Usefulness of biodegradable polydioxanone stents in the treatment of postsurgical colorectal strictures and fistulas.

Benign colonic strictures and fistulas are a growing problem presenting most commonly after bowel resection. Standard treatment is with endoscopic bougies or, more usually, balloon dilation. When these approaches are not successful, other solutions are available and different endoscopic and surgical approaches have been used to treat fistulas. We present an additional option--biodegradable stents--for the treatment of colonic strictures and fistulas that have proven refractory to other endoscopic interventions. We analyzed the results from 10 patients with either a postsurgical colorectal stricture (n =7) or rectocutaneous fistula (n =3) treated with the biodegradable SX-ELLA esophageal stent (covered or uncovered). Stents were successfully placed in nine patients, although early migration subsequently occurred in one. Placement was impossible in one patient due to deformity of the area and the fact that the stricture was approximately 30cm from the anus. The fistulas were successfully closed in all patients, although symptoms reappeared in one patient. In the six patients who received stents for strictures, symptoms resolved in five; in the remaining patient, the stent migrated shortly after the endoscopy. Treatment of colonic strictures and rectocutaneous fistulas with biodegradable stents is an effective alternative in the short-to-medium term. The stent does not have to be removed and is subject to very few complications. The drawbacks of this approach are the need to repeat the procedure in some patients and the lack of published series on efficacy.

Efficacy of pediatric colonoscopy used as push enteroscopy in the management of capsule endoscopy findings.

BACKGROUND: recent advances in endoscopy have enabled us to explore the small intestine more efficiently, both with capsule endoscopy and double-balloon enteroscopy. However, these methods are not available in all hospitals. Therefore, when capsule endoscopy reveals proximal jejunal lesions, a possible alternative for treatment could involve push enteroscopy combined with colonoscopy. Lesions can thus be marked for subsequent monitoring. OBJECTIVES: to describe the efficacy of pediatric colonoscopy for diagnosis, the marking of the area explored, and therapeutic options. MATERIAL AND METHODS: between October 2007 and September 2008 a total of 21 enteroscopies were performed using a pediatric colonoscope. Nine of these were used to take jejunal biopsy samples due to suspected disease of the mucosa. In 10 of the remaining 12, capsule endoscopy revealed lesions (vascular malformations or jejunal bleeding), and in 2 intestinal transit time was analyzed due to suspected jejunal stenosis. We used a PENTAX EC-3470-LK pediatric colonoscope, whose 11.6-mm sectional diameter and 3.8-mm working channel make it possible to administer all the usual endoscopic treatments. RESULTS: therapeutic endoscopy was performed on 7 men and 5 women (mean age 63.3 years). Jejunal lesions were observed in 10 cases (5 cases of angiodysplasia, 2 cases of jejunal stenosis, 1 case of nonmalignant thickened jejunal folds, 1 eroded submucosal tumor, and 1 case of duodenal and jejunal varices). The most distal area was marked with India ink (2), hemoclips (4), or both to help locate the lesions using simple abdominal radiography or capsule endoscopy. CONCLUSIONS: jejunal enteroscopy enabled a firm diagnosis to be made in most of the patients studied. We were able to treat 58% of patients and mark the areas explored for subsequent follow-up. With hemoclips we were able to locate the most distal point explored using simple abdominal radiography.

Esophagoenteral stents in patients with recurrent gastric adenocarcinoma.

One of the problems that can appear in patients with total gastrectomy for adenocarcinoma with esophagoenteral anastomosis is the appearance of a stenosis of the anastomosis. These stenosis are frequently malignant due to relapse of neoplasia. The therapeutic possibilities available are the surgical bypass or palliative treatment. There is very little experience described in the literature (21 cases) on the placing of self-expandable metal stents as a palliative treatment for the symptoms of stenosis.We present our experience of 3 patients, in whom 4 esophageal stents were fitted (1 covered and 3 uncovered) with good results. The dysphagia disappeared or improved, it allowed the ingestion of a soft diet and meant an improvement in the quality of life and at the same time stopped the weight loss. It seems an effective palliative treatment as a treatment for dysphagia in patients with tumoral relapse in the anastomosis of total gastrectomies.

[Cholestatic hepatitis caused by glybenclamide in a patient with hepatitis C virus]. / Hepatitis colestática por glibenclamida en paciente con virus de hepatitis C.

We report the case of a 68-year-old male HVC+ diagnosed as cholestatic hepatitis induced by glybenclamide, following a non-insulin dependent diabetes mellitus treatment. When the drug was discontinued normal analytic parameters were obtained. However, HVC may induce more cholestatic and cytolysic changes on the hepatitis due to glybenclamide. When reviewing the literature only one similar case has been previously reported, although several disturbances in liver function tests have been described in other reports. Routine biochemical tests including liver function are indicated in patients receiving antidiabetic agents in order to make an early diagnosis of liver toxicity.

