulation, choledocolithiasis extraction and stents placement under the hiliar bifurcation rates were 96.2%, 95.4% and 100%, respectively. The complication rate was 5.6% and the mortality was 0.27%. The severity of complications was evaluated according to the classification of Masci (30 mild, 7 moderate and 4 severe). CONCLUSIONS: Quality is a basic tool that allows the comparison between our actions and the indicators already predetermined as suitable. The appropriate indication is an indicator to improve. We believe that 12% of registered normal studies could be due to a difficult accessibility to magnetic resonance cholangiography in our health system. Achievement of the internationally validated indicators place us as a high-quality endoscopic cholagiography unit and as a training center with appropriate expertise.

NORMAL VALUES OF ESOPHAGEAL 24-HOUR IMPEDANCE-PH AMBULATORY IN AN ARGENTINE COHORT OF HEALTHY VOLUNTEERS.

BACKGROUND: There are no data of reference values on 24-hour multichannel intraluminal impedance and pH (pH-MII) monitoring in Argentinian populations. OBJECTIVE: Our aim was to obtain the normal values of pH-MII variables among healthy asymptomatic volunteers in a metropolitan Health Care Center of Argentina, and to compare them with data already published from other regions around the world. METHODS: A cross-sectional study was undertaken in a tertiary referral center in Buenos Aires. We enrolled healthy subjects and asked them to undergo esophageal pH-MII 24hours monitoring. pH-MII variables were recorded and described. RESULTS: Median reflux events was 20.5 (25-75%, 95%) interquartile range: (14-46, 50) and proximal reflux episodes was 2.5 (0-10, 11). Sixty percent were acid reflux episodes: 12 (5-29, 38), representing a relatively low value when compared to those reported in European, American and Chinese populations. CONCLUSION: Our study shows the first reference of normal values of gastroesophageal reflux in an Argentinian population. We found a total number of reflux events and a total number of proximal reflux events lower than what was reported until this date by other authors.

Valores normais de impedância-pHmetria de 24 horas em uma coorte de voluntários saudáveis na Argentina / Normal values of esophageal 24-hour impedance-ph ambulatory in an argentine cohort of healthy volunteers

ABSTRACT Background There are no data of reference values on 24-hour multichannel intraluminal impedance and pH (pH-MII) monitoring in Argentinian populations. Objective Our aim was to obtain the normal values of pH-MII variables among healthy asymptomatic volunteers in a metropolitan Health Care Center of Argentina, and to compare them with data already published from other regions around the world. Methods A cross-sectional study was undertaken in a tertiary referral center in Buenos Aires. We enrolled healthy subjects and asked them to undergo esophageal pH-MII 24hours monitoring. pH-MII variables were recorded and described. Results Median reflux events was 20.5 (25-75%, 95%) interquartile range: (14-46, 50) and proximal reflux episodes was 2.5 (0-10, 11). Sixty percent were acid reflux episodes: 12 (5-29, 38), representing a relatively low value when compared to those reported in European, American and Chinese populations. Conclusion Our study shows the first reference of normal values of gastroesophageal reflux in an Argentinian population. We found a total number of reflux events and a total number of proximal reflux events lower than what was reported until this date by other authors.

RESUMO Contexto Não há dados de valores de referência sobre o monitoramento de impedância intraluminal multicanal 24 horas e monitoramento de pH (pH-MII) em populações argentinas. Objetivo O objetivo foi obter os valores normais das variáveis pH-MII entre voluntários assintomáticos saudáveis em um centro metropolitano de saúde da Argentina, e compará-los com dados já publicados de outras regiões do mundo. Métodos Estudo transversal foi realizado em um centro de referência terciário em Buenos Aires. Foram recrutados indivíduos saudáveis para se submeterem ao monitoramento esofágico pH-MII 24 horas. As variáveis pH-MII foram registradas e descritas. Resultados A média de eventos de refluxo foi de 20,5 (25-75%, 95%) entre os episódios interquartis: (14-46, 50) e os episódios de refluxo proximal foram de 2,5 (0-10, 11). Sessenta por cento foram episódios de refluxo ácido: 12 (5-29, 38), representando um valor relativamente baixo quando comparado com os relatados em populações europeias, americanas e chinesas. Conclusão Nosso estudo mostra a primeira referência de valores normais de refluxo gastroesofágico em uma população argentina. Encontramos um número total de eventos de refluxo e um número total de eventos de refluxo proximal menor do que o relatado até esta data por outros autores.

