Partially covered vs uncovered sphincterotome and post-endoscopic sphincterotomy bleeding.

AIM: To prospectively compare partially covered vs uncovered sphincterotome use on post-endoscopic biliary sphincterotomy (ES) hemorrhage and other complications. METHODS: All patients referred for therapeutic endoscopic retrograde cholangiopancreatography (ERCP) were randomly assigned to undergo ES either with a partially covered or an uncovered sphincterotome. Both patient and technical risk factors contributing to the development of post-ES bleeding were recorded and analyzed. The characteristics of bleeding was recorded during and after ES. Other complications were also compared. RESULTS: Three-hundred and eighty-seven patients were recruited in this study; 194 patients underwent ES with a partially covered sphincterotome and 193 with conventional uncovered sphincterotome. No statistical difference was noted in the baseline characteristics and risk factors for post-ES induced hemorrhage between the 2 groups. No significant difference in the incidence and pattern of visible bleeding rates was found between the 2 groups (immediate bleeding in 24 patients with the partially covered sphincterotome vs 19 patients with the uncovered sphincterotome, P = 0.418). Delayed bleeding was observed in 2 patients with a partially covered sphincterotome and in 1 patient with an uncovered sphincterotome (P = 0.62). No statistical difference was noted in the rate of other complications. CONCLUSION: The partially covered sphincterotome was not associated with a lower frequency of bleeding. Also, there was no difference in the incidence of other significant complications between the 2 types of sphincterotome.

Migration of plastic biliary stents and endoscopic retrieval: an experience of three referral centers.

BACKGROUND: Proximal or distal migration of a plastic biliary stent is uncommon, but its management can be a technical challenge to the pancreatobiliary endoscopist. PATIENTS AND METHODS: All cases (n=51) of proximally and distally migrated plastic biliary stents over an 8-year period at 3 referral pancreaticobiliary centers were included in this retrospective study. Indications for stenting, risk factors for migration, presentation of migration, and various techniques used for stent's retrieval are herein analyzed. RESULTS: Twenty-one proximal and 30 distal bile duct-migrated stents were identified. All patients with proximally and 17 (56.7%) with distally migrated stents were symptomatic. Choledocholithiasis, dilated common bile duct, short and large size stent were the main risk factors. The retrieval of proximally migrated stents was successful in 15 patients (71.4%) and in all symptomatic patients with distal migration. The retrieval techniques included forceps, Dormia basket, snare, Soehendra stent retriever, and balloon. One patient died of sepsis due to peritonitis from duodenal perforation from a distally migrated stent. CONCLUSIONS: Retrieval of a proximally migrated stent requires experience with different endoscopic devices. Moreover, distal migration needs attention because it can cause severe complications.

Prevalence, bowel habit subtypes and medical care-seeking behaviour of patients with irritable bowel syndrome in Northern Greece.

AIM: Although irritable bowel syndrome (IBS) prevalence ranges between 10 and 20% in the general population, it appears to be considerably undiagnosed with only 25-50% of patients with IBS seeking medical advice. The aim of this study was to determine the prevalence of IBS in Northern Greece and the prevalence by symptom subtype including diarrhoea-predominant IBS, constipation-predominant IBS (C-IBS) and mixed type IBS; to identify factors contributing to the development of this syndrome; to assess its effect on health-related quality of life and to evaluate the medical care-seeking behaviour of IBS patients. PATIENTS AND METHODS: Between January 2004 and December 2007, 3112 participants were requested to fill out a questionnaire during an interview with a primary health care clinician. Data on participants' demographics, medical history, symptoms and earlier health care-seeking behaviour were also recorded. The Rome II criteria were used to establish the diagnosis of IBS. The impact of IBS on the quality of life was examined using the EuroQol with five domains (EQ-5D) measure of health status. RESULTS: Out of 2397 participants [704 men (29.4%), mean age 46.1+/-15.0 years] included, 373 (15.7%) reported gastrointestinal symptoms compatible with IBS of whom 136 (36.5%) suffered from diarrhoea-predominant IBS, 165 (44.2%) suffered from C-IBS and 72 (19.3%) suffered from mixed type IBS. IBS patients were more likely to be female living in an urban area compared with healthy controls (P=0.03 and 0.0001, respectively). A significant decrease in health-related quality of life (impairment in two or more of measured parameters) was noted in 246 (66%) IBS patients. Female sex, older age and housekeeping were associated with C-IBS (P=0.02, 0.001, and 0.001, respectively). Female sex and IBS-M were associated with health care-seeking behaviour. CONCLUSION: The prevalence of IBS in Northern Greece is relatively high, mainly affecting female participants living in urban areas.

