Iatrogenic Colonic Perforations: Changing the Paradigm.

PURPOSE: The purpose of our study was to investigate the clinical outcomes of colonoscopic perforations in patients. MATERIALS AND METHODS: We retrospectively studied patients with perforations secondary to diagnostic/therapeutic colonoscopy between 2009 and 2015 at the Pontevedra Hospital Complex. We analyzed age, closure method, length of hospitalization, and long-term progress. RESULTS: Of the 34 perforations detected, 67.6% occurred in patients aged below 75 years. Most perforations occurred in the descending colon (55%). Perforations occurred in 55.9% of outpatients and 45% of inpatients. Diagnostic and therapeutic colonoscopies caused perforations in 20.6% and 79.4% of patients, respectively. Conservative treatment alone was performed in 5.9%, complete or partial endoscopic closure in 14.7%, and surgery in 79.4% of patients. Patients treated only conservatively or with concomitant endoscopic closure showed no mortality. The mortality rate was 14.8% in those treated surgically, and 55% of these patients required a subsequent ostomy. CONCLUSIONS: Conservative management with antibiotics and parenteral nutrition concomitant with complete/partial endoscopic closure effectively treats perforations, provided intraprocedural diagnosis is possible with immediate administration of antibiotics after the procedure. Nevertheless, studies with larger number of patients and statistical analysis are necessary in the near future.

Rate of adverse events of gastroduodenal snare polypectomy for non-flat polyp is low: A prospective and multicenter study.

AIM: To evaluate the rate of adverse events (AEs) during consecutive gastric and duodenal polypectomies in several Spanish centers. METHODS: Polypectomies of protruded gastric or duodenal polyps ≥ 5 mm using hot snare were prospectively included. Prophylactic measures of hemorrhage were allowed in predefined cases. AEs were defined and graded according to the lexicon recommended by the American Society for Gastrointestinal Endoscopy. Patients were followed for 48 h, one week and 1 mo after the procedure. RESULTS: 308 patients were included and a single polypectomy was performed in 205. Only 36 (11.7%) were on prior anticoagulant therapy. Mean polyp size was 15 ± 8.9 mm (5-60) and in 294 cases (95.4%) were located in the stomach. Hemorrhage prophylaxis was performed in 219 (71.1%) patients. Nine patients presented AEs (2.9%), and 6 of them were bleeding (n = 6, 1.9%) (in 5 out of 6 AE, different types of endoscopic treatment were performed). Other 24 hemorrhagic episodes could be managed without any change in the outcome of the endoscopy and, consequently, were considered incidents. We did not find any independent risk factor of bleeding. CONCLUSION: Gastroduodenal polypectomy using prophylactic measures has a rate of AEs small enough to consider this procedure a safe and effective method for polyp resection independently of the polyp size and location.

Insuficiencia renal aguda secundaria a diarrea severa por enteropatía esprue-like asociada a olmesartán / Acute renal failure secondary to diarrhea due to sprue like-enteropathy associated with olmesartan

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Morbimortalidad de la resección pancreática / Morbidity and mortality in pancreatic resection

Objetivo Evaluar la morbimortalidad postoperatoria de la resección pancreática.Material y métodosEstudio observacional prospectivo que incluye 117 pacientes intervenidos quirúrgicamente de forma consecutiva por presentar tumoración pancreática o periampular. En 61 de ellos se hizo pancreatectomía cefálica; en 15, pancreatectomía total; en uno, enucleación y en 40, resección corporocaudal.ResultadosLa morbilidad global fue de 48,7% (59% para la pancreatectomía cefálica, 35% para la resección corporocaudal y 46,7% para la pancreatectomía total). Las complicaciones más frecuentes fueron las colecciones y abscesos intraabdominales, con un 15,38% y las complicaciones médicas, con un 13,68%. La incidencia de fístula pancreática fue de 9,83%, para la pancreatectomía cefálica y de 10% para la resección corporocaudal. La incidencia de reintervención fue de 14,53%. La mortalidad global fue de 5,12% (6,56% para la pancreatectomía cefálica, 2,5% para la resección corporocaudal y 6,67% para la pancreatectomía total). La presencia de complicaciones postoperatorias, la necesidad de reintervención y la edad superior a 70 años correlacionaron significativamente con la mortalidad.DiscusiónLa resección pancreática tiene una morbilidad alta. La mortalidad es baja y está prácticamente limitada a los pacientes mayores de 70 años (AU)

