[Diagnostic and therapeutic endoscopic cholangiopancreatography in biliary leak after liver transplantation. Report of 2 cases]. / Colangiopancreatografía endoscópica diagnóstica y terapéutica en fuga biliar posterior a trasplante hepático. Reporte de dos casos.

BACKGROUND: The most common biliary tract complications after orthotopic liver transplantation are anastomotic strictures and bile leaks. These remain important causes of morbidity, frequently prompting surgical approach and/or biliary drainage. OBJECTIVE: To report our experience using endoscopic retrograde cholangiopancreatography (ERCP) in the diagnosis and management of biliary tract complications in patients with hepatic transplantation. PATIENTS/METHODS AND RESULTS: We present two patients with hepatic transplantation who developed bile peritonitis secondary to biliary leaks diagnosed by ERCP, both treated with sphincterotomy and biliary endoprostheses. Bile leaks rapidly resolved after endoscopic sphincterotomy and stent placement. CONCLUSIONS: ERCP is a useful diagnostic and therapeutic intervention for post-transplantation biliary tract complications.

[Proximal migration of biliary prosthesis. Endoscopic extraction techniques]. / Migración proximal de prótesis biliares. Técnicas endoscópicas de extracción.

BACKGROUND: Proximal migration of a biliary stent is an uncommon event, but its management can present a technical challenge to the therapeutic endoscopist. OBJECTIVE: We reviewed the methods that have been used for retrieval of proximally migrated biliary stents in a referral endoscopic center. PATIENTS-METHOD, AND RESULTS: From January 1995 to December 1998, there were 410 procedures for insertion of biliary stents. Eighteen patients had migrated biliary stents; 15 stents (83%) were extracted successfully. One half of the stents were retrieved by grasping the stent directly with a wire basket. Four were recovered using the Soehendra device, and a stone retrieval balloon alongside the stents to provide traction indirectly in two patients. Surgical techniques were necessary in three cases. CONCLUSIONS: In patients with a dilated duct, indirect traction with a balloon or direct grasping of the stent with a wire basket is usually successful. Cannulating the stent lumen with a wire is often the best approach in patients with biliary stricture or nondilated duct. Using these techniques, most proximally migrated biliary stents can be retrieved endoscopically.

[Insertion of biliary endoprosthesis as ambulatory procedure]. / Colocación de endoprótesis biliares como procedimiento ambulatorio.

BACKGROUND: Because of possible complications, it has been common practice to admit to the hospital most if not all patients undergoing therapeutic ERCP. Therefore, little descriptive data exist on the safety of out-patient therapeutic ERCP for endobiliary stent placement. OBJECTIVE: To assure quality patient care and patient safety, we reviewed our experience with out-patient therapeutic ERCP for palliation of benign and malignant common bile duct obstruction by means of endobiliary stent insertion. PATIENTS-METHODS AND RESULTS: A retrospective review of all therapeutic ERCPs for palliation of benign and malignant common bile duct obstruction with endobiliary stents was performed from January 1, 1998, through December 31, 1999. One hundred forty therapeutic ERCPs were performed to place an endobiliary stent for benign and malignant common bile duct obstruction. Seventy-two procedures were performed on out-patients, sixty-eight on in-patients. There was no significant difference between out-patient and in-patient groups with regard to age, gender, need for endoscopic sphincterotomy, and complication rate. In patients had one procedure-related complication; out patients had four. There was no procedure-related mortality in either group. CONCLUSIONS: Therapeutic ERCP for palliation of benign and malignant common bile duct obstruction with endobiliary stents can be safely and successfully performed on an out-patient basis for selected patients. This should result in substantial cost savings.

[Incidence and relation of endoscopic sphincterotomy to the proximal migration of biliary prostheses]. / Incidencia y relación de esfinterotomía endoscópica en la migración proximal de prótesis biliares.

