[Duodenal perforation due to an endoscopic biliary prosthesis]. / Perforación duodenal por prótesis biliar endoscópica.

Endoscopic biliary drainage through endoscopic retrograde cholangiopancreatography (ERCP) is a widely accepted therapeutic option in malignant biliary obstructions. However, the procedure is not free of complications. Perforation is one possible complication although it is much less frequent (less than 1%) than pancreatitis (5.4%) or hemorrhage (2%). We present 2 cases of duodenal perforation after placement of a biliary prosthesis through ERCP. Both patients had extensive hilar cholangiocarcinoma. Onset of symptoms of perforation occurred a few hours after placement of the prosthesis and the diagnosis was confirmed by computed tomography and laparotomy. We believe that the mechanism through which perforation occurred was proximal adhesion of the prosthesis to the tumor. This increased the intensity of distal trauma produced by the intraduodenal segment, preventing adaptation of the prosthesis to intestinal peristalsis. A good preventive measure would consist of correctly adjusting the length of the prosthesis in relation to the proximal end of the biliary stenosis.

Endoscopic polypectomy in the treatment of colonic adenomas containing adenocarcinoma.

Fifty-seven adenomas containing adenocarcinoma were removed endoscopically from the colons of 56 patients (36 males and 20 females) with a mean age of 64.5 years. The 13 polyps containing carcinoma in situ were satisfactorily treated by endoscopic resection. In 29 cases, the carcinoma had invaded the head, neck or stalk of the polyp. The outcome was good in every case, including one involving invasion of the resection margin. Follow-up or intraoperative studies disclosed the presence of residual lesion in only 4 patients out of 15 with submucosal invasion. All four had invaded resection margins and incomplete endoscopic excision. Endoscopic polypectomy is a suitable therapeutic option for most colonic adenomas containing a carcinoma provided a complete resection is achieved with wide resection margins, particularly in those cases in which the submucosa is not reached.

Failure of endoscopic therapy in upper gastrointestinal hemorrhage due to duodenal ulcers.

OBJECTIVES: to evaluate the efficacy of endoscopic treatment in patients with upper gastrointestinal (UGIH) due to duodenal ulcer with high risk of persistent or recurrent bleeding and to determine the associated failure factors of this procedure. PATIENTS AND METHOD: three hundred and thirty-six patients with UGIH due to duodenal ulcer requiring endoscopic treatment were analyzed between January 1992 and December 2001. The patients were classified according to the endoscopic findings: a) patients with limited bleeding; and b) patients with persistent and/or recurrent bleeding due to therapeutic failure. The clinical guidelines followed in patients with endoscopic treatment failure were previously established in the internal protocol. The variables that obtained statistical significance in the univariate analysis were included in the logistic regression model to identify those with an independent predictive value for failure of the endoscopic treatment. RESULTS: mean age of the patients was 60 +/- 17 years, 271 (81%) were male. Bleeding with severe hemodynamic affectation was detected in 82 patients (24%). The most common location of the duodenal ulcer was on the anterosuperior part of the duodenal bulb (227 patients, 68%). In 43 patients (13%) the ulcer was larger than 2 cm. The bleeding stigmata were classified as: Forrest I in 125 (38%) and Forrest II in 211 (62%). It was initially reached in 297 patients (88%). Twenty-two patients required emergency surgery (6,5%) and the global mortality rate was 3%. Severe hemodynamic affectation at admission (OR 11.8, p>0.001), ulcers exceeding 2 cm (OR 6.95, p = 0.019) and the presence of active bleeding during endoscopy (Forrest I) (OR 3.55, p = 0.08) were the variables included in the multivariate analysis independently associated to endoscopic therapy failure. CONCLUSION: endoscopic therapy is an efficient treatment of upper gastrointestinal bleeding due to duodenal ulcer. By means of a clinical variable, the hemodynamic status and two endoscopies, bleeding stigmata and the size of the ulcer, a group of patients with high risk of endoscopic treatment failure can be selected.

[The incidence of gastric carcinoma after gastrectomy for peptic ulcer in the Vigo region. A case-control study]. / Frecuencia del carcinoma gástrico postgastrectomía para úlcera péptica en la comarca de Vigo. Estudio caso-control.

After reviewing 10,000 upper gastrointestinal endoscopies performed at the endoscopy unit of the city of Vigo over a 38 month period, we have found 485 partial gastric resections for peptic ulcer, 357 gastric carcinomas were found, of which 26 occurred after partial gastric resection for peptic ulcer. Therefore the incidence of gastric cancer in this area was 22-23/100,000. The frequency of gastric cancer after partial resective surgery was lower than expected during the first 20 years after surgery. However, thereafter a significant increase of gastric cancer occurred in those patients in which a Billroth-II but not Billroth-I procedure was used.