[Hepato-cholangiocarcinoma with diffuse metastases and hypercalcemia]. / Hepatocolangiocarcinoma con metástasis difusas e hipercalcemia.

The combined hepatocellular-cholangiocarcinoma (C-HCC) is a very uncommon neoplasm, its diagnosis is difficult and its course is usually very rapid. We report the case of a patient with CHCC type II or transitional tumor, which shows two cellular types in certain zones. Our patient had tumoral hypercalcemia as well, which was very difficult to control. There was a metastatic spread with cholangiolar features almost from the beginning, that made impossible any sort of therapy. It seems that dissemination followed lymphatic pathways.

[Mixed cryoglobulinemia associated with hepatitis C virus]. / Crioglobulinemia mixta asociada al virus de la hepatitis C.

We report six cases of essential mixed cryoglobulinemia associated with chronic liver disease and positive HCV markers, who showed several acute symptoms of vasculitis, arthralgias, neuropathy and glomerulonephritis. The presence in the serum and cryoprecipitates of anti HCV antibodies detected by the second-generation ELISA (ELISA 2) and the of HCV RNA by PCR in the serum in all six cases, suggest an important role for this virus in the pathogenesis of mixed cryoglobulinemia.

[Treatment with interferon alfa-2b in patients with chronic hepatitis caused by hepatitis C virus: predictive factors for the response, relapse and early development to cirrhosis after treatment]. / Tratamiento con interferón alfa-2b en pacientes con hepatitis crónica por el virus C de la hepatitis: factores predictivos de respuesta, recaída y evolución precoz a cirrosis tras el tratamiento.

UNLABELLED: The treatment of chronic hepatitis C is interferon (IFN). Diverse predictive factors influence a complete response. The aim of this study was to determine the response to IFN-alpha therapy and factors that may predict a sustained response before and after the first month of treatment. Likewise, it evaluates the relapse and liver cirrhosis evolution after therapy. PATIENTS AND METHODS: We have treated 155 consecutively patients with chronic hepatitis C. Nine left therapy because of severe side effects. We studied the patients who had had persistently elevated serum aminotransferase concentrations, HBsAg negative, HIV negative and antiHCV positive with polymerase chain reaction confirmation, and without any other liver disease. The schedule of IFN-alpha 2b therapy was 5 MU three times per week for 3 months, and later, 3 MU three times per week for 6 more months. There were two groups of response: A) Complete response, if serum aminotransferase levels were normal and RNA-HCV negative, B) No response, if it didn't meet these conditions. The sustained response was complete response during follow-up. The relapse described as aminotransferase increase after suppression therapy with or without positive RNA-HCV, or positive RNA-HCV only. RESULTS: A complete response was obtained in 34.9%. Ten variables were statistically significant (p < 0.05) on univariate analysis: weight, corporal surface, dosage IFN/m2, bilirubin and total protein pretreatment; polymorphonuclears/mononuclears cells, AST, ALT, AST/ALT, and gamma GT in the first therapy's month. In multivariate analysis, serum AST levels < 40 U/l (odds ratio 0.15, 95% CI 0.04-0.52), and AST/ALT ratio > 0.75 (odds ratio 3.05, 95% CI 1.04-8.9) in the first month, were correlated independently with complete response. Incidence of relapse was 47% of responders, with mean appearance period a of 2.7 +/- 2.1 months. Therefore, a sustained response was obtained in 27 patients (18.5%). Seventeen of 115 patients (14.6%) without cirrhosis initially, developed liver cirrhosis after a second biopsy. Two variables were statistically significant in multiple regression analysis: RNA-HCV positive after treatment (odds ratio 2.99, 95% CI 0.9-2.99), and platelet count < 180,000/mm3 before therapy (odds ratio 17.7, 95% CI 3.7-83.2) were correlated independently with cirrhosis development. CONCLUSIONS: A 9 months course of IFN therapy is effective in a third of patients, but almost half of them have relapsed within 6 months after treatment's suppression. The AST levels and AST/ALT ratio in the first of month therapy were correlated independently with complete response. Liver cirrhosis appears in a small percentage. Platelet count before therapy and RNA-HCV positive at the end treatment, were predictor variables of this evolution.

[Elastic band ligation: preliminary experience in esophagogastric varices]. / Ligadura con bandas elásticas: experiencia preliminar en varices esofagogástricas.