BACKGROUND: Endoprostheses are commonly used in the treatment of biliary disorders. The frequency of and potential risk factors for stent migration, however, remain largely unknown. OBJECTIVE: To determine how often biliary duct stents migrate proximally and to quantify the influence of specific risk factors on the occurrence of stent migration. PATIENTS METHODS AND RESULTS: We analyzed the occurrence of stent migration among the 410 stents for which follow-up data were available between January 1995 to December 1998. In 272 cases, we performed endoscopic sphincterotomy. Results demonstrated incidence rates of 4.4% for proximal biliary stent migration iatrogenic strictures were significantly associated with proximal biliary stent migration. CONCLUSIONS: Iatrogenic strictures were significantly associated with proximal common bile duct migration and the association between sphincterotomy and proximal migration failed to reach statistical significance.

[Precut sphincterotomy: efficacy and complications]. / Esfinterotomía de precorte: eficacia y complicaciones.

BACKGROUND: The use of precut sphincterotomy has been criticized as potentially unsafe. Despite this, a number of tertiary referral center have reported their successful use of this technique to increase the rate of common bile duct cannulation and therapeutic procedures. AIM: To evaluate precut papillotomy and correlate the complication rate. METHODS-PATIENTS AND RESULTS: We performed precut sphincterotomy in 120 patients in whom attempts at standard common bile duct cannulation and sphincterotomy were unsuccessful. Bile duct diameters were correlated to the complication rate. Cannulation of the common bile duct and endoscopic sphincterotomy was successful immediately after precut sphincterotomy in 103 patients (86%), and was successful in 12 of the 17 patients who underwent repeat ERCP, for a total cannulation and sphincterotomy rate of 96%. Eight patients (6.9%) experienced complications: six bleeding, and two retroduodenal perforation. There was no procedure-related mortality, and complications were managed medically except on patient with bleeding who required surgical intervention. CONCLUSIONS: Precut sphincterotomy was effective and safe in facilitating cannulation and sphincterotomy in patients in whom standard cannulation attempts failed. Excluding patients with small duct size may further reduce the complication rate.

[Self-expanding metal prosthesis as palliative treatment in esophageal cancer]. / Prótesis metálicas auto-expandibles como tratamiento paliativo en cáncer de esófago.

BACKGROUND: Current non-surgical or endoscopic therapeutic modalities in esophageal cancer include dilatation, thermocoagulation, injection of alcohol or chemotherapeutic agents, photodynamic therapy, intracavitary irradiation, and placement of plastic or metallic prostheses. None of these procedures, however, has proved to be a simple and well-tolerated like the last one. AIM: Achieve palliation of dysphagia, in patients with nonresectable esophageal cancer treated with a metal self-expanding endoprosthesis. PATIENTS--METHODS AND RESULTS: Twelve patients (6 men and 6 women, mean age 58) with dysphagia caused by non-resectable esophageal cancer were treated with a metal self-expanding endoprosthesis. Prior to treatment, they had mean dysphagia grade of 3.5. Histologic diagnosis was squamous carcinoma in 4 cases, and adenocarcinoma in 8. Six tumors were located at the gastroesophageal junction, 4 in the distal esophagus, and 2 in the mid-esophagus. None of the patients had cervical esophageal tumor. All procedures were performed under mild intravenous sedation. Stent insertion was technically successful in 91.6%, and led to a reduction of dysphagia from a mean score of 3.5 to a mean score of 0.5 at first and 4th weeks. Ninety-one percent of the patients continued to swallow during follow-up (average follow-up: 10.5 weeks, range 1 day-35 weeks). Early complications (within 30 days) included retrosternal pain in 2 patients which resolved in a few days and one patient with recurrent bleeding from the tumor site. CONCLUSIONS: Self-expanding metal stents placement is a relatively simple and atraumatic procedure, it is safe and effective in treatment of malignant dysphagia.

[Endoscopic cholangiopancreatography (ERCP) in pediatric patients]. / Colangiopancreatografía endoscópica (CPE) en pacientes pediátricos.

