Canulación biliar difícil: precorte precoz tipo fistulotomía para evitar la pancreatitis post CPRE. Un análisis retrospectivo de dos años / Difficult biliary cannulation: early precut fistulotomy to avoid post ERCP pancreatitis. A retrospective analysis for two years

Antecedentes: La canulación biliar difícil es un factor de riesgo para la pancreatitis post-CPRE. En estos casos el precorte es la técnica más usada. Objetivo: Demostrar que el precorte tipo fistulotomía es seguro y eficaz. Materiales y métodos: Se revisaron los datos de mayo de 2016 a mayo de 2018. Se definió canulación difícil como: litiasis impactada, canulación inadvertida del conducto pancreático en tres ocasiones e incapacidad para lograr la canulación en 3 minutos. Las medidas de resultados fueron la canulación biliar exitosa y la pancreatitis post-CPRE. Resultados: Se realizó precorte tipo fistulotomía en 96 casos (67 mujeres, 29 hombres). La tasa de éxito de la canulación biliar fue del 95,8% (92/96). Ochenta pacientes tenían factores de riesgo para pancreatitis post CPRE: 29 tuvieron un solo factor de riesgo, 26 tuvieron dos, 19 tuvieron tres y 6 tuvieron cuatro. Factores de riesgo ampulares de canulación difícil: calculo impactado 9 casos, abultamiento de la papila en 10 casos, ubicación inferior del orificio papilar en 38 casos, localización parcial del poro papilar en 23 y estenosis del orificio papilar en 16 casos. Diez pacientes tuvieron divertículo periampular, 7 pacientes tuvieron conducto biliar normal. Ninguno de los pacientes experimentó pancreatitis. Tres pacientes tuvieron sangrado precoz, una paciente presento sangrado tardío. Un paciente (2%) tuvo fiebre y fue hospitalizado. Conclusiones: En casos de canulación biliar difícil el precorte tipo fistulotomía es seguro y eficaz.

Background: Difficult biliary cannulation is a risk factor for post-ERCP pancreatitis. In these cases, precutting is the most used technique. Objective: To demonstrate that precut fistulotomy is safe and effective. Materials and methods: Data from May 2016 to May 2018 were reviewed. Difficult cannulation was defined as: impacted lithiasis, inadvertent cannulation of the pancreatic duct on three occasions and inability to achieve deep biliary cannulation in 3 minutes. The outcome measures were successful biliary cannulation and post-ERCP Pancreatitis. Results: Precut fistulotomy was performed in 96 cases (67 women, 29 men). The success rate of biliary cannulation was 95.8% (92/96). Eighty patients had risk factors for post-ERCP pancreatitis: 29 had 1 risk factor, 26 had 2 risk factors, 19 had 3 risk factors, and 6 had four risk factors. Ampullary risk factors of difficult cannulation: impacted stone in the papilla: 9 cases, papilla bulging: 10 cases, lower location of the hole papillary 38 cases, partial location of the papillary pore 23 and papillary orifice stenosis 16 cases. Ten patients had periampullary diverticulum, 7 patients had normal bile duct. None of the patients experienced Pancreatitis. Three patients had early bleeding, one patient had late bleeding. One patient (2%) had a fever and was hospitalized. Conclusions: In cases of difficult biliary cannulation, the precut fistulotomy is safe and effective.

Éxito de CPRE 72 horas después de precorte / ERCP success after 72 hours of pre-cut

Introducción A pesar de los avances en las técnicas para canalizar la vía biliar no se puede asegurar su éxito. Se han publicado pocos estudios que soporten un segundo intento de CPRE que, sin embargo, reportan un aumento en la tasa de canalización. Objetivo: Determinar si una CPRE 72 horas después de realizarse una papilotomía por precorte permite la canalización de la vía biliar. Materiales y métodos: Se realizó un estudio de cohorte descriptiva, se incluyeron todos los pacientes llevados a CPRE más papilotomía por precorte sin lograr el ingreso a la vía biliar y que 72 horas después fueron programados para una nueva CPRE entre septiembre de 2015 y septiembre de 2016.Los pacientes en quienes no se logró canalizar la via biliar a pesar de la papilotomia por precorte no tenían ninguna característica de edad, género o anatómica que se asocie con fracaso en la canalización respecto a la población general. Se analizó el porcentaje de éxito en la canalización a las 72 horas y las complicaciones asociadas a la papilotomía por precorte en el procedimiento inicial. Resultados: Ingresaron al estudio 16 pacientes, con edad promedio de 61.3 años (DE: 10.6), se logró canalizar la vía biliar en 14 de los casos que se llevaron a una CPRE 72 horas después de una papilotomía por precorte. No se presentaron complicaciones después de la papilotomía por precorte. En los dos pacientes no canalizados se indicó cirugía: Conclusiones: La experiencia reportada en este estudio sobre el éxito de canalización de la vía biliar 72 horas después de la realización de una papilotomía por precorte en un 87% sin complicaciones nos permite sugerirla como una alternativa de manejo antes de una exploración quirúrgica.