A comparative study of 50% dextrose and normal saline solution on their ability to create submucosal fluid cushions for endoscopic resection of sessile rectosigmoid polyps.

BACKGROUND: EMR traditionally performed by using normal saline solution (NS) plus epinephrine (E) as a submucosal fluid cushion does not maintain the submucosal elevation for a prolonged time. It was hypothesized that 50% dextrose (D(50)) plus E as a hypertonic, inexpensive, and easily available solution might be an ideal alternative for producing and maintaining more-prolonged mucosal elevation. OBJECTIVE: To evaluate D(50)+E versus NS+E during an EMR of sessile rectosigmoid polyps (> 10 mm). DESIGN: A prospective, double-blind, randomized study that compared EMR by using either D(50)+E or NS+E submucosal fluid cushions. SETTING: Four tertiary endoscopic referral centers with 1370 polypectomies in 2006, performed by 5 experienced endoscopists. PATIENTS: Patients treated for sessile rectosigmoid polyps (> 10 mm). INTERVENTIONS: Polypectomy with D(50)+E or NS+E submucosal fluid cushions. MAIN OUTCOME MEASUREMENTS: The duration of submucosal elevation, volume of solution, number of required injections to maintain the elevation, and observations for complications. RESULTS: Ninety-two sessile rectosigmoid polyps were removed. Injected solution volumes and the number of injections to maintain submucosal elevation were lower in the D(50)+E group than in the NS+E group (P = .033 and P = .028, respectively). Submucosal elevation had a longer duration in the D(50)+E group (P = .043). This difference mainly included large (> or = 20 mm) and giant (> 40 mm) polyps. There were 6 and 1 cases of postpolypectomy syndrome in the D(50)+E and NS+E groups, respectively (P = .01). LIMITATIONS: May be limited by inexperienced endoscopist's lack of injection and polypectomy skills. CONCLUSIONS: D(50)+E is superior to NS+E for an EMR, particularly in large and giant sessile polyps, but the risk of thermal tissue injury should be considered.

Endoscopic treatment and follow-up of gastrointestinal Dieulafoy's lesions.

AIM: To investigate retrospectively the clinical and endoscopic features of bleeding Dieulafoy's lesions and to assess the short- and long-term effectiveness of endoscopic treatment. METHODS: Twenty-three patients who had gastrointestinal bleeding from Dieulafoy's lesions underwent endoscopic therapy. Demographic data, mode of presentation, risk factors for gastrointestinal bleeding, blood transfusion requirements, endoscopic findings, details of endoscopic therapy, recurrence of bleeding and mortality rates were collected and analyzed retrospectively. RESULTS: Hemostasis was attempted by dextrose 50% plus epinephrine in 10 patients, hemoclipping in 8 patients, heater probe in 2 patients and ethanolamine oleate in 2 patients. Comorbid conditions were present in 17 patients (74%). Overall permanent hemostasis was achieved in 18 patients (78%). Initial hemostasis was successful with no recurrent bleeding in patients treated with hemoclipping, heater probe or ethanolamine injection. In the group of patients who received dextrose 50% plus epinephrine injection treatment, four (40%) had recurrent bleeding and one (10%) had unsuccessful initial hemostasis. Of the four patients who had rebleeding, three had unsuccessful hemostasis with similar treatment. Surgical treatment was required in five patients (22%) owing to uncontrolled bleeding, recurrent bleeding with unsuccessful retreatment and inability to approach the lesion. One patient (4.3%) died of sepsis after operation during hospitalization. There were no side-effects related to endoscopic therapy. None of the patients in whom permanent hemostasis was achieved presented with rebleeding from Dieulafoy's lesion over a mean long-term follow-up of 29.8 mo. CONCLUSION: Bleeding from Dieulafoy's lesions can be managed successfully by endoscopic methods, which should be regarded as the first choice. Endoscopic hemoclipping therapy is recommended for bleeding Dieulafoy's lesions.