BACKGROUND: While Endoscopic Retrograde Cholangio-Pancreatography (ERCP) is widely employed in the management of adult pancreaticobiliary disease, its use in children has been limited. AIMS: To evaluate if ERCP diagnostic and therapeutic, is a safe and useful procedure in the diagnosis and treatment of pancreatobiliary disorders in children. PATIENTS, METHODS AND RESULTS: We reviewed our experience with 72 ERCPs performed in 50 children (age 7-17 y, mean 14.5 y). The procedures were performed using standard adult side-viewing duodenoscopes. We used general anesthesia in 25 and conscious sedation in 47. In 38 patients we performed one, in 7/2, in 2/3, in 1/4 and in 2/5 ERCPs. The biliary or pancreatic ducts were successfully cannulated in 98%. Abnormal papilla accounted for the unsuccessful attempt. Abnormalities were found in biliary ducts in 54% and pancreatic duct in 24%, including choledocholithiasis (10), stenosis of the papilla (5), benign biliary stenoses (5), recurrent pancreatitis (4), pancreatic fistula (4), bile duct leak (3), cholelithiasis (3), chronic calcifying pancreatitis (2), pancreas divisum (2) and choledochal cyst (1). Endoscopic sphincterotomy was performed in 19 patients, 15 on biliary segment and four on pancreatic segment. Stents were placed in the biliary duct in nine patients and in pancreatic duct in six patients. Complications included abdominal pain and elevated amylase in three patients (6%), which resolved rapidly. CONCLUSIONS: ERCP in children and adolescents is a safe and underutilized diagnostic and therapeutic procedure.

Dissolution of pancreatic lithiasis by direct citrate application into the pancreatic duct in two patients with chronic idiopathic pancreatitis.

Several experimental and clinical studies have shown that citrates are useful in dissolving calcifications and proteic plug in pancreatic ducts both of alcoholic etiology and in patients with chronic pancreatitis. Until now, using citrates to dissolve stones in clinical studies was performed orally with satisfactory medium-term results, including control of abdominal pain and eradication of shadows on X-rays. Laboratory studies have shown that these concretions dissolve quickly when such compounds are applied directly. This paper reports 2 women aged 27 and 40 with histories of chronic abdominal pain, and who, by abdominal X-ray and endoscopic retrograde cholangiopancreatography (ERCP), were shown to have multiple calcifications in the main and accessory pancreatic ducts. In both patients, endoscopic sphincterotomy of the bile and pancreatic segments of the sphincter of Oddi and introduction of a nasopancreatic catheter and intraductal infusion of citrates were performed. Radiological controls showed fragmentation and disappearance of calcifications. Clinically, there was complete absence of abdominal pain in the first week following the procedure. This is the first human study of intraductal administration of citrates to dissolve pancreatic lithiasis with highly favorable results.

[Inadequate function of Oddi's sphincter. Endoscopic treatment and long-term follow up]. / Función inadecuada del esfínter de Oddi. Tratamiento endoscópico y evaluación a largo plazo.

Inadequate function of Oddi sphincter is a clinical entity of difficult diagnosis and controversial treatment. The diagnosis can be suspected by the clinical history, biochemical tests, ultrasonography and endoscopy but can only be proved by manometry. We studied 35 patients, 23 women and 12 men with a mean age of 56.4 years. They were all cholecystectomized and had pain as before they were operated. 33 had elevation of alkaline phosphatase all of them had dilatation of the main bile duct over 12 mm and delayed contrast emptying over a 45 minutes period. Manometry demonstrated high pressure of Oddi sphincter above 30 mmHg. We performed endoscopic sphincterotomy in all cases without complications. We did a clinical, biochemical and endoscopic evaluation every 3 months during the first year and every 6 months during the second and third year. Thirty one patients (81.6%) remained asymptomatic after the procedure, with improvement of the biochemical tests in all cases. We concluded that endoscopic sphincterotomy is a good alternative in the management of these patients.

[Treatment of bile duct calculi with extracorporeal lithotripsy]. / Tratamiento de los cálculos de los conductos biliares con litotripsia extracorpórea.