Aim Assess the postoperative morbidity rates in pancreatic resection.Material and methodProspective observational study which includes 117 patients who underwent surgery consecutively due to pancreatic or periampullary tumours. In 61 of the patients, cephalic pancreatectomy was carried out; 15 underwent total pancreatectomy; one underwent enucleation and 40 underwent distal pancreatectomy.ResultsOverall morbidity was 48.7% (59% for cephalic pancreatectomy, 35% for distal pancreatectomy and 46.7% for total pancreatectomy). The most frequent complications were intra-abdominal abscesses and collections (15.38%) and medical complications (13.68%). The incidence of pancreatic fistula was 9.83% for cephalic pancreatectomy and 10% for distal pancreatectomy. The reintervention incidence was 14.53%. Overall mortality was 5.12% (6.56% for cephalic pancreatectomy, 2.5% for distal pancreatectomy and 6.67% for total pancreatectomy). The presence of postoperative complications, the need for reintervention and the fact of being over 70 years of age correlated significantly with mortality.DiscussionPancreatic resection has high morbidity rates. Mortality is low and is practically limited to patients older than 70 years. (AU)

[Morbidity and mortality in pancreatic resection]. / Morbimortalidad de la resección pancreática.

AIM: Assess the postoperative morbidity rates in pancreatic resection. MATERIAL AND METHOD: Prospective observational study which includes 117 patients who underwent surgery consecutively due to pancreatic or periampullary tumours. In 61 of the patients, cephalic pancreatectomy was carried out; 15 underwent total pancreatectomy; one underwent enucleation and 40 underwent distal pancreatectomy. RESULTS: Overall morbidity was 48.7% (59% for cephalic pancreatectomy, 35% for distal pancreatectomy and 46.7% for total pancreatectomy). The most frequent complications were intra-abdominal abscesses and collections (15.38%) and medical complications (13.68%). The incidence of pancreatic fistula was 9.83% for cephalic pancreatectomy and 10% for distal pancreatectomy. The reintervention incidence was 14.53%. Overall mortality was 5.12% (6.56% for cephalic pancreatectomy, 2.5% for distal pancreatectomy and 6.67% for total pancreatectomy). The presence of postoperative complications, the need for reintervention and the fact of being over 70 years of age correlated significantly with mortality. DISCUSSION: Pancreatic resection has high morbidity rates. Mortality is low and is practically limited to patients older than 70 years.

Seudomixoma peritoneal presentado como ascitis en paciente cirrótico / Peritoneal pseudomyxoma presenting as ascites in a patient with cirrhosis

Presentamos el caso de un paciente cirrótico con ascitis y gradiente de albúmina menor de 1,1g/dl. Tras la realización de pruebas endoscópicas, incluyendo ecoendoscopia alta con PAAF, se decide llevar a cabo una laparoscopia exploradora para esclarecer el diagnóstico, observándose mucina por toda la cavidad peritoneal y nódulos sobre el peritoneo parietal y elvisceral. Tras el estudio anatomopatológico se estableció seudomixoma peritoneal como diagnóstico. Esta infrecuente entidad, de pronóstico infausto en ausencia de tratamiento, suele generarse en tumores mucinosos apendiculares, y en segundo lugar desde tumores ováricos (AU)

We present the case of a cirrhotic patient with ascites and an albumin gradient of less than 1.1g/dl. After endoscopic tests, including upper gastrointestinal endoscopic ultrasound-guided fine-needle aspiration, exploratory laparoscopy was performed to provide the diagnosis, revealing mucin throughout the peritoneal cavity and nodules on the parietal and visceral peritoneum. Histopathological analysis established the diagnosis as peritoneal pseudomyxoma. This uncommon entity, which has a poor prognosis without treatment, is most frequently associated with mucinous tumors of the appendix, and secondly, with tumors of the ovary (AU)

EUS-guided drainage and stent placement for postoperative intra-abdominal and pelvic fluid collections in oncological surgery.

OBJECTIVES: The objective of this study was to evaluate the role and benefits of endoscopic ultrasonography (EUS) in the management of postoperative intra-abdominal fluid collections after attempted curative surgery for abdominal cancer. METHODS: The authors retrospectively analysed the Endobase from 1 July 2007 to 30 January 2011 for patients with a postoperative intra-abdominal fluid collection who had undergone EUS-guided drainage and the placement of a stent. The data analysed included the demographics, type of surgery and clinical indications of each patient as well as their clinical and radiological findings. RESULTS: Six patients (three men and three women; mean age, 61.8 years [range, 38-78 years]) with intra-abdominal and pelvic fluid collections after abdominal surgery for cancer had undergone EUS-guided internal drainage. All procedures had been performed using linear EUS guidance and 8-Fr stent drainage catheters ('one step device', Giovannini, NWOA system Needle-Wire, Cook). The collection types included perigastric abscess (n = 3), perigastric hematoma and rectal hematoma (n = 1), perirectal biloma (n = 1), and perirectal abscess (n = 1). Patients had undergone the following types of surgery: lower-anterior rectal resection (n = 2), Whipple's duodenopancreatectomy type (n = 1), total gastrectomy (n = 1), splenectomy (n = 1), and distal pancreatectomy (n = 1). The number of stents inserted for each collection was one (five patients) and two (one patient). CONCLUSIONS: EUS-guided drainage and stenting provide another option for the management of postoperative collections. It allows access to areas that are difficult to reach with the CT-guided approach and it can be performed accurately, efficiently and safely. In addition to this, the internal nature of the drainage offers patients more comfort.