Endoscopic ligation is a new technique that shows an efficacy for acute hemorrhage and prevention similar to sclerotherapy. Its principal advantage is the smaller number of complications (2%), which seem to be related to the presence of post-treatment ulcers which are indeed more extensive but more superficial. In our preliminary study on 8 patients, eradication of varices in 62.5% was obtained. The mean number of bands placed at each ligation session was of 2.4 +/- 0.96 and the mean number of treatment sessions to achieve the eradication was 3.4 +/- 1.5. The complications that appear during the positioning of bands, a minimum bleeding was observed during the polyp formation, and in one occasion, the partial detachment of an eschar followed the bleeding was also observed. Rebleeding occurred in two patients (25%), and in other patient, spontaneous bacterial peritonitis was observed. The two patients who presented recurrent variceal bleeding, received a transjugular intrahepatic portosystemic shunt to control their hemorrhage.

[Spontaneous bacterial peritonitis caused by Listeria monocytogenes]. / Peritonitis bacteriana espontánea por Listeria monocytogenes.

Listeria monocytogenes is a gram-positive coccobacillus that produces infections in both the normal and the compromised host. Symptomatic bacteremia and pulmonary infection or meningitis are the most common clinical presentations in adults. According to a current review of the literature, Listeria is a rare bacteria that may produce spontaneous bacterial peritonitis (23 cases reported). Listeria peritonitis occurs in more than two-thirds of the cases in patients with chronic liver disease, but may also occur in patients with malignancy or undergoing peritoneal dialysis. We describe two cases of SBP in cirrhotic patients, one with alcoholic cirrhosis and other due to HCV infection. One patient also presented with acute meningitis. Peritonitis due to Listeria was clinically and analytically similar to any SBP. Third-generation cephalosporins commonly used in the therapy of SBP, are ineffective in this infection. Ampicillin is the drug of choice, although it should be used in combination therapy usually with an aminoglycoside. The mortality from Listeria peritonitis is similar to that of other SBP (17%).

Endoscopic resection of large colorectal polyps.

BACKGROUND: Endoscopic polypectomy is a common technique, but there are discrepancies over which treatment--surgical or endoscopic--to follow in case of polyps of 2 cm or larger. OBJECTIVES: To analyse the efficacy and complications of colonoscopic polypectomy of large colorectal polyps. PATIENTS AND METHODS: 147 polypectomies were performed on 142 patients over an eight-year period. The technique used was that of submucosal adrenaline 1:10000 or saline injection at the base of the polyp, followed by resection of the polyp using a diathermic snare in the smallest number of fragments. Remnant adenomatous tissue was fulgurated with an argon plasma coagulator. Lately, prophylactic hemoclips have been used for thick-pedicle polyps. Complete removal was defined as when a polyp was completely resected in one or more polypectomy sessions. Polypectomy failure was defined as when a polyp could not be completely resected or contained an invasive carcinoma. RESULTS: The mean patient age was 67.9 years (range, 4-90 years), with 68 men and 79 women. There were 74 sessile polyps, and the most common location was the sigmoid colon. The most frequent histology was tubulovillous. Most of the polyps (96.6%), were resected and cured. This was not achieved in four cases of invasive carcinoma, and a villous polyp of the cecum. All pedunculated polyps were resected in one session, whereas the average number of colonoscopies for sessile polyps was 1.35 +/- 0.6 (range, 1-4). The polypectomy was curative in all of the in situ carcinomata except one. As for complications, 2 colonic perforations (requiring surgery) and 8 hemorrhages appeared, which were controlled via endoscopy. There was no associated mortality. CONCLUSIONS: Endoscopic polypectomy of large polyps (> or =2 cm) is a safe, effective treatment, though it is not free from complications. Complete resection is achieved in a high percentage, and there are few relapses. It should be considered a technique of choice for this type of polyp, except in cases of invasive carcinoma.

[The response to hepatitis B vaccine prior to orthotopic liver transplantation]. / Respuesta a la vacuna de la hepatitis B previa al trasplante hepático ortotópico.

UNLABELLED: HBV hepatitis is a severe complication of orthotopic liver transplantation (OLT) due to the immunosuppression therapy. OBJECTIVES: The aim of this study is to evaluate the efficacy of the active HBV immunization on these patients before OLT. PATIENTS AND METHODS: This was a prospective trial, with 34 patients (20 M and 14 F), that received a double dose (40 micrograms) of HBV surface proteic Ag, on the 0th, 30th and 60th days of the study and posterior control of anti-HBs levels. If there wasn't a response, they received two more doses on the 90th and 120th days. RESULTS: There was a seroconversion in 22 patients (64.7%). Chronic alcoholism determined a lower rate of response than other etiologies (p < 0.05); this was the same in HCV chronic liver disease (p < 0.01). During their follow up, two patients had acute HBV hepatitis: one of them presented a negative response from the beginning, and in the other, anti-HBs developed transiently, when the HBV markers appeared. CONCLUSIONS: Previous HBV active immunization in OLT patients with double dose in a quick sequence, determined a positive response in a high number of patients with a higher rate of seroconversion than in other studies. The response was not so high in patients with chronic alcoholism or HVC chronic liver disease. We conclude that HVB vaccination should be done in these patients.

