Uso de prótesis esofágicas cubiertas de doble malla en fístulas esofágicas postquirúrgicas y perforaciones esofágicas: experiencia en nuestro centro / Use of double-layered covered esophageal stents in post-surgical esophageal leaks and esophageal perforation: Our experience

Introducción: El uso de prótesis esofágicas para el manejo endoscópico de fístulas y perforaciones se ha convertido en un procedimiento habitual. Una de sus limitaciones es su alta tasa de migración. Para resolver esta situación, se ha propuesto el uso de prótesis cubiertas de doble malla.Objetivos: Analizar nuestra experiencia práctica en el empleo de prótesis esofágicas cubiertas de doble malla (PECDM) (modelo Niti S™ DOUBLE™ Esophageal Metal Stent) en pacientes con fístula o perforación esofágica.Material y métodos: Estudio retrospectivo, descriptivo y unicéntrico, donde se incluyen pacientes con diagnóstico de fístula o perforación esofágica, desde noviembre 2010 hasta octubre 2018. Como objetivo primario, se evaluará su eficacia en términos de éxito técnico. Como objetivo secundario, se analizará su perfil de seguridad.Resultados: Se incluyeron inicialmente un total de 31 pacientes, siendo 8 de ellos excluidos por fallecimiento por causas ajenas a la técnica. Se detectó un éxito técnico del 100%, con un éxito primario del 75% tras la recolocación de la prótesis. Entre sus complicaciones, la migración ocurrió en un 21,7% de los pacientes (n=5), resolviéndose vía endoscópica en el 100% de los casos.Conclusiones: Según nuestros hallazgos, las PECDM suponen una alternativa en el tratamiento de fístulas y perforaciones esofágicas, con una alta tasa de éxito en la resolución de fístulas y baja de complicaciones, en contraste con lo expuesto en las series publicadas. En todos los casos, la migración de la prótesis se resolvió mediante recolocación endoscópica, sin requerir nueva prótesis ni cirugía.(AU)

Introduction: The use of esophageal stents for the endoscopic management of esophageal leaks and perforations has become a usual procedure. One of its limitations is its high migration rate. To solve this incovenience, the double-layered covered esophageal stents have become an option.Objectives: To analyse our daily practice according to the usage of double-layered covered esophageal metal stents (DLCEMS) (Niti S™ DOUBLE™ Esophageal Metal Stent Model) among patients diagnosed of esophageal leak or perforation.Methods: Retrospective, descriptive and unicentric study, with inclusion of patients diagnosed of esophageal leak or perforation, from November 2010 until October 2018. The main aim is to evaluate the efficacy of DLCEMS, in terms of primary success and technical success. The secondary aim is to evaluate their (the DLCEMS) safety profile.Results: Thirty-one patients were firstly included. Among those, 8 were excluded due to mortality not related to the procedure. Following stent placement, technical success was reached in 100% of the cases, and primary success, in 75% (n=17). Among the complications, stent migration was present in 21.7% of the patients (n=5), in whom the incident was solved by endoscopic means.Conclusions: According to our findings, DLCEMS represent an alternative for esophageal leak and perforation management, with a high success rate in leak and perforation resolutions and low complication rate, in contrast to the published data. The whole number of migrations were corrected by endoscopic replacement, without the need of a new stent or surgery.(AU)

Use of double-layered covered esophageal stents in post-surgical esophageal leaks and esophageal perforation: Our experience. / Uso de prótesis esofágicas cubiertas de doble malla en fístulas esofágicas postquirúrgicas y perforaciones esofágicas: experiencia en nuestro centro.