Introduction: Despite the advances of bile duct catheterization, its success is still not guaranteed. Few studies have been published regarding a second ERCP attempt, however those reports enhance the catheterization success Objective: To determine whether an ERCP performed 72 hours after a first precut papillotomy enhances the bile duct catheterization. Material and methods: A cohort study was performed including all patients that had ERCP with precut papilotomy without catheterization of the bile duct and 72 hours later were programmed to a new ERCP between September 2015 and September 2016. These patients did not have any distinctive characteristic such as age, gender or anatomy that were associated with the failure to catheterize the bile duct, compared to the general population. Result: 16 patients were included with a mean age of 61,3 years (SD: 10,6), bile duct catheterization was successful in 14 cases. No complications presented after precut papilotomy. Both failures went to surgery. Conclusions: Our experience about an 87% successful bile duct catheterization, 72 hours after precut papillotomy allows us to suggest it as an alternative before considering surgery

Tratamiento endoscópico en la pancreatitis crónica: seguimiento a largo plazo / Endoscopic treatment in chronic pancreatitis: long-term results in 18 patients

Background: Intraductal stones, ductal abnormalities and pancreatic pseudocysts are part of chronic pancreatitis (CP). The goal of treatment is pain relief, resolution of local complications and relapse prevention. Endoscopic therapy (ET) can be considered in those who do not respond to medical treatment. Aim: To evaluate the indication, immediate and long-term results of ET in CP patients. Patients and Methods: Review of a database of patients with CP analyzing results of ET in 18 patients aged 16 to 60 years (13 males). Demographics, etiology, endoscopic technique, indication for treatment, pain relief, relapses and complications were recorded. Results: The etiology of CP was alcohol consumption in 5, idiopathic in 11, hereditary in one and autoimmune in one case. The follow-up period was 6 months to 14 years. Seven patients had diabetes mellitus type 3c and eight had moderate to severe exocrine pancreatic insufficiency. Pancreatic papillotomy was performed in all patients, with removal of some stones, without attempting a complete clearance of the pancreatic duct. In addition, a 7-10 French stent was placed in the main pancreatic duct in 15 patients with varying permanence (months to years). The stent was changed guided by recurrence of clinical symptoms. During the follow-up period, 10 patients remained asymptomatic and in three, pain or relapse were significantly reduced. Stenting failed in one patient for technical reasons. Two patients were operated. There were neither immediate nor late complications from ET. Conclusions: Long-lasting improvement of CP was observed in 13 of 18 patients treated with ET, without complications associated with the procedure.

Percutaneous Papillary Large Balloon Dilation during Percutaneous Cholangioscopic Lithotripsy for the Treatment of Large Bile-Duct Stones: A Feasibility Study

When access to a major duodenal papilla or endoscopic retrograde cholangiopancreatography has failed, percutaneous transhepatic cholangioscopic lithotripsy (PTCS-L) may be useful for removing common bile duct (CBD) stones. However, the feasibility and usefulness of percutaneous transhepatic papillary large-balloon dilation (PPLBD) during PTCS-L for the removal of large CBD stones has not been established. We aimed to determine the safety and efficacy of PPLBD for the treatment of large CBD stones. Eleven patients with large CBD stones in whom the access to the major papilla or bile duct had failed were enrolled prospectively. Papillary dilation was performed using a large (12-20 mm) dilation balloon catheter via the percutaneous transhepatic route. Post-procedure adverse events and efficacy of the stone retrieval were measured. The initial success rate of PPLBD was 100%. No patient required a basket to remove a stone after PPLBD. Electrohydraulic lithotripsy was required in 2 (18.2%) patients. The median time to complete stone removal after PPLBD was 17.8 min and no adverse events occurred after PPLBD. Asymptomatic hyperamylasemia was not encountered in any patients. This study indicates that PPLBD is safe and effective for removal of large CBD stones.

Percutaneous Papillary Large Balloon Dilation during Percutaneous Cholangioscopic Lithotripsy for the Treatment of Large Bile-Duct Stones: A Feasibility Study

When access to a major duodenal papilla or endoscopic retrograde cholangiopancreatography has failed, percutaneous transhepatic cholangioscopic lithotripsy (PTCS-L) may be useful for removing common bile duct (CBD) stones. However, the feasibility and usefulness of percutaneous transhepatic papillary large-balloon dilation (PPLBD) during PTCS-L for the removal of large CBD stones has not been established. We aimed to determine the safety and efficacy of PPLBD for the treatment of large CBD stones. Eleven patients with large CBD stones in whom the access to the major papilla or bile duct had failed were enrolled prospectively. Papillary dilation was performed using a large (12-20 mm) dilation balloon catheter via the percutaneous transhepatic route. Post-procedure adverse events and efficacy of the stone retrieval were measured. The initial success rate of PPLBD was 100%. No patient required a basket to remove a stone after PPLBD. Electrohydraulic lithotripsy was required in 2 (18.2%) patients. The median time to complete stone removal after PPLBD was 17.8 min and no adverse events occurred after PPLBD. Asymptomatic hyperamylasemia was not encountered in any patients. This study indicates that PPLBD is safe and effective for removal of large CBD stones.