[The treatment of anal fissure with botulinum toxin]. / Tratamiento de la fisura anal con toxina botulínica.

BACKGROUND: The use of botulinic toxin has led to new perspectives in the treatment of anal fissures. However, the most effective dose, length of treatment and long term results require further studies to determine the most appropriate place for this therapy. PATIENTS AND METHODS: A prospective study was carried out in 40 consecutive patients diagnosed with anal fissure of more than 3 months in duration. Fifteen U of botulinic toxin were injected in the external anal sphincter and the evolution was studied over 6 months. The patients completed a pain scale designed for the study after 1 week, and 1, 3 and 6 months after the injection. The degree of pain, healing and need for surgery were evaluated during the follow up. RESULTS: Healing occurred in 17 patients after 3 months (42.5%) and after 6 months in 3 more patients (50%). Eight patients required surgery during follow up (20%). In the remaining patients, the pain significantly decreased allowing conservative management. Only 2 patients demonstrated incontinence for slight, transitory gases (5%). CONCLUSIONS: Injection of botulinic toxin is well tolerated and is relatively effective as an alternative in the treatment of anal fissure. Most patients respond in the first days after treatment and the effect persists for at least 6 months. The use of doses higher than those used in this study merits further studies.

[Severe complications of percutaneous hepatic biopsy in patients with orthotopic liver transplantation]. / Complicaciones graves de la biopsia hepática percutánea en los pacientes con trasplante hepático ortotópico.

The incidence and type of complications appearing following the performance of liver biopsies were analyzed in the first 166 liver transplants in our hospital. The presence of a severe complications was defined if a patient presented hemoperitoneum, pneumothorax, hemothorax, post biopsy infection or symptomatic puncture of abdominal organs other than the liver. Four hundred thirty-eight liver biopsies were carried out in 129 patients with a mean of 3.4 biopsies per patient. The severe complications were observed in 7 (1.6%), all of which were bleeding episodes. Four hemothorax requiring the placement of a thoracic drainage tube were observed. In two cases thoracotomy was required with death occurring in one patient. Three hemoperitoneum were also seen requiring laparotomy in one and transfusion in the remaining two patients. Out of the non transplanted patients, four presented severe complications (0.7%), 50% of which were hemoperitoneum. No patient presented hemothorax and no deaths were reported. The authors conclude that the incidence of severe post liver biopsy complications in transplanted is low, similar to that reported in non transplanted patients. Nonetheless, there does appear to be a higher incidence of bleeding complications in the transplanted patients.

[Hemolysis associated with intrahepatic percutaneous portosystemic shunt]. / Hemólisis asociada a la derivación portosistémica percutánea intrahepática.

Two cases of intravascular hemolysis in patients with intrahepatic percutaneous portosystemic shunt are described. This is a recently reported complication, the incidence of which currently remains unknown. Following analysis of different possible mechanisms, it is suggested that a relationship may exist between the hemolysis and the number of the inserted prosthesis and length of the intraportal segment of the stent.

Endoscopic treatment with self-expanding metal stents for Crohn's disease strictures.

BACKGROUND: Balloon dilation (with or without steroid injection) is the endoscopic treatment of choice for short strictures in Crohn's disease (CD). The placement of a stent has only rarely been reported in this setting, and it may be a good alternative. AIM: To describe the efficacy of temporary placement of a self-expanding metallic stent (SEMS) in the endoscopic treatment of symptomatic strictures in CD. METHODS: We included 17 CD patients treated with SEMS (4 partially covered SEMS and 21 fully covered SEMS) for symptomatic strictures refractory to medical and/or endoscopic treatment. RESULTS: We placed 25 stents in 17 patients with stenosis (<8 cm), in the colon and in the ileocolonic anastomosis. In two cases, two stents were placed in the same endoscopic procedure. All except three cases had previously been unsuccessfully treated with endoscopic dilatation. The stents were maintained for an average of 28 days (1­112). The treatment was effective in 64.7% of the patients after a mean follow-up time of 60 weeks (5­266). In four cases, removal of the stents was technically difficult due to stent impaction (moderate adverse events-AEs) and one patient had a proximal stent migration requiring delayed surgery (severe AE). CONCLUSION: The placement of self-expanding metallic stent in Crohn's disease maintained over a period of 4 weeks is a safe, effective treatment for strictures refractory to medical treatment and/or balloon dilatation, and might be an alternative endoscopic