INTRODUCTION: The use of esophageal stents for the endoscopic management of esophageal leaks and perforations has become a usual procedure. One of its limitations is its high migration rate. To solve this incovenience, the double-layered covered esophageal stents have become an option. OBJECTIVES: To analyse our daily practice according to the usage of double-layered covered esophageal metal stents (DLCEMS) (Niti S™ DOUBLE™ Esophageal Metal Stent Model) among patients diagnosed of esophageal leak or perforation. METHODS: Retrospective, descriptive and unicentric study, with inclusion of patients diagnosed of esophageal leak or perforation, from November 2010 until October 2018. The main aim is to evaluate the efficacy of DLCEMS, in terms of primary success and technical success. The secondary aim is to evaluate their (the DLCEMS) safety profile. RESULTS: Thirty-one patients were firstly included. Among those, 8 were excluded due to mortality not related to the procedure. Following stent placement, technical success was reached in 100% of the cases, and primary success, in 75% (n=17). Among the complications, stent migration was present in 21.7% of the patients (n=5), in whom the incident was solved by endoscopic means. CONCLUSIONS: According to our findings, DLCEMS represent an alternative for esophageal leak and perforation management, with a high success rate in leak and perforation resolutions and low complication rate, in contrast to the published data. The whole number of migrations were corrected by endoscopic replacement, without the need of a new stent or surgery.

The safety of deep sedation with propofol controlled by the endoscopist in endoscopic retrograde cholangiopancreatography (ERCP): a prospective study in a tertiary hospital.

INTRODUCTION: propofol administered by an endoscopist with a trained nurse has evolved as an alternative to anesthesia monitoring and is increasingly common in the routine clinical practice, even in advanced endoscopy. OBJECTIVE: to evaluate the safety of deep sedation with endoscopist-controlled propofol in patients undergoing endoscopic retrograde cholangiopancreatography (ERCP). MATERIAL AND METHODS: this was a prospective study in patients undergoing ERCP under deep sedation with propofol. Different patient-related variables were included and the initial and final data on oxygen saturation (SatO2), blood pressure (BP) and heart rate (HR) were recorded in order to determine the presence of adverse events due to sedation (hypoxemia, hypotension, or bradycardia). RESULTS: a total of 661 patients underwent ERCP under sedation with propofol over a 24-month period. The rate of recorded adverse events was 9.7%. The most frequent adverse event was hypoxemia (5.7%), followed by bradycardia (2.4%) and hypotension (1.6%). According to the univariate analysis, the occurrence of adverse events due to sedation (AES) was associated with an ASA score ≥ III (p = 0.026), older patients (p = 0.009), higher body mass index (BMI) (p = 0.002) and a longer exploration time (p = 0.034). The induction dose of propofol was also associated with a greater likelihood of adverse events (p = 0.045) but not the total dose of propofol administered (p = 0.153). According to the multivariate logistic regression analysis, age, body mass index (BMI) and the duration of the exploration were independent predictors of SAE (p < 0.05). CONCLUSION: deep sedation with propofol controlled by trained endoscopy staff is a safe method in complex endoscopic procedures such as ERCP.

Tratamiento actual de la hepatitis B: ¿dónde encajan los nuevos análogos de los núcleos(t)idos? / Current treatment of hepatitis B infection: where do the new nucleos(t)ide analogues fit in?

La aparición de los análogos de nucleós(t)idos ha sido uno de los avances más importantes en el tratamiento de la hepatitis crónica por infección del virus de la hepatitis B. Los primeros antivirales empleados presentaban una eficacia limitada por la tasa de resistencias elevada pero en los últimos años han aparecido nuevas moléculas (tenofovir, entecavir) con mayor potencia antiviral y menor tasa de resistencias, y por ello las guías clínicas más actuales los consideran de primera elección. No obstante, el interferón todavía puede tener un papel relevante en el tratamiento de la hepatitis B en pacientes seleccionados. Además, en determinadas circunstancias como la insuficiencia renal, el embarazo o la inmunodepresión no se ha definido con exactitud el papel de los nuevos antivirales orales.En esta revisión se analizan estos aspectos, así como algunas peculiaridades del manejo de los pacientes tratados con análogos de nucleós(t)idos (AU)

