Ambulatory seton placement followed by fistulotomy: efficacy and safety for perianal fistula treatment.

PURPOSE: To evaluate the efficacy and safety of ambulatory seton placement followed by superficial fistulotomy as treatment of perianal fistula. METHODS: Retrospective observational analysis of patients with cryptogenic perianal fistula aged 18-90 years, followed in a central hospital proctology consultation between 2006 and 2017. Data were obtained through clinical record's analysis. Fistula was characterized, using Parks Classification. A probe was passed through the fistula tract, followed by a seton, which remained in situ until superficial fistulotomy was possible. RESULTS: Ninety-six patients were included (66.67% males, mean age 56 ± 15 years old). Nineteen patients (19.89%) had previous history of perianal fistula and 14 (14.58%) previous anorectal surgery. Seventy-four patients (78.72%) were submitted to fistulotomy, three (3.19%) had seton fistulotomy and one had no seton progression. Intention-to-treat and per-protocol efficacy analyses were 80.2 and 98.7%, respectively. Among the 74 patients who completed the procedure, type of fistula and time with seton were distributed as followed: 47 (63.51%) intersphincteric fistula (15 ± 31 weeks), 26 (35.14%) transsphincteric fistula (32 ± 47 weeks), one (1.35%) suprasphincteric fistula (11 weeks). Previous fistula was associated with a longer time with seton (P = 0.018). Incontinence was reported in two (2.7%) patients, who had previous perianal fistula or anorectal surgery. Two patients (2.7%) had recurrence after fistulotomy. CONCLUSION: Placement of seton followed by superficial fistulotomy in an ambulatory setting is a safe and effective method for simple low perianal fistula treatment. Incontinence rate may be higher in patients with previous perianal fistula or anorectal surgery.

Long-Term Self-Expandable Metal Stent (SEMS) for Esophageal Variceal Bleeding: A Picture of the Natural History.

INTRODUCTION: We aim to discuss the utility of self-expandable esophageal metal stent (SEMS) in variceal bleeding in challenging cases. METHODS: Case description, discussion on patient management and decision-making process in an uncommon situation, from a multidisciplinary point of view. RESULTS: We report a case of a cirrhotic patient with refractory variceal bleeding who underwent a SEMS placement, which remained in situ for 9 months. This decision was based on the initial poor status and short life expectancy, limiting the consideration of other options for lowering portal hypertension, along with an underlying prothrombotic predisposition. However, the patient's general and hepatic improvement and the development of dysphagia led to the SEMS removal, exposing a large esophageal-tracheal fistula. DISCUSSION: Early patient evaluation, risks of long-term SEMS, and life expectancy should be taken in consideration before SEMS placement.

Endoscopic Treatment of Early Gastric Obstruction After Sleeve Gastrectomy: Report of Two Cases.

Morbid obesity is an epidemic and complex disease which imposes a multidisciplinary approach. Laparoscopic sleeve gastrectomy has become a frequent procedure given its efficacy and safety compared to other surgical options. However, it isn't free from complications. Lax gastric fixation or incorrect positioning of the stomach during surgery can result in early gastric outlet obstruction caused by a volvulus-like mechanism by rotation of the stomach around its anatomic axes. This report refers to two cases of post sleeve gastric torsion resulting in persisting vomiting after initiating oral intake. The diagnosis was confirmed by upper gastrointestinal-contrast study and gastroscopy. In both cases, a fully covered self-expandable metallic stent was inserted which prompted the gastric lumen to become permeable resulting in symptomatic resolution. The stents were removed endoscopically after two and three months. Beyond more than three years of follow-up, the patients remain asymptomatic and no recurring "stenosis" was noticed. In these cases the use of fully covered self-expandable metallic stents demonstrated to be effective and safe in the treatment of post sleeve gastric torsion.