Confrontational Strategy Is Essential for Being Effective Precut Papillotomy

No abstract available.

Pseudomixoma peritoneal por tumor del apéndice cecal / Peritoneal pseudomyxoma due to cecal appendix tumor

Objetivo: presentar un caso de una patología de muy baja incidencia y realizar una revisión bibliográfica de la misma. Paciente y método: paciente femenina de 87 años de edad que ingresa por guardia por cuadro compatible con hernia inguinal atascada, por lo que se decide cirugía de urgencia. En el acto operatorio se identifica un saco herniario de paredes engrosadas, con contenido intestinal con buena vitalidad, sin signos de necrosis, identificando además abundante secreción mucinosa en el saco herniario y proveniente de la cavidad abdominal. Se decide terminar con la hernioplastia y realizar estudios complementarios diferidos. Luego de los mismos, el comité de tumores decide la realización de nueva cirugía (hemicolectomía derecha con ileotransverso anastomosis por tumor mucinoso de apéndice), durante la cual se constata ascitis gelatinosa. La paciente evoluciona favorablemente y es dada de alta a las 72 horas del post operatorio. La anatomía patológica informa adenocarcinoma mucinoso de apéndice bien diferenciado. Discusión: el Pseudomixoma Peritoneal es una entidad muy poco frecuente, que hace referencia a la diseminación peritoneal de un tumor cuyas células producen gran cantidad de mucina. La supervivencia global de los pacientes es de aproximadamente 75 y 68% durante 5 y 10 años. La clasificación más aceptada es la de Ronnet. Tradicionalmente, el tratamiento ha sido la cirugía de citoreducción, aunque hay autores que proponen procedimientos más agresivos como la peritonectomía más quimioterapia hipertérmica intraoperatoria.

Objective: to present a case of a very low incidence disease and a bibliographic review of it. Patient and method: 87 years old female patient with a compatible history and physical exam for a stuck inguinal hernia, for which we decided to perform emergency surgery. During the surgical procedure, we find a thickened hernia sac, with mucus in it and in the abdominal cavity. The small intestine was vital and not complicated. We finished the hernioplasty, and decided to perform complementary ambulatory studies to the patient. After having them done, we decided, in an interdisciplinary committee, to perform an exploratory surgery, (hemicolectomy with ileum transverse anastomosis for an appendix tumor), during which gelatinous ascites was noticed. The patient evolve favorably and was discharged 72 hours post operation. The surgical biopsy informed an appendix mucinous adenocarcinoma well differentiated. Discussion: the peritoneal pseudomyxoma is a very infrequent entity. The overall survival is 75 and 68% for 5 and 10 years, respectively. Ronnet had published the most accepted histological classification. The accepted treatment is the cytoreductive surgery, although some authors proposed a more aggressive treatment such peritonectomy with hyerthermic intraperitoneal chemotherapy.

Acute Biliary Pancreatitis: A Case Report.

Acute biliary pancreatitis (ABP) a condition caused by gallstones; can be a life-threatening condition if not treated early (mortality ~2-7%). Complications and symptoms of ABP can be ranging from mild (nausea, vomiting, and fever) to severe (necrosis, infections, hemorrhage, abscesses, renal failure, and adult respiratory distress syndrome). Th is paper presents a specifi c case of a middle-aged male diagnosed with ABP to illustrate the disease in a clinical setting, mainly looking at its presentation, diagnosis and focusing more on treatment and management. Clinical examinations and radiological investigations are crucial to recognize the diagnosis and foresee the prognosis of this condition. Th e medications that are administered to patients suff ering from this condition include analgesics (like morphine), intravenous fl uids, and antibiotics (e.g. ciprofl oxacin). Th e limitations and lack of knowledge described above are immense concerns. It is highly encouraged that future research opportunities will compensate for the present gap in knowledge, contributing to current literature, as well as having practical implications for treatment and management of ABP.

Is endoscopic sphincterotomy plus large-balloon dilation a better option than endoscopic large-balloon dilation alone in removal of large bile duct stones? A retrospective comparison study.