Biliopancreatic tumors: patient survival and quality of life after palliative treatment.

OBJECTIVES: to analyse survival and quality of life of patients with malignant obstructive jaundice after palliative treatment, comparing endoscopic stent insertion and palliative surgical (palliative resection and bypass surgical). PATIENTS AND METHOD: eighty and seven patients were included in a trial. They were distributed to endoscopic stent (50) and palliative surgical (37). It analysed survival, quality of life and comfort index of jaundiced patients. The good quality of life was defined by absence of jaundice, pruritus and cholangitis after the initial treatment. RESULTS: the median survival of the patients treated to endoscopic stent was 9,6 months whereas the patients to surgical treatment survived a median of 17 months. The time free of disease was 4 months in stented patients and 10,5 months in surgical patients. There was no significant difference in comfort index between the two groups (stented 34%, surgical 42,5%) Neither was there significant difference in survival and quality of life between palliative resection and bypass surgery. CONCLUSIONS: despite the survival and time free of disease being better in surgical patients, there was no significant difference in overall quality of life between the two groups. The survival and quality of life are the same after palliative resection as after bypass surgery, for this should not be performed routinely or to justify resection as a debulking procedure.

[Prevention of recurrence of acute biliary pancreatitis by endoscopic sphincterotomy]. / Prevención de la recidiva de la pancreatitis aguda biliar mediante esfinterotomía endoscópica.

The aim of this study was to know if endoscopic sphincterectomy could be an alternative to cholecystectomy in high surgical risk patients that have suffered acute biliary pancreatitis. Between January 1992 to December 1995 endoscopic sphincterectomy was carried out in 52 high surgical risk patients who had suffered an episode of acute biliary pancreatitis. The lithiasic gallbladder was not removed. The mean age was 75.6 years (35-91). After a follow up of 15.9 months (1-46.5), no patient suffered from a new episode of acute pancreatitis. Six patients (12%) required cholecystectomy due to complications derived from the lithiasic gallbladder. Endoscopic sphincterectomy is an effective alternative to cholecystectomy in the prevention of new episodes of acute biliary pancreatitis in patients with lithiasic gallbladder and high surgical risk. The complications of the lithiasic gallbladder in situ after endoscopic sphincterectomy are relatively infrequent.

[Endoscopic dilatation of caustic esophageal strictures]. / Tratamiento mediante dilatación endoscópica de las estenosis esofágicas cáusticas.

OBJECTIVE: To evaluate the results of endoscopic dilatation in caustic esophageal strictures and to analyze the factors associated with a favorable response. PATIENTS AND METHOD: We performed a retrospective study of 33 patients who underwent dilatation with Savary bougie between 1989 and 2001. Response to initial dilatation and outcome during follow-up were analyzed. RESULTS: The mean age was 50 years (8-83) and 58% were women. Intake was accidental in 29 (88%). In all patients, the caustic substance ingested was alkali. Dilatation was started in the acute phase in 12 patients (36%) and 13 presented inflammatory phenomena adjacent to the stenosis. During initial dilatation, 2 1.6 sessions (2-18) were performed and a favorable response was obtained in 18 patients (54%). At the end of follow-up, 68% of the patients presented satisfactory health status. The comparative study revealed that statistically significant variables for a favorable response to treatment were: accidental alkali intake, instauration of treatment in the chronic phase, absence of inflammatory phenomena, and a small number of initial dilatation sessions. CONCLUSIONS: In our series, more than half the patients with esophageal stenosis due to intake of corrosive alkalis showed a favorable initial response. In these patients with acute-phase stenosis who required a greater number of initial dilatation sessions, endoscopic therapy was less effective.

[Resident physician training in the digestive system. The point of view of the residents]. / Formación MIR en aparato digestivo. El punto de vista de los residentes.

AIM: To evaluate various aspects of current training of Spanish residents in gastroenterology. METHOD: An anonymous postal questionnaire was sent to fourth-year resident physicians in Spanish hospitals with accredited gastroenterology residency programs. RESULTS: Forty residents in the fourth year (53% offered positions), four from the second year and one from the first year (20 men, 25 women) answered the survey. Mean age was 29.7 years (26-42 years). Fifty-one percent of the departments did not have ultrasonography facilities apart from those in the radiology department. Endoscopic retrograde cholangiopancreatography (ERCP) was available in all the departments but in 55% of these, residents did not receive training in this technique. Forty-one percent of residents did not know the objectives of the various training periods. Eighty-four percent evaluated the pressure of clinical work as "intense" or "very intense" with 67% reporting that it disturbed their training "seriously" or "very seriously" and 71% that it disturbed their personal lives. Supervision in ultrasonography, endoscopy and clinical work were mainly evaluated as "good" or "very good". Supervision was rated lower in outpatient departments and while on duty. Forty-two percent of residents rated the supervision of the personal tutor as "average". Seventy-six percent were "fairly" or "very interested" in the introduction of "areas of specific training". CONCLUSIONS: The quality of residents' training in general and of gastroenterology training in particular is high. There are, however, several aspects which could be improved.