[Peritoneal pseudomyxoma presenting as ascites in a patient with cirrhosis]. / Seudomixoma peritoneal presentado como ascitis en paciente cirrótico.

We present the case of a cirrhotic patient with ascites and an albumin gradient of less than 1.1 g/dl. After endoscopic tests, including upper gastrointestinal endoscopic ultrasound-guided fine-needle aspiration, exploratory laparoscopy was performed to provide the diagnosis, revealing mucin throughout the peritoneal cavity and nodules on the parietal and visceral peritoneum. Histopathological analysis established the diagnosis as peritoneal pseudomyxoma. This uncommon entity, which has a poor prognosis without treatment, is most frequently associated with mucinous tumors of the appendix, and secondly, with tumors of the ovary.

Extraparietal or lymphatic late relapse of neoplasms: confirmation by means of EUS-FNA key for the treatment.

BACKGROUND: After treatment intended to cure systemic neoplasms, a series of monitoring strategies are followed. OBJECTIVE: To analyse our experience in confirming the cases of lymphatic or extraparietal relapse in areas accessible to endoscopic ultrasonography plus fine-needle aspiration (EUS-FNA) in long-term monitoring (>1 year of treatment for the primary neoplasm) and define what implications have been derived with regards histopathological confirmation in relation to treatment. MATERIALS AND METHODS: Retrospective analysis was made of all EUS-FNA carried out in our Endoscopy Unit during the period from 1/07/2007 to 28/02/2010 by means of searches in the Endobase (Olympus) database. Medical records of patients and drug therapy were reviewed in order to check the chemotherapy used in each case. RESULTS: From a total of 154 EUS-FNA carried out in our service, we have detected histopathological confirmation of malignancy in primary neoplasm treated with initial curative intention at least 1 year before. Locations were: esophageal extraparietal involvement of a squamous cell carcinoma (one patient), perirectal adenopathy of rectal adenocarcinoma (one patient), multiple lymphatic relapse of melanoma (two patients), perigastric adenopathy relapse of gastric adenocarcinoma (one patient), pancreatic head mass secondary to initial breast ductal carcinoma (one patient). In all cases, this fact has involved a directed treatment: surgery (one patient), radiotherapy (one patient), chemotherapy (four patients). CONCLUSIONS: Confirmation by means of EUS-FNA of late relapse in any section of the digestive tract allowed a treatment to be carried out by surgery, radiotherapy, or chemotherapy.

The global impact of endoscopic ultrasound (EUS) regarding the survival of a pancreatic adenocarcinoma in a tertiary hospital.

BACKGROUND: Pancreatic ductal adenocarcinoma is a type of neoplasm with a high mortality rate. There are a number of different procedures that may be followed in the study of the pancreas; one such procedure is endoscopic ultrasonography (EUS). OBJECTIVE: This study aimed to retrospectively evaluate the impact on patient survival of a biliopancreatic EUS performed 2 months prior to the first treatment session of the pancreatic ductal adenocarcinoma. MATERIAL AND METHODS: We carried out a retrospective evaluation of the medical case histories of our patients who had been diagnosed with pancreatic ductal adenocarcinoma over a period of 10 years (1 Jan 1999-31 Dec 2008), combining the computer archives of our Pathological Anatomy (biopsy and cytology) Dept. and those of the Digestive Department's Endoscopic Ultrasonography Unit in order to exclude any pancreatic neoplasms derived from other origins. Information regarding the patients' age, sex, tumor location, and various diagnostic tests (EUS, EUS-fine-needle aspiration (FNA), helical computed tomography (CT), multidetector-row CT (MDCT)) were recorded, along with the different treatments that had been followed in each case. RESULT: When the survival rates of patients diagnosed with and without EUS were compared, evaluating the average survival rate and the survival rate after 1, 3, and 5 years, respectively, the differences in the results proved to be statistically significant (p = 0.014) in favor of the diagnosis with EUS. However, no significant differences were found when using other diagnostic imaging methods, such as EUS-FNA (p = 0.271), helical CT (p = 0.843), or MDCT (p = 0.738). To evaluate other influencing survival factors, a study was undertaken to record data depending on the sex of the patients. Results showed a higher survival rate in the female patients with a median of 6.57 months compared to that of the male patients with a median of 4.7 months (p = 0.014). Variables, which had resulted significant prior to treatment, were included in a multivariate Cox regression model, after which only the sex and EUS remained significant. CONCLUSION: A biliopancreatic EUS carried out during the 2 months prior to the start of the treatment of the pancreatic ductal adenocarcinoma has a statistically significant impact on the patient survival rate. We believe that this is due to the possibility of a very-early-stage diagnosis of the adenocarcinoma permitted by the use of this technique.