Background: Several comparison studies have demonstrated that endoscopic sphincterotomy (EST) combined with large-balloon dilation (LBD) may be a better option than EST alone to manage large bile duct stones. However, limited data were available to compare this combination method with LBD alone in removal of large bile duct stones. Objective: To compare EST plus LBD and LBD alone for the management of large bile duct stones, and analyze the outcomes of each method. Patients and Methods: Sixty-one patients were included in the EST plus LBD group, and 48 patients were included in the LBD alone group retrospectively. The therapeutic success, clinical characteristics, procedure-related parameters and adverse events were compared. Results: Compared with EST plus LBD, LBD alone was more frequently performed in patients with potential bleeding diathesis or anatomical changes (P = 0.021). The procedure time from successful cannulating to complete stone removal was shorter in the LBD alone group significantly (21.5 vs. 17.3 min, P = 0.041). The EST plus LBD group and the LBD alone group had similar outcomes in terms of overall complete stone removal (90.2% vs. 91.7%, P = 1.000) and complete stone removal without the need for mechanical lithotripsy (78.7% vs. 83.3%, P = 0.542). Massive bleeding occurred in one patient of the EST plus LBD group, and successfully coagulated. Postoperative pancreatitis did not differ significantly between the EST plus LBD group and the LBD alone group (4.9% vs. 6.3%; P = 1.000). Conclusion: Endoscopic sphincterotomy combined with LBD offers no significant advantage over LBD alone for the removal of large bile duct stones. LBD can simplify the procedure compared with EST plus LBD in terms of shorten the procedure time.

Prophylactic Pancreatic Stent Placement for Endoscopic Duodenal Ampullectomy: A Single-Center Retrospective Study

BACKGROUND/AIMS: We investigated the efficacy of prophylactic pancreatic stent placement for preventing postprocedure pancreatitis in patients undergoing endoscopic papillectomy. METHODS: This retrospective study included 82 consecutive patients who underwent endoscopic papillectomy for benign ampullary neoplasm at Samsung Medical Center between August 2002 and June 2011. The patients were subdivided into two groups, namely, those who received prophylactic pancreatic stent placement and those who did not. Patient demographics, baseline blood test, tumor characteristics, and endoscopic treatment data were collected. The primary endpoint was postprocedure pancreatitis. RESULTS: There was no difference in the development of postprocedure pancreatitis between the stent group and the no stent group (6/54, 10.5% and 2/28, 7.14%, respectively; p=1.00). At baseline, there were no significant differences between the two groups in terms of their risk factors for pancreatitis except pancreatic duct dye injection. The stent group was more likely to have dye injection than the nonstent group (100% vs 42.8%, p<0.001). However, in a logistic regression analysis, no significant difference was observed in the risk factors for pancreatitis including dye injection. CONCLUSIONS: Our data suggest that routine prophylactic pancreatic duct stent placement in all patients undergoing endoscopic papillectomy may not be necessary and that large-scale prospective studies are required to identify the subgroup of patients who would benefit.

Endoscopic Papillary Large Balloon Dilation: It Is about Time We Did for a Whopper

No abstract available.

Esfinterotomía de aguja / Needle sphincterotomy

La canulación fallida del conducto biliar común durante la colangiopancreatografía retrógrada endoscópica es del 5 al 20% según la experticia del operador. El uso de guías hidrofílicas y la canulación profunda y selectiva son claves en el adecuado abordaje de la vía biliar. La inadecuada selección del paciente, papilas pequeñas o peridiverticulares, cálculo impactado, disfunción del Oddi o traumatismo repetido durante la canulación son las causas más frecuentes. La esfinterotomía de aguja en sus dos modalidades infundibulotomía y el precorte son técnicas opcionales para el abordaje del conducto biliar ante el fallo de la técnica convencional. Ambas técnicas son igualmente efectivas para el abordaje biliar en coledocolitiasis. La hiperamilasemia es más frecuente en el precorte (17.75%) en infundibulotomía (2.7%). La incidencia de pancreatitis post colangiografía es de 15% posterior a 15 o más intentos de canulación. La pancreatitis en el precorte puede alcanzar el 8% y es rara durante la infundibulotomía. El sangramiento ocurre de forma comparable con ambas técnicas. La esfinterotomía de aguja temprana en la canulación fallida disminuye la ocurrencia de pancreatitis post procedimiento. Debe ser realizada por colangiografistas expertos en la técnica y manejo de las complicaciones y contarse con los equipos y materiales adecuados

The failed cannulation of the common bile duct during endoscopic retrograde cholangiopancreatography is from 5 to 20% depending on operator expertise. The use of hydrophilic guides and the deep and selective cannulation are key to sucessfull access to the bile duct. Inadequate patient selection, small duodenal papilla or peridiverticular, impacted gallstone, Oddi dysfunction or repeated trauma during cannulation are the most common causes of failure. Needle-knife sphincterotomy in its two modalities: infundibulotomy and precut are optional techniques for accessing the bile duct when confronted with the conventional technique failure. Both techniques are equally effective for biliary choledocholithiasis. Hyperamylasemia is more common in the precut (17.75%) infundibulotomy (2.7% ). The incidence of post cholangiography pancreatitis is 15% after 15 or more cannulation attempts. Pancreatitis in precut can reach 8% and is rare during the infundibulotomy. Bleeding occurs in a similar way in both techniques. Early needle-knife use, in failed in cannulation decreases the occurrence of post procedure pancreatitis. It must be perfomed by experts in the technique that are able to manage eventual complications beside having adequate equipment and materials available