Introducción La aparición de los análogos de nucleósidos y nucleótidos ha sido uno de los avances más importantes en el tratamiento de la hepatitis crónica por infección del virus de la hepatitis B (VHB). El primer fármaco de administración oral que se aprobó fue la lamivudina en 1998, y posteriormente se han incluido otros 4 (adefovir, tenofovir, entecavir y telbivudina). También hay una combinación de emtricitabina y tenofovir (Trubada®), aprobada para el tratamiento de la infección por el virus de la inmunodeficiencia humana (VIH), y con eficacia demostrada frente al VHB. El VHB es un virus ADN que se replica casi exclusivamente en los hepatocitos, aunque se han detectado bajos niveles de replicación en otros tejidos como páncreas, riñón y linfocitos. Una vez que el virus entra en la célula hepática, la cápside se transporta hasta el núcleo donde se libera el ADN viral que formará el ADNccc (ADN circular covalentemente cerrado) a partir del cual se sintetizan los ARNm que, una vez pasan al citoplasma, dirigen la síntesis de las diferentes proteínas que darán lugar a las nuevas partículas virales. El HBcAg polimeriza alrededor del complejo de ribonucleoproteínas que contiene el genoma en forma de ARN para constituir las cápsides inmaduras. En éstas, a partir del ARN y mediante la polimerasa viral, que tiene acción transcriptasa inversa similar a la del VIH, se sintetizan las nuevas cadenas de ADN, con la consiguiente maduración de las partículas virales que pueden seguir 2 caminos: volver al núcleo para replecionar el ADNccc o bien (AU)

[Current treatment of hepatitis B infection: where do the new nucleos(t)ide analogues fit in?]. / Tratamiento actual de la hepatitis B: dónde encajan los nuevos análogos de los núcleos(t)idos?

One of the most important advances made in the treatment of chronic hepatitis B infection has been the development of nucleos(t)ide analogues. The first antiviral agents used had limited efficacy due to the high resistance rate. However, in the last few years, new agents (tenofovir, entecavir) have been developed with greater antiviral potency and a lower resistance rate. Consequently, these agents are considered to be the treatment of choice in the most recent clinical guidelines. Nevertheless, interferon may still play an important role in the treatment of hepatitis B in selected patients. Moreover, in some contexts, such as renal insufficiency, pregnancy or immunosuppression, the role of the new oral antiviral agents has not been precisely defined. The present review analyzes these aspects, as well as some of the particular features of the management of patients treated with nucleos(t)ide analogues.

Prognostic value of lymph node micrometastasis in patients with colorectal cancer in Dukes stages A and B (T1-T4, N0, M0).

BACKGROUND: 30% of patients with colorectal cancer (CRC) in Dukes stages A and B (T1-T4, N0, M0) present tumor recurrence and die after 5 years follow up. This unexpectedly poor evolution might be attributable to the presence of lymph node micrometastasis undetected in routine examination with haematoxilin-eosine (H&E). OBJECTIVE: To assess the presence of undetected micrometastasis. PATIENTS AND METHODS: we conducted a retrospective study of the locoregional lymph nodes in 85 patients operated for CRC in Dukes stages A and B (T1-T4, N0, M0), using immunohistochemistry with anticytokeratin antibodies AE1/AE3. In this descriptive, inferential bivariant and survival study, we analyzed different risk factors, including local infiltration T1/T4, Dukes A/B, number of dissected lymph nodes, vascular invasion, micrometastasis, tumor recurrence and death in the context of the presence or absence of micrometastases. RESULTS: Dukes stage and neoplastic angioinvasion are influential in patient prognosis; however, lymph node micrometastases were not associated with a poorer outcome of CRC. CONCLUSIONS: Locorregional lymph node micrometastases detected with anticytokeratine antibodies AE1/AE3 in Dukes A and B CRC patients are not associated with reduced survival.