[Treatment with endoscopic endoprosthesis in choledocholithiasis]. / Tratamiento con endoprótesis endoscópica de la litiasis de la vía biliar principal.

The results of the placement of endoscopic endoprosthesis in 51 patients with choledocholithiasis from October 1991 to December 1995 are reviewed. In 13 cases the endoprosthesis was provisionally placed. Surgical or endoscopic treatment was electively completed in all the cases. Thirty-eight patients received the endoprosthesis on a permanent basis. During the follow up (mean 15.2 months) extraction was completed and the prosthesis removed in three cases, one by emigration. Six patients presented recurrent biliary obstruction and underwent surgery or replacement of another prosthesis. In the latter cases, another two underwent surgery due to repeated obstructions. The remaining patients remained asymptomatic until the end of follow up or until death (8 cases) due to unrelated causes. Only three mild episodes of cholangitis were observed as complications related to prosthesis placement. The authors conclude that endoscopic endoprosthesis is an effective provisional treatment to solve acute situations and is a permanent alternative for unextracted choledocholithiasis following sphincterotomy in patients who cannot undergo other techniques and who have a short life expectancy.

[Efficacy of fecal detection of Helicobacter pylori with the HpSA technique in patients with upper digestive hemorrhage]. / Eficacia de la determinación fecal de Helicobacter pylori mediante la técnica HpSA en enfermos con hemorragia digestiva alta.

BACKGROUND: The rapid urease test is the most commonly used test in the diagnosis of Helicobacter pylori infection in patients with upper gastrointestinal hemorrhage. However, some studies have suggested that results of this test are frequently false negative when blood is present. An effective new enzyme immunoassay for determining H. pylori antigens in stools has recently begun to be used. AIM: To determine the efficacy of the H. pylori stool antigen test (HpSAT) in patients with upper gastrointestinal hemorrhage. PATIENTS AND METHODS: Thirty-two patients with upper gastrointestinal hemorrhage were prospectively studied from November 1998 to April 1999. In all patients the following tests were performed in the first 72 hours after onset of bleeding and 24 hours after hospital admission: upper gastrointestinal endoscopy, biopsy samples for the rapid urease test and histological study, blood samples for serology, stool samples for HpSAT, and the 13C urea breath test. Criteria for infection was a positive result in at least two of the four diagnostic techniques, except in the case of HpSAT. Sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) were calculated. RESULTS: Of the 32 patients, 23 (71.8%) were infected. The results of four HpSAT (12.5%) were negative and 28 were positive (87.5%). HpSAT showed high sensitivity (95.6%) but low specificity (33.3%). The PPV and NPV were 78.5% and 75% respectively. Of the 32 HpSAT, 25 (78.1) were performed in melenic stools: 22 were positive and 3 were negative. Seventy-five percent of negative HpSAT and 78.5% of positive HpSAT corresponded to melenic stools. CONCLUSIONS: HpSAT is a rapid, non-invasive technique that does not appear to be influenced by the presence of blood. Consequently, it can be applied in patients with upper gastrointestinal hemorrhage. The rapid urease test showed high sensitivity, specificity and PPV and should remain the first-line test in patients with upper gastrointestinal hemorrhage. HpSAT is appropriate as a second-line technique and is useful when the rapid urease test is negative and infection is strongly suspected, when no samples for the rapid urease test have been taken and when endoscopy cannot be performed. The result obtained in the present study should be confirmed in future studies with larger samples.

[Evaluation of the efficacy of the endoscopic treatment in volvulus of the colon]. / Evaluación de la eficacia del tratamiento endoscópico en el vólvulo de colon.