Prótesis metálicas autoexpansibles en lesiones malignas avanzadas del tracto digestivo / Self-expandable metallic stents into advanced malignant injuries of the gastrointestinal tract

La inserción endoscópica de prótesis metálicas autoexpansibles en lesiones malignas del tracto gastrointestinal ha sido descrita como tratamiento paliativo. Reportar el uso de dichas prótesis en pacientes con obstrucción del tubo digestivo por lesiones malignas, evaluados en el Centro Médico "Valle de San Diego" y en el Hospital Oncológico "Dr. Miguel Pérez Carreño" de Valencia, estado Carabobo entre enero 2009 y noviembre 2011. 14 prótesis; 6 en sujetos masculinos y 8 en femeninos, con edad de 61,21± 10,43 años. Los tipos fueron: esofágica Ultraflex y enterales Wallstent. La lesión fue localizada en el esófago en 4 casos, e igual número para la unión esogafogastrica y estómago, 1 caso en rectocolon y otro por complicaciones de órganos vecinos (páncreas). La tipología histológica (78,6%) fue reportada como adenocarcinoma. Hubo dolor como complicación en 6 casos, obstrucción por alimentos y dolor unido a migración en un caso y crecimiento tumoral intraprótesis en dos casos. La sobrevida en un 57,1% fue entre 3 y 6 meses. La paliación fue efectiva, presentándose éxito técnico y clínico, considerándose a las prótesis metálicas autoexpansibles como una solución simple y efectiva para la paliación de las estenosis malignas del tracto gastrointestinal

The endoscopic insertion of self-expandable metallic stents into malignant injuries of the gastrointestinal tract has been described as palliative treatment. To report the use of such stents in patients with obstruction caused by malignant injuries, evaluated in the medical center "Valle de San Diego" and oncologic hospital "Dr. Miguel Pérez Carreño" of the Valencia, Carabobo between January 2009 and November 2011. 14 stents; 6 in male subjects and 8 in female subjects, with 61,21 ± 10,43 years. The types were: esophagic Ultraflex and enteral Wallstent. The injury was located in the esophagus region in 4 cases, and an equal amount in the esophagastric union and in the gastric area, 1 case in the rectocolon and another one originated by complications in neighboring organs. The histological typology (78,6%) reported as adenocarcinoma. There was a pain as a complication in one case, food obstruction and pain with migration in a one case and growth tumoral in two cases. The over life of 57,1% was between 3 and 6 months. The palliation was effective, by having technical and clinical success, therefore considering self-expandable metallic stents as a simple and effective solution for the palliation of malignant stenosis of the gastrointestinal tract

Is Limited Endoscopic Sphincterotomy with Large Balloon Dilation Safer and More Effective than Standard Endoscopic Sphincterotomy? / 대한소화기학회지

No abstract available.

Tratamiento endoscópico ambulatorio en un paciente con coledocolitiasis de gran tamaño / Outpatient endoscopic treatment in a patient with choledocholithiasis of great size

Se presenta el caso clínico de un anciano de 75 años de edad, operado desde hacía 18 meses por presentar colelitiasis sintomática, quien acudió al cuerpo de guardia del Hospital General Docente Dr Juan Bruno Zayas Alfonso de Santiago de Cuba con dolor en hipocondrio derecho de tipo cólico biliar, intenso y con aparición posprandial tardía, acompañado de náuseas, vómitos, íctero verdínico, coluria, hipocolia e inapetencia. Los exámenes complementarios efectuados confirmaron el diagnóstico de coledocolitiasis de gran tamaño, por lo cual se le realizó colangiopancreatografía retrógrada endoscópica, esfinterotomía endoscópica y litotricia mecánica dentro del lumen coledociano. Se extrajeron con éxito todos los fragmentos resultantes del cálculo y la evolución posoperatoria resultó favorable. El paciente egresó antes de las 24 horas de haber sido intervenido, fue reevaluado a los 5 días y se le dio el alta definitiva, totalmente asintomático

The case report of a 75 year-old man, surgically treated for 18 months due to a symptomatic cholelithiasis who attended the emergency room from Dr Juan Bruno Zayas Alfonso Teaching General Hospital in Santiago de Cuba, with pain in the right hypochondrium of intense biliary-colic type and with late postprandial occurrence, accompanied by nauseas, vomits, green jaundice, brown urine, hipocolia and inappetence is presented. Additional tests confirmed the diagnosis of choledocholithiasis of a great size, reason why he was surgically treated with endoscopic retrograde cholangiopancreatography, endoscopic sphincterotomy and mechanical lithotripsy inside the choledochal lumen. All the resulting fragments of the stones were successfully extracted and the postoperative clinical course was favorable. The patient was discharged before the 24 hours of the surgery, he was re-examined after 5 days and he was definitively discharged completely asymptomatic

