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

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.

El gradiente de presión venoso hepático y la biopsia hepática transyugular en la evaluación de los pacientes con insuficiencia renal y hepatopatía crónica / Hepatic venous pressure gradient and transjugular liver biopsy to assess patients with kidney failure and chronic liver disease

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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.

Eficacia del colonoscopio pediátrico como enteroscopio de pulsión en el manejo de los hallazgos de la cápsula endoscópica / Efficacy of pediatric colonoscopy used as push enteroscopy in the management of capsule endoscopy findings

Introducción: los recientes avances en endoscopia nos hanpermitido explorar de una forma más eficaz el intestino delgado,tanto con la cápsula endoscópica (CE) como con enteroscopia dedoble balón. El problema que aparece es la no disponibilidad deestos dos métodos en todos los hospitales. Por ello, cuando se venlesiones en la CE, una alternativa posible para el tratamiento delas lesiones de yeyuno proximal podría ser la realización de unaenteroscopia de pulsión con colonoscopio con fines terapéuticosy de marcaje para control de las lesiones.Objetivos: describir la eficacia del colonoscopio pediátrico encuanto al diagnóstico, señalización de zona explorada y posibilidadesterapéuticas.Material y métodos: durante el periodo comprendido entreoctubre de 2007 y septiembre de 2008, se han realizado 21 enteroscopiascon colonoscopio pediátrico, de las cuales 9 eran paratomar biopsias yeyunales por sospecha de patología mucosa. Delas otras 12, en 10 se vieron lesiones por la cápsula endoscópica(malformaciones vasculares o sangrado yeyunal) y en 2 se hizotránsito intestinal sospecha de estenosis yeyunal.Se utilizó un colonoscopio pediátrico PENTAX EC-3470-LKque presenta un diámetro de sección de 11,6 mm y un canal detrabajo de 3,8 mm, lo cual nos permite realizar cualquier tipo detratamiento endoscópico habitual.Resultados: se hizo enteroscopia con fines terapéuticos en7 hombres y 5 mujeres, con una edad media de 63,3 años. Sevieron lesiones endoscópicas en yeyuno en diez casos: 5 angiodisplasias,2 estenosis yeyunales, uno con pliegues engrosados yeyunalescon histología normal, un tumor submucoso erosionado yun caso de varices duodenales y yeyunales.En los últimos pacientes se hizo marcaje de la zona más distalexplorada con tinta china (2) o con hemoclips (4) o con ambos,para ayudar a localizar topográficamente las lesiones mediante radiologíasimple de abdomen o cápsula endoscópica...(AU)

Background: recent advances in endoscopy have enabled us toexplore the small intestine more efficiently, both with capsule endoscopyand double-balloon enteroscopy. However, these methodsare not available in all hospitals. Therefore, when capsule endoscopyreveals proximal jejunal lesions, a possible alternative for treatmentcould involve push enteroscopy combined with colonoscopy. Lesionscan thus be marked for subsequent monitoring.Objectives: to describe the efficacy of pediatric colonoscopyfor diagnosis, the marking of the area explored, and therapeuticoptions.Material and methods: between October 2007 and September2008 a total of 21 enteroscopies were performed using apediatric colonoscope. Nine of these were used to take jejunalbiopsy samples due to suspected disease of the mucosa. In 10 ofthe remaining 12, capsule endoscopy revealed lesions (vascularmalformations or jejunal bleeding), and in 2 intestinal transit timewas analyzed due to suspected jejunal stenosis. We used a PENTAXEC-3470-LK pediatric colonoscope, whose 11.6-mm sectionaldiameter and 3.8-mm working channel make it possible toadminister all the usual endoscopic treatments.Results: therapeutic endoscopy was performed on 7 men and5 women (mean age 63.3 years). Jejunal lesions were observed in10 cases (5 cases of angiodysplasia, 2 cases of jejunal stenosis, 1case of nonmalignant thickened jejunal folds, 1 eroded submucosaltumor, and 1 case of duodenal and jejunal varices). The mostdistal area was marked with India ink (2), hemoclips (4), or both tohelp locate the lesions using simple abdominal radiography orcapsule endoscopy.Conclusions: jejunal enteroscopy enabled a firm diagnosis tobe made in most of the patients studied. We were able to treat58% of patients and mark the areas explored for subsequent follow-up. With hemoclips we were able to locate the most distalpoint explored using simple abdominal radiography(AU)

Treatment cost of ulcerative colitis is apheresis with Adacolumn cost-effective?

BACKGROUND: Scarce data are available in Europe on the cost of treatment for ulcerative colitis (UC). AIM: To assess the cost of illness of moderate-to-severe UC in two scenarios: traditional treatment versus alternative treatment incorporating granulocyte, monocyte adsorption - apheresis (GMA-Apheresis; Adacolumn). To determine the relative cost-effectiveness of both options in steroid-dependent patients. METHODS: One-year cost-of-illness and cost-effectiveness analysis from the third-payer perspective using a decision tree model was carried out. Probabilities of each event were derived from the literature and an expert panel. Direct medical costs were obtained from official sources (euro2004). Effectiveness was measured by the proportion of patients achieving clinical remission. RESULTS: The average annual cost per patient treated with traditional treatment was estimated to be euro6740; with GMA-Apheresis, the cost was estimated to be euro6959. In steroid-dependent patients, the average annual cost was euro6059 and euro11,436, respectively. The proportion of patients achieving clinical remission with GMA-Apheresis was 22.5% higher. As second- and third-line therapy, a new course of corticosteroids and surgery was avoided in 18.5 and 4% of patients, respectively. CONCLUSIONS: Incorporating GMA-Apheresis (Adacolumn) in the therapeutic management of moderate-to-severe UC patients is cost-effective and implies savings related to the reduction of adverse effects derived from corticosteroid use and to the decreased number of surgical interventions.

Enfermedad de Castleman multicéntrica: hallazgos ecoendoscópicos / Multicentric Castleman disease: endoscopic ultrasonographic findings

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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.

Hepatitis inducida por infliximab en un paciente con enfermedad de Crohn / Infliximab-induced hepatitis in a patient with Crohn’s disease

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Prótesis esofagoenterales en pacientes con recidiva de adenocarcinoma gástrico / Esophagoenteral stents in patients with recurrent gastric adenocarcinoma

Uno de los problemas que puede aparecer en los pacientescon gastrectomía total por adenocarcinoma con anastomosis esofagoenterales la aparición de estenosis de la anastomosis o próximaa ella. Estas estenosis con frecuencia son malignas debido a laaparición de recidiva en la neoplasia. Las posibilidades terapéuticasde las que disponemos son el bypass quirúrgico o bien el tratamientopaliativo. Existe muy poca experiencia descrita en la literatura(21 casos) sobre la colocación de prótesis metálicasautoexpandibles como tratamiento paliativo de los síntomas de laestenosis.Presentamos nuestra experiencia en 3 pacientes, en los que secolocaron 4 prótesis esofágicas (1 recubierta y 3 no recubiertas)con buenos resultados. Desapareció o mejoró la disfagia, permitióla ingesta de dieta blanda y supuso una mejora en la calidad devida a la vez que impide la pérdida ponderal. Parece un tratamientopaliativo eficaz como tratamiento de la disfagia en pacientescon recidiva tumoral en la anastomosis de las gastrectomías totales

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

Documento de consenso en el uso de la granulocitoaféresis en pacientes con enfermedad inflamatoria intestinal / Consensus document on the use of granulocytapheresis in patients with inflammatory bowel disease

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