Cirugía Pancreática: Rol de la evaluación nutricional como parte del manejo interdisciplinario / Pancreatic Surgery: Role of nutritional assessment as part of interdisciplinary management

El soporte nutricional óptimo en el campo de la cirugía pancreática aún es objeto de debate. Se buscó evaluar la importancia de la evaluación nutricional en pacientes con resecciones pancreáticas. Análisis retrospectivo de una base de datos prospectiva. Se realizó evaluación nutricional sistemática. Las variables analizadas fueron, tiempo de estadía hospitalaria y en UTI, complicaciones y mortalidad. No se observaron diferencias estadísticamente significativas usando test de forma aislada. Sin embargo la asociación de desnutrición severa por más de un test se asoció a un aumento significativo en la mortalidad post-operatoria. La evaluación interdisciplinaria de los pacientes con tumores bilio-pancreáticos, debe incluir una adecuada valoración del estado nutricional para identificar aquellos con mayor riesgo

The optimal nutritional support in pancreatic surgery is still under debate. We performed a retrospective analysis of a prospective data base. Systematic nutritional assessment was performed. Length of hospital stay and in ICU, morbidityand mortality, were analyzed. We didn't find significative differences between any of the nutritional test. However, patients with severe malnutrition in different tests were associated with higher mortality. Interdisciplinary management of patients with biliopancreatic tumors should include an adequate nutritional evaluation to identify high risk patients.

Reutilización de materiales de colangiografía endoscópica. Estudio prospectivo de minimización de costos / Reusing materials in endoscopic cholangiography. A prospective study on cost minimization

ANTECEDENTES: la colangiografía endoscópica enfrenta el desafío del control de costos en un área de constantes avances tecnológicos. La reutilización es el uso de un dispositivo médico más veces de las especificadas por el fabricante. Esta práctica se halla precedida por las maniobras de reprocesamiento y amparada por la legislación vigente. OBJETIVOS: cuantificar la reducción en el costo de los insumos y evaluar las complicaciones. Método: estudio prospectivo, descriptivo y análisis sobre minimización de costos comparando la reutilización de dispositivos médicos con el uso único de los mismos. RESULTADOS: durante un período de tres meses se realizaron 144 estudios. Con la estrategia de reutilización, se utilizaron: 9 papilótomos, 12 guías hidrofílica, 3 canastillas de Dormia, 4 balones extractor, 5 balones dilatadores y 2 cuchillos de precorte. Representó un costo total de U$ 10 943 (promedio de costo de materiales