PCRE: ampulotomía o fistulotomía suprapapilar con needle knife para acceder a la vía biliar en canulación dificil / ERCP: ampulotomy or suprapapillary fistulotomy with needle knife to access bile ductin difficult cannulation

INTRODUCCIÓN: la canulación profunda de la via biliar principal es requisito para una Pancreato-colangiografía Retrograda Endoscópica (PCRE) de carácter terapéutico. El pre corte es una técnica practicada en casos de canulación difícil. Objetivo: Reportar los casos de pacientes con canulación difícil y fistulotomia suprapapilar como un método para la canulación selectiva del colédoco. Reportar la eficacia, hallazgos demográficos, endoscópicos y complicaciones de éste procedimiento. MATERIAL Y MÉTODOS: estudio prospectivo, descriptivo y observacional de casos. Se ha realizado en 93 pacientes sometidos a PCRE con canulación difícil en quienes se practicó el pre corte tipo Fistulotomia, en un Centro privado de Endoscopia Digestiva del 2000 al 2010 en Lima. RESULTADOS: En 1205 (100%) CPRE se hicieron 1152 (96%) papiloesfinterotomias, de éstos en 93 casos (8%) casos se hizo fistulotomia previa a la papiloesfinterotomia. El grupo atareo más frecuente fue de 61 a 70 años, la relación F:M, 2.4:1. La eficacia fue 96%, los hallazgos endoscópicos más frecuentes fueron Odditis, impactación de cálculo y la presencia de ampuloma, los diagnósticos finales fueron enfermedad litiásica (34%), seguida de la Odditis con o sin litiasis coledociana (29%), en el 75% de casos se realizó terapéutica, el 8.5% de casos presentó complicaciones (pancreatitis y sangrado). No se registró perforaciones ni colangitis. CONCLUSIONES: en esta serie la fistulotomia en casos de canulación difícil es eficaz, es más frecuente en casos de Odditis, cálculo impactado y ampuloma y las complicaciones son bajas. RECOMENDACIONES: el pre corte tipo fistulotomia está dirigida a pacientes que requieren PCRE terapéutica, la decisión de realizarla debe ser precoz, la firma de un consentimiento informado es primordial.

INTRODUCTION: Biliary conducts deep cannulation is a requirement for therapeutic Endoscopic Retrograde Cholangio-Pancreatography (ERCP). The pre-cut papillotomy is a technique for difficult cannulation cases. Aims: Report cases of hard cannulation and suprapapilar fistulotomy as a method for selective common bile duct cannulation. Report efficacy, demographic and endoscopic findings and complications of this procedure. MATERIALS AND METHODS: Observational, descriptive and prospective study of cases. Sample of 93 patients who had a difficult cannulation ERCP, in which suprapapilar fistulotomy pre-cut type was done, in a private digestive endoscopic center between 2000 and 2010 in Lima, Peru. RESULTS: 1205 (100%) ERCP were made 1152 (96%) papillosphincterotomies. Fistulotomy was done in 93 cases (8%) of these papillosphincterotomies. The most prevalent age group was 61 to 70 years old, the female-male proportion was 2.4:1. The efficacy was 96%. The most prevalent endoscopy findings were odditis, gallstone impactation and ampulloma presence, final diagnosis were lithiasic disease (34%), Odditis with or without common bile duct lithiasis (29%). Therapeutic ERCP was done in 75% of the cases, 8.5% showed complications (pancreatitis and bleeding). No perforation or cholangitis were registered. CONCLUSIONS: In this case series, fistulotomy in difficult cannulation procedures had good efficacy. Is most prevalent in cases with odditis, gallstone impactation and ampulloma. Complications of the procedure are low. RECOMMENDATIONS: The fistulotomy type of pre-cut is leaded for patients who require therapeutic ERCP. The decision for doing the procedure must be precocious and informed consent is primordial.