Reutilización de materiales de colangiografía endoscópica. Estudio prospectivo de minimización de costos / Reusing materials in endoscopic cholangiography. A prospective study on cost minimization

ANTECEDENTES: la colangiografía endoscópica enfrenta el desafío del control de costos en un área de constantes avances tecnológicos. La reutilización es el uso de un dispositivo médico más veces de las especificadas por el fabricante. Esta práctica se halla precedida por las maniobras de reprocesamiento y amparada por la legislación vigente. OBJETIVOS: cuantificar la reducción en el costo de los insumos y evaluar las complicaciones. Método: estudio prospectivo, descriptivo y análisis sobre minimización de costos comparando la reutilización de dispositivos médicos con el uso único de los mismos. RESULTADOS: durante un período de tres meses se realizaron 144 estudios. Con la estrategia de reutilización, se utilizaron: 9 papilótomos, 12 guías hidrofílica, 3 canastillas de Dormia, 4 balones extractor, 5 balones dilatadores y 2 cuchillos de precorte. Representó un costo total de U$ 10 943 (promedio de costo de materiales por cada estudio: U$ 76). Con la estrategia de uso único se hubieran utilizado: 144 papilótomos, 144 alambres guías, 24 canastillas de Dormia, 20 balones dilatadores, 72 balones extractores y 24 agujas de precorte. Esta estrategia hubiera generado un costo total de U$ 126 280 (promedio por estudio U$ 877). Al comparar los valores entre ambas estrategias observamos una minimización significativa en el costo (p< 0.001). No se registraron complicaciones. Conclusión: Con la estrategia de reutilización de los DM los costos se minimizaron significativamente sin generarse complicaciones

BACKGROUND: cost control is challenging endoscopic cholangiography in an area of constant technological advances. Reusing is using a medical device more times than what was specified by the manufacturer. This practice is preceded by reprocessing maneuvers and protected by the applicable laws. OBJECTIVES: to quantify the cost reduction of supplies and assess the complications. Method: a prospective descriptive study and an analysis of cost minimization by comparing the reuse and the single use of medical devices. Results: 144 studies were conducted during a period of three months. The reuse strategy included: 9 papillotomes, 12 hydrophilic guide wires, 3 Dormia baskets, 4 balloon extraction catheters, 5 balloon dilatation catheters and 2 pre-cut knives. It accounted for a total cost of USD 10,943 (average cost of materials per study: USD 76). The single-use strategy would have included: 144 papillotomes, 144 hydrophilic guide wires, 24 Dormia baskets, 20 balloon extraction catheters, 72 balloon dilatation catheters and 24 pre-cut needle knives. This strategy would have amounted to a total cost of USD 126,280 (average per study: USD 877). By comparing the values of both strategies, a significant minimization is seen in the cost (p< 0.001). No complications were seen. CONCLUSION: the strategy for reusing MD involveda significant minimization of costs without causing any complications.

Colédoco-duodenostomía guiada por ecoendoscopia en cáncer de páncreas avanzado con obstrucción duodenal / Endoscopic ultrasound-guided choledocho-duodenostomy in advanced pancreatic cancer with duodenal obstruction

La colangiopancreatografía retrógrada endoscópica (CPRE) se considera el tratamiento de primera línea para el drenaje biliar en pacientes con cáncer de páncreas. En los casos de fracaso por CPRE, generalmente se realiza un drenaje biliar transparietohepático o una derivación biliar quirúrgica. En la última década, las indicaciones y la utilidad de la ecoendoscopia en pacientes con cáncer de páncreas han ido creciendo, y se han informado numerosos casos de drenajes biliares guiados por ecoendoscopia como una alternativa al drenaje biliar percutáneo o quirúrgico en fracasos en la CPRE. Nuestro objetivo es comunicar un caso con cáncer de páncreas localmente avanzado que se presentó con ictericia indolora y síndrome coledociano con obstrucción biliar y duodenal, en el que se realizó una colédoco-duodenostomía guiada por ecoendoscopia mediante la colocación de una prótesis metálica autoexpandible.

Endoscopic retrograde cholangiopancreatography (ERCP) is considered the first-approach for biliary drainage. In cases of ERCP failure, patients are usually referred for percutaneous transhepatic biliary drainage or surgical biliary bypass. In the last decade, the indications of endoscopic ultrasound (EUS) in the management of patients with pancreatic cancer have increased, and numerous cases of EUS-guided biliary drainage have been reported in patients with failures during the ERCP. Our goal is to report a patient with locally advanced pancreatic cancer who presented with painless jaundice and cholestasis with biliary and duodenal obstruction. A EUS-guided choledochoduodenostomy was performed by placement of a self-expanding metal stent.

Actualización en gastroenterología y endoscopia digestiva / Update in gastroenterology and digestive endoscopy

Se describen las temáticas abordadas durante los días 5 y 6 de junio de 2008 en las XII Jornadas Internacionales de Gastroenterología y Endoscopía Digestiva en la ciudad de La Plata, las cuales son organizadas anualmente por la Sociedad de Gastroenterología de la provincia de Buenos Aires, el Grupo Endoscópico de La Plata y la Cátedra de Postgrado en Gastroenterología. Los temas más salientes abordados en las recientes jornadas estuvieron relacionados con: Hipertensión portal: Fisiopatología, Hemorragia, Varicela, Indicaciones de TIPS (derivación transyugolo intrahepática portosistémica) y patología bilio pancreática: CA de Páncreas, Tratamiento endoscópico de la Pancreatitis Crónica, Ecoendoscopía en patología biliopancreática. La conferencia "CA de Páncreas: Tratamiento endoscópico vs. quirúrgico" estuvo a cargo del Dr. Everson Artifon, responsable de la sección de patología bilio-pancreática del Servicio de Endoscopía del hospital de clínica de San Pablo, a cargo del Dr. Paulo Sakai, destacado referente de nuestra especialidad en Sudamérica.