Inicio de la enfermedad celíaca tras curación de hepatitis aguda por el virus de la hepatitis B / Onset of celiac disease after acute hepatitis B infection

La enfermedad celíaca se caracteriza por el daño de la mucosa intestinal y la consiguiente malabsorción de nutrientes en individuos genéticamente predispuestos tras la ingesta de gluten. Es una enfermedad compleja, resultado de la interacción de un componente genético poligénico y varios factores ambientales. Se ha propuesto la teoría de que procesos infecciosos transitorios o aumentos en la permeabilidad de la barrera mucosa podrían facilitar el inicio de la enfermedad por los péptidos del gluten de la luz intestinal. Presentamos el caso de 2 pacientes que presentaron el inicio de la enfermedad tras la curación de una hepatitis aguda por virus de la hepatitis B. Se discute la fisiopatología de la enfermedad y se plantean hipótesis que expliquen esta asociación (AU)

Celiac disease is characterized by small intestinal mucosal injury and nutrient malabsorption in genetically susceptible individuals following dietary ingestion of gluten. The pathogenesis of the disease involves interactions between environmental, genetic, and immunologic factors. Transient infections or increased permeability of the mucosa may facilitate disease onset induced by the uptake of gluten peptides into a microenvironmental milieu in the small intestinal mucosa. We present two patients with onset of celiac disease after resolution of acute hepatitis B virus infection. The physiopathology of celiac disease is discussed and possible explanations for this association are proposed (AU)

[Onset of celiac disease after acute hepatitis B infection]. / Inicio de la enfermedad celíaca tras curación de hepatitis aguda por el virus de la hepatitis B.

Celiac disease is characterized by small intestinal mucosal injury and nutrient malabsorption in genetically susceptible individuals following dietary ingestion of gluten. The pathogenesis of the disease involves interactions between environmental, genetic, and immunologic factors. Transient infections or increased permeability of the mucosa may facilitate disease onset induced by the uptake of gluten peptides into a microenvironmental milieu in the small intestinal mucosa. We present two patients with onset of celiac disease after resolution of acute hepatitis B virus infection. The physiopathology of celiac disease is discussed and possible explanations for this association are proposed.

Evaluation of the bilio-pancreatic region using endoscopic ultrasonography in patients referred with and without abdominal pain and CA 19-9 serum level elevation.

CONTEXT: When assessing the bilio-pancreatic region, collating the findings of serum CA 19-9 values together with findings from various imaging tests--especially endoscopic ultrasonography--is not a simple issue in daily clinical practice. AIM: To assess the usefulness of endoscopic ultrasonography in an Endoscopic Ultrasonography Unit in two situations: patients with asymptomatic elevation of serum CA 19-9 and patients who presented with abdominal pain plus elevation of CA 19-9. METHODS: A retrospective study of those patients who underwent radial endoscopic ultrasonography between October 2004 and September 2005 in our institution, considering an elevation of CA 19-9 (equal to or greater than 37 U/mL) with or without symptoms. In each case, the parameters recorded were: levels of CA 19-9 one week before EUS, results from other imaging techniques (US, helical CT), and final diagnosis according to pathological and/or clinical evolution criteria. Patients with previous attacks of acute pancreatitis and also those who presented with bile duct dilation or space-occupying lesions in image studies (US and CT) were excluded. Twenty-two patients met the inclusion criteria. RESULTS: Asymptomatic elevation of CA 19-9 was found in 15 patients while 7 patients had elevated CA 19-9 levels as well as pain of uncertain origin. The results of EUS in the asymptomatic patients were: chronic pancreatitis in 7 patients, no pancreatic alterations in 3 patients, and renal cysts, choledocholithiasis, microlithiasis and liver cirrhosis in one patient, respectively. In patients with abdominal pain, EUS showed chronic pancreatitis in 6 cases and adenocarcinoma of the tail of the pancreas in the remaining patient. CONCLUSIONS: When EUS was indicated for the asymptomatic elevation of CA 19-9, the main findings were benign diseases. EUS was useful in studying patients with idiopathic abdominal pain and a slight elevation of CA 19-9 since it allowed us to detect chronic pancreatitis and even early adenocarcinoma of the pancreatic tail.