Tratamiento médico de la fisura anal con tadafilo tópico como principio activo / Medical treatment of chronic anal fissure with topical tadalafil

Introducción: La fisura anal es una úlcera lineal dolorosa que generalmente, aparece en la línea media posterior del canal anal, extendiéndose desde la línea dentada hasta el margen del ano. Su persistencia se debe al espasmo anómalo del músculo del esfínter interno. Hasta hace poco, la curación definitiva de las fisuras solo se logró mediante procedimientos quirúrgicos dirigidos a la ablación del espasmo esfinteriano. Diseño: Estudio prospectivo, controlado y aleatorio para comprobar la hipótesis de que la aplicación tópica de una preparación de Tadalafilo es un método efectivo y seguro para relajar el músculo liso y promover la cicatrización de la fisura anal. Población y métodos: Se seleccionaron los pacientes que acudieron a la consulta de coloproctología del HCC con diagnóstico de fisura anal (726). Todos fueron sometidos a una historia clínica y examen físico, antes del comienzo del tratamiento y seguimiento por 1 año. Los pacientes fueron divididos en tres grupos: Grupo A: tratados de forma médica con AINES por via oral, sediluvios y pomadas tópicas de esteroides 3 veces al dia. Grupo B: tratados con nitroglicerina 0,25% locales crema 3 veces al día. Grupo C: tratados con toxina botulínica inyectada 1 sola dosis en el espesor del esfínter interno del ano. Grupo D: tratados con formula magistral crema tópica de Tadalafilo aplicada 3 veces al día. Grupo E: pacientes a quienes se les realiza la Esfinterotomía Lateral Interna una vez que se considera ha fracasado el manejo médico y tratamiento farmacológico. Resultados: Se encontró predominio del sexo femenino con 370 pacientes (50.97%). Las edades en las cual se agrupó mayor cantidad de individuos fue entre los 26 a 35 años con 218 pacientes (30,02%). Predominó el diagnóstico de fisura crónica con 382 casos (52,61 %). El tratamiento inicial que se utilizó más frecuentemente fue el quirúrgico con 270 pacientes (37,19%), seguido de Tadalafilo tópico con 196 pacientes (26,99%)...

Introduction: Anal fissure is a painful linear ulcer usually appears in the posterior midline of the anal canal, extending from the dentate line to the margin of the anus. Its persistence is due to spasm abnormal internal sphincter muscle. Until recently, a definitive cure was achieved only cracks by surgical procedures aimed at ablation of the sphincter spasm. Design: Prospective. controlled trial to test the hypothesis that topical application of a preparation of Tadalafil is a safe and effective method to relax the smooth muscle and promote healing of anal fissure. Population and methods: We selected patients who attended the consultation of Coloproctology of HCC diagnosed with anal fissure (726). AIl underwent a medical history and physical examination before starting treatment and followed for 1 year. The patients were divided into three groups: Group A: treated medical oral NSAlDs, topical ointments sediluvios and steroids 3 times a day. Group B: treated with local nitroglycerin cream 0.25% 3 times a day. Group C: treated with botulinum toxin injection 1 dose in the thickness of the internal anal sphincter. Group D: treated with topical cream formulation TadalafiI masterfully applied 3 times a day. Group E: patients who underwent lateral internal sphincterotomy is considered after failed medical management and pharmacological treatment. Results: There was a predominance of females with 370 patientes (50.97%). The ages at which more individuals grouped was between 26 to 35 years with 218 patients (30.02%). The predominant diagnosis of chronic fissure with 382 cases (52.61%). The initial treatment was most frequently used surgical treatment of 270 patients (37.19%), followed by topical Tadalafil 196 patients (26.99%). The initial treatment had less failure was the use of topical Tadalafil 10 cases (1.37%), which required surgery...

Manejo médico y endoscópico de pancreatitis ascaridiana aguda en niños / Medical and endoscopic managment of acute pancreatitis ascariasis in children

La migración errática de los áscaris hacia vías biliares, vesícula biliar y conducto pancreático puede ocasionar la obstrucción de esas estructuras, manifestándose como cólico biliar, colecistitis alitiásica, colangitis, pancreatitis aguda y absceso hepático. Objetivo: reportar el manejo clínico y endoscópico de pacientes con pancreatitis ascaridiana. Pacientes y Método: estudio descriptivo, retrospectivo, de pacientes con Pancreatitis Aguda, se revisa cuadro clínico, datos epidemiológicos, etiología, exámenes paraclínicos, ultrasonido y terapia médica. Resultados: 10/34 (29,41%) con Pancreatitis Aguda por Áscaris lumbricoides; edad promedio 6,3 años, antecedente de expulsión de vermes por boca (60,00%). El dolor abdominal y vómitos en el 100%, con elevación de amilasa y lipasa. Ecografía abdominal: aumento de volumen de páncreas, vermes en vías biliares y colédoco en 100%, 4/10 (40,00%) absceso hepático y 1/10 (10,00%) pseudoquiste pancreático. Se realizo la remoción de ovillo de áscaris en duodeno por endoscopia a 5/10(50,00%), utilizando pinza de cuerpos extraño y 3/5(60,00%) para vermes impactado en papila, papilotomía mínima con extracción. Se indico Albendazol por 5 días. Conclusión: en todo niño con dolor abdominal y vómitos, se deben realizar pruebas de funcionalismo pancreático y ultrasonido abdominal para descartar pancreatitis. En la pancreatitis ascaridiana el Albendazol resulto ser una terapia satisfactoria.