Volvulus of the colon mainly affects the elderly and early surgery, with high morbidity and mortality, is often required. The efficacy of endoscopic devolvulization as an alternative is evaluated herein. From January 1993 to April 1999, 25 patients diagnosed with volvulus of the colon were retrospectively reviewed. Endoscopic devolvulization was not performed in one patient who showed signs of necrosis but was carried out in the remaining 24. The mean follow-up was 35.3 months. In all patients the procedure was initially effective. After the first attempt, 9 of the 24 patients (37%) relapsed, 4 out of 7 (57%) after a second attempt and 2 out of 2 (100%) after a third attempt. No morbidity or mortality was associated with the endoscopy. Six patients underwent surgery. Of these, none relapsed but two presented complications associated with the surgery. Mean hospital stay of the patients undergoing surgery was 30.8 days and that of those undergoing endoscopic devolvulization was 9.1 days. We conclude that endoscopic devolvulizatio is an effective therapeutic option when the mucosa is viable, with a high percentage of initial success, few complications inherent to the technique and with the possibility of carrying out a maximum of two attempts in cases of relapse. In the majority of patients, this technique is a valid alternative to urgent surgery, which has higher morbidity and mortality and longer mean hospital stay.

[Role of early colonoscopy in severe acute lower gastrointestinal bleeding]. / Rendimiento de la colonoscopia precoz en la hemorragia digestiva baja aguda grave.

BACKGROUND: Severe acute lower gastrointestinal bleeding (SALGIB) accounts for 15% of cases of acute lower gastrointestinal bleeding (ALGIB). The incidence increases with age and comorbidity. Identification of the origin of bleeding may be difficult. Colonoscopy has been proposed as the primary investigative tool. AIM: To assess the role of early colonoscopy as the primary method of evaluation in patients with SALGIB. PATIENTS AND METHOD: Retrospective study based on a guideline for clinical practice approved in our institution. The study included 50 patients with SALGIB admitted to our gastrointestinal bleeding unit between January 1998 and April 2000. SALGIB was suspected when patients fulfilled two or more of the following criteria: 1) significant hemodynamic compromise, 2) decrease in hemoglobin 2 g/dl, and 3) transfusion requirement >= 2 blood units. Early colonoscopy was performed within 24 hours of onset of bleeding. An accurate endoscopic diagnosis was established if a lesion with active bleeding, visible non-hemorrhagic vessel or adherent red clot was identified. A presumptive diagnosis was made when hematochezia or fresh blood localized in a colonic segment, associated with a single, potentially hemorrhagic lesion, was observed and when the results of esophagogastroduodenoscopy were negative. Colonoscopy, esophagogastroduodenoscopy, barium studies, nuclear scan and angiography were performed. RESULTS: Two hundred twenty-two patients were admitted for ALGIB. Fifty patients(22%) fulfilled the SALGIB criteria. The male/female ratio was 1:1. Definitive diagnosis was accurate in 20 patients. The most frequent cause was angiodysplasia (6 patients) and rectal ulcer (6 patients). Eighteen patients had a presumptive diagnosis; of these 14 had diverticulosis. In 12 patients, no cause was identified. Colonoscopy was performed in 45 patients, of which 32 were performed early and 13 electively. Accurate endoscopic diagnosis was more frequently established with early colonoscopy than with elective colonoscopy (15 [47%] vs 2 [15%], p < 0.05). The results of urgent nuclear scans contributed to accurate diagnosis in 5 out of the 10 patients in whom this technique was performed. Angiography was performed in 2 patients. Endoscopic therapy was attempted in 4 patients, all during early colonoscopy. Ten patients (20%) underwent surgery and 3 patients (6%) died. CONCLUSIONS: In 22% of patients with ALGIB admitted to our hospital bleeding was severe. Colonoscopy is the diagnostic tool of choice. When performed within 24 hours of hospital admission, this technique provides more accurate diagnosis than when performed electively.

[Endoscopic drainage with polyethylene endoprosthesis of malignant obstructive jaundice]. / Drenaje endoscópico mediante prótesis de polietileno de la ictericia obstructiva maligna.

AIM: To evaluate the efficacy and complications of endoscopic drainage of malignant obstructive jaundice with plastic endoprosthesis as well as to identify possible factors related with occlusion. PATIENTS AND METHODS: One-hundred and forty patients with malignant obstructive jaundice were retrospectively evaluated. The site of obstruction was proximal in 35 patients (25.0%), distal in 64 (45.7) and ampullary in 41 (29.3). Amsterdam or pigtail polyethylene prostheses of variable caliber and length were used. Drainage was preoperative in 41 patients and palliative in 99. Seventy-seven patients who underwent with palliative drainage were followed up long-term. RESULTS: Drainage was satisfactory in 132 patients (94.2%). Early morbidity was 10.7% (14/140) and early mortality related with the technique was 5% (7/140). Time free of obstruction was 4.6 +/- 1.0 months and in 47/77 (60%) the prostheses were still working at the end of follow-up. The actuarial rate of obstruction at 6 months was 42%, the majority (61%) occurring in the first 3 months. The median survival was 5.9 +/- 1.3 months. Of all the factors analyzed, greater permeability was found only in the ampullary tumors (p < 0.01) and in prostheses of caliber equal or superior to 10 French (p < 0.01). CONCLUSIONS: Endoscopic biliary drainage using plastic prostheses is satisfactory in the majority of patients with malignant jaundice. It has a low complication rate and provides acceptable palliation: the majority of patients do not require prostheses to be replaced and, when they becomes clogged, substitution usually solves the problem. Ampullary tumors and prostheses of higher caliber (> or = 10F) have been associated with greater permeability.