Currently there are several non-surgical procedures on biliary duct stones treatment; one of them is extracorporeal shock-waves lithotripsy (ESWL), which has advantages over the others. It is safe, effective and non invasive method, that does not need direct contact with the stone and has low morbidity. We treated 10 patients with ESWL generated by a piezoelectric system with ultrasonic localization. The stones were fragmented in 80% of the patients and eventually the concrements were eliminated in 63%. The complications were one case of hemobilia and another of pancreatitis.

[Effect of nasogastric tube on esophageal mucosa]. / Efecto de la sonda nasogástrica sobre la mucosa del esófago.

We studied 30 patients. 20 were males and 10 females. Mean age was 48 year old. Esophageal disease was not present neither gastro-esophageal reflux. Biopsy was taken between 24 hours and 25 days after nasogastric tube (NG) was put into place. Endoscopic findings were: hyperemic mucosa, submucosal hemorrhage, clots, erosions and ulcers near Esophago-gastric junction. Intraepithelial edema, vessel congestion, polymorphonuclear infiltration, fibrin thrombosis of submucosal vessels, ischemia, epithelial regeneration and ulcer were common histologic findings. All endoscopic and histologic alterations were related to the length of time of NG tube contact with the esophageal mucosa. We concluded that NG tube damages the esophageal mucosa by two mechanisms: a) Local irritation that favors b) gastric reflux by decreasing lower esophageal sphincter pressure.

[Usefulness of nasobiliary catheter during treatment of choledocholithiasis with extracorporeal lithotripsy]. / Utilidad de la sonda nasobiliar durante el tratamiento de la colédocolitiasis con litotricia extracorpórea.

From April to June 1990, five female patients with a mean age of 47 years, with previous cholecystectomy and the presence of bile duct stones, were treated by extracorporeal shock wave lithotripsy. Pain and jaundice was present in 4, one patient only had jaundice. In 3 patients the stones were located in the intrahepatic bile ducts, in the other 2 they were located in the common bile duct but were judged to be to large for endoscopic treatment. In all patients a sphincterotomy was performed and a nasobiliary catheter was inserted, after which extracorporeal shock wave lithotripsy was performed. Saline solution was infused through the nasobiliary tube (1 ml per minute) for 24 hours. In all the patients except one, the problem was solved in one session. Saline infusion through a nasobiliary catheter was useful as a complement of shock wave lithotripsy of bile duct stones to prevent the obstruction of the bile duct by fragments.

[Endoscopic management of biliary stones]. / Tratamiento endoscópico de la litiasis biliar.

Endoscopic sphincterotomy is one of the more effective therapeutic procedures for the management of some biliary tree abnormalities. In choledocolitiasis, a 90% succesfull rate has been obtained. Complications include bleeding, perforation, cholangitis, and pancreatitis. Mortality rates between 1.0 to 1.3% are informed. Contraindications are the same as for panendoscopy as well as the presence of stones greater than 2.5 cms. In giant stones, some other endoscopic approaches can be used, including mechanical lithotripsy, chemical treatment, electrohydraulic shockwaves, laser and biliary stent application. Endoscopic sphincterotomy is also indicated as an adjuvant therapy previous to extracorporeal lithotripsy.

Inyeccion transendoscopica del fleboesclerosante hidroxi-polietoxi-dodecano en la mucosa esofagica del perro. / Transendoscopical injection of sclerosing hydroxypolyethoxydodecane in the mucosa of the esophagus of dogs

Con objeto de conocer los efectos sobre la pared esofagica del fleboesclerosante hidroxi-polietoxidodecano, se les inyecto a 10 perros, por via transendoscopica, 1 ml.de la substancia en la mucosa submucosa del esofago. Este fleoesclerosante a diferencia de otros tiene efecto trombogenico al ser aplicado en la luz de una vena o en el tejido perivenoso. Cuando la concentracion empleada es al 2 o 3% puede producir areas de inflamacion severa, isquemia o aun necrosis, por lo que se concluye que la inyeccion al 1% es la adecuada