The migration of Ascaris erratic to bile ducts, gallbladder and pancreatic duct can cause obstruction of these structures, manifesting as biliary colic, acalculous cholecystitis, cholangitis, acute pancreatitis and liver abscesses. Objective: To report the clinical and endoscopic ascariasis pancreatitis. Patients and Methods: A descriptive and retrospective study of patients with acute pancreatitis, we review the clinical, epidemiological, etiology, laboratory test results, ultrasound and medical therapy. Results: 10/34 (29.41%) with acute pancreatitis caused by Ascaris lumbricoides, mean age 6.3 years, history of expulsion of worms by mouth (60.00%). Abdominal pain and vomiting in 100%, with elevation of amylase and lipase. Abdominal ultrasound enlargement of the pancreas, worms in bile ducts and bile duct in 100%,%), 4/10 (40.00%), hepatic abscess and 1/10 (10.00%) pancreatic pseudocyst. Removal was performed ascaris ball of the duodenum by endoscopy at 5/10 (50.00%), using foreign body forceps and 3/5 (60.00%) for worms impacted papilla use papillotomy minimum. Albendazole is indicated for 5 days. Conclusion: In all children with abdominal pain and vomiting, should be performed pancreatic function tests and abdominal ultrasound to rule out pancreatitis. In pancreatitis ascariasis Albendazole therapy was found to be satisfactory.

Prevalencia de complicaciones biliares en colecistectomias realizadas en el Hospital Miguel Pérez Carreño en el período 2006-2009 / Prevalence of bile duct injuries after cholecystectomy performed at Hospital Miguel Pérez Carreño during 2006-2009

Las lesiones de vías biliares ocurren en un 0,2% a 1,4% de los pacientes sometidos a colecistectomías laparoscópicas, y 0,3% en las colecistectomías abiertas. La colangiopancreatografia retrograda endoscópica (PCRE) se ha convertido en una técnica de amplia utilidad terapéutica para el manejo de estas lesiones. La mayoría de las lesiones de vías biliares pueden ser tratadas de manera exitosa (en un 70-95% de los pacientes) con intervenciones endoscópicas. En el periodo 2006-2009 se han realizado en este centro 1089 colecistectomías, 486 por vía convencional y 600 vía laparoscópica. Determinar la prevalencia de complicaciones post quirúrgicas de las vías biliares, mediante PCRE, y el tipo de tratamiento realizado endoscópico o quirúrgico. Se revisaron historias clínicas y base de datos de la unidad de gastroenterología, realizándose un análisis retrospectivo, descriptivo, transversal. Se utilizo la escala de clasificación de las lesiones biliares post quirúrgica de Amsterdam. Se registraron 20 casos de lesiones postquirúrgicas de vías biliares. La técnica de colecistectomía convencional fue realizada en un 50% (N=10), la laparoscópica en un 40%(N=8). La lesión biliar más frecuente fue la tipo A en un 35% (N=7), la tipo B se presento en un 25% (N=5). y la tipo D en un 30% (N=6). La esfinterotomía endoscópica se realizo en un 70% de los pacientes (N=14). La colocación de prótesis biliar se practicó en un 55% (N=11), y requirieron tratamiento quirúrgico solo un 20% de los casos (N=5). La lesión postquirúrgica más frecuente fue la lesión biliar tipo A. El tratamiento endoscópico probó ser el tratamiento de elección y el más aplicado...

Bile duct injuries occur in 0,2% to 1,4% of patients following laparoscopic cholecystectomy and, in 0,3% in open cholecystectomy. Endoscopic retrograde cholangiopancreatography (ERCP) has become a broadly useful therapeutic technique for the treatment of these lesions. The majority of bile duct injuries can be successfully treated endoscopically in 70-95% with ERCP. One thousand eighty-nine (1089) cholecystectomies have been performed in this institution during 2006-2009; 486 open and 600 laparoscopic cholecystectomies. To determine the prevalence of post-surgical bile duct injuries by ERCP, and the type of treatment performed, endoscopic or surgical. The clinical records and database of the Gastroenterology Division; carrying out a retrospective, transversal and descriptive study. The system used to determine the type of injury was the Amsterdam post-surgical bile duct injuries rating scale. Twenty (20) cases of bile duct injury following laparoscopic or conventional cholecystectomy were registered. Conventional cholecystectomy was performed in 50% of patients (N=10), laparoscopic in 40%. The mostfrequent biliary lesions were: type A in 35% (N=7), type B in 25% (N=5) and, type D in 30% (N06). Endoscopic sphincterotomy was performed in 70% of patients (N=14). Biliary prosthesis placement was performed in 55% (N=11) and, 20% (N=5) of the cases needed surgical treatment. The mostfrequent post-surgical bile duct injury was biliary lesion type A. Endoscopic treatment proved to be the most performed, and the treatment of choice...