[Factors associated with failure of endoscopic therapy in gastric ulcer bleeding]. / Factores asociados al fracaso de la terapéutica endoscópica en la hemorragia digestiva por úlcera gástrica.

INTRODUCTION: Endoscopic therapy is an effective technique in the control of bleeding due to peptic ulcer. However, bleeding persists or recurs in as many as 10-30% of patients. Gastric and duodenal ulcers present different clinical and endoscopic features and consequently the efficacy of endoscopic therapy and the factors associated with its failure should be studied separately. OBJECTIVES: To analyze the efficacy of endoscopic therapy in patients at high risk of persistent or recurrent bleeding due to gastric ulcer and to identify the factors associated with the failure of this technique. PATIENTS AND METHODS: We performed a retrospective study based on a clinical intervention protocol. Two hundred eight patients admitted for bleeding secondary to gastric ulcer with active bleeding or stigmas of recent bleeding who received endoscopic therapy between January 1992 and December 2001 were analyzed. Clinical, laboratory and endoscopic variables on admission, as well as the medical treatment and endoscopic procedure applied, were registered. Endoscopy was performed within 12 hours of admission. Patients were classified according to their response to endoscopic therapy: a) patients with limited bleeding, and b) patients with persistent or recurrent bleeding due to therapeutic failure. Intervention in patients with therapeutic failure was performed according to a previously established protocol. Variables that were statistically significant in the univariate analysis were included in a logistic regression model to identify those with an independent predictive value for failure of endoscopic therapy. RESULTS: Definitive hemostasis was achieved after initial therapy in 181 patients (87%). The efficacy of a second procedure increased the percentage of hemostasis to 91% of the patients. In the logistic regression model, the only variables that were independently associated with initial therapeutic failure were: hemodynamic status on admission (p = 0.016; OR = 3.99), the need for transfusion of blood products prior to endoscopy (p = 0.025; OR = 3.48), upper localization of the gastric ulcer (p = 0.050; OR = 3.08) and unsatisfactory endoscopic therapy (p = 0.009; OR = 17.39). CONCLUSION: These variables could contribute to the early identification of a subgroup of patients, which would enable us to increase medical-surgical surveillance and offer them other therapeutic alternatives.

[Evaluation of body fluid compartments and their relationship with water-electrolyte changes in obstructive jaundice]. / Evaluación de los compartimientos corporales y su relación con las alteraciones hidroelectrolíticas en la ictericia obstructiva.

BACKGROUND: The alteration of the mechanisms of water and sodium preservation may be an important factor in the development of acute postoperative renal failure in obstructive jaundice (OJ). Experimental OJ has been associated with a depletion of the extracellular volume and alteration of the mechanisms of regulation of hydrosaline metabolism. The aim of this study was to evaluate the distribution of the body volumes and the regulating hormones of hydrosaline metabolism in human OJ. PATIENTS AND METHOD: A prospective, clinical study evaluating 18 patients with OJ (9 females and 9 males) with a mean age of 69 +/- 8.9 years was performed. The plasma levels of antinatriuretic peptide (ANP), aldosterone and renin were determined. The body volumes were evaluated by tetrapolar bioimpedanciometry. The results of the patients with OJ were compared with a control group (CG) of 12 healthy subjects, matched for age and sex (6 females and 6 males with a mean age of 64.5 +/- 14 years). RESULTS: High ANP values were observed in 87.5% of the patients. The results of the hormonal studies compared with the CG were: ANP (117.33 +/- 37.7 vs 41.31 +/- 16.8 pg/ml; p < 0.001), aldosterone (185.68 +/- 82.1 vs 44.3 +/- 21.6 pg/ml; p < 0.001) and renine (57.18 +/- 69.9 vs 16.08 +/- 9.7 microU/ml; p < 0.05). Depletion of extracellular volume was found in 75% of the patients. CONCLUSIONS: Human obstructive jaundice is associated with an important alteration in the hormonal mechanisms of water and sodium regulation. This alteration is accompanied by a marked depletion of extracellular volume.