A obesidade mórbida é uma doença epidémica complexa, que impõe uma abordagem multidisciplinar. A gastrectomia vertical laparoscópica tornou-se um procedimento frequentemente utilizado dada a sua eficácia e segurança em comparação com outras opções cirúrgicas. Contudo não é isenta de complicações. A fixação gástrica mais laxa ou o posicionamento incorreto do estômago durante a cirurgia pode resultar em obstrução gástrica precoce após a cirurgia, que é provocada por um mecanismo semelhante ao do volvo ­ por rotação do estômago em torno do seu próprio eixo anatómico. Apresentam-se dois casos de torção gástrica pós gastrectomia tubular, resultando em vómitos persistentes depois do início da dieta oral. O diagnóstico foi confirmado por estudo contrastado gastrointestinal e gastroscopia. Em ambos os casos, foram colocadas próteses metálicas auto-expansíveis totalmente cobertas, restituindo a permeabilidade do lúmen gástrico com resolução sintomática. As próteses foram removidas endoscopicamente ao fim de 2 e 3 meses. Após mais de 3 anos de seguimento, os doentes permanecem assintomáticos e não se verificou "estenose" recorrente. Nestes casos, o uso de próteses metálicas auto-expansíveis totalmente cobertas demonstrou ser eficaz e seguro no tratamento da torção gástrica pós gastrectomia tubular.

Endoscopic bilio-duodenal bypass: outcomes of primary and revision efficacy of combined metallic stents in malignant duodenal and biliary obstructions.

BACKGROUND: Self-expandable metal stents (SEMSs) can be used for palliation of combined malignant biliary and duodenal obstructions. However, the results of the concomitant stent placement for the duration of the patients' lives, as well as the need for and efficacy of endoscopic revision, are unclear. AIM: This study evaluated the clinical effectiveness of SEMS placement for combined biliary and duodenal obstructions throughout the patients' lives and the need for endoscopic revision. METHODS: This study is a retrospective multicenter study of 50 consecutive patients who underwent simultaneous or sequential SEMS placement for malignant biliary and duodenal obstructions. The data were collected to analyze the sustained relief of obstructive symptoms until the patients' death and the efficacy of endoscopic revision, as well as stent patency, adverse events, survival and prognostic factors for stent patency. RESULTS: Technical and immediate clinical success was achieved in all of the patients. Duodenal stricture occurred before the papilla in 35 patients (70 %), involved the papilla in 11 patients (22 %) and was observed distal to the papilla in four patients (8 %). Initial biliary stenting was performed endoscopically in 42 patients (84 %) and percutaneously in eight patients. After combined stenting, 30 patients (60 %) required no additional intervention until the time of their death. The remaining 20 patients were successfully treated using endoscopic stent reinsertion: nine patients needed biliary revision, three patients needed duodenal restenting and eight patients needed both biliary and duodenal reinsertion. The median duodenal stent patency and median biliary stent patency were 34 and 27 weeks, respectively. The median survival after combined stent placement was 18 weeks. A Cox multivariate analysis showed that duodenal stent obstruction after combined stenting was a risk factor for biliary stent obstruction (hazard ratio 6.85; 95 % confidence interval 1.43-198.98; P = 0.025). CONCLUSIONS: Endoscopic bilio-duodenal bypass is clinically effective, and the majority of the patients need no additional intervention until their death. Endoscopic revision is feasible and has a high success rate.

[Prognostic value of the finding of blood/clots in the stomach at the emergency upper endoscopy]. / Valor prognóstico da presença de sangue/coágulos no lúmen gástrico na endoscopia de urgência.

INTRODUCTION: In the setting of upper endoscopy after upper gastrointestinal bleeding (UGIB), the presence of blood or clots in the gastric lumen precluding the complete mucosal examination is a frequent finding. AIMS: To define the prognostic value of this endoscopic finding and the need of a follow-up endoscopy. METHODS: Retrospective study of 100 consecutive patients with UGIB and the endoscopic finding of blood in the stomach (Group A) and 100 at the same conditions but without this endoscopic finding (Group B). In both groups we compared the bleeding lesions and the presence of clinic, laboratorial and endoscopic signs of severity. RESULTS: Gastric and duodenal ulcers were the bleeding lesions more frequently identified in both groups. Lesions related to portal hypertension were more frequent in the first than in the second one. There was also a significant association with other endoscopic signs of severe haemorrhage and with the clinical signs of bad prognosis. In the follow-up endoscopy we found new lesions in 46% of the patients in the first group and only in 15% of the second one. CONCLUSIONS: The endoscopic finding of blood or clots in the stomach should be considered as a bad prognostic sign and lead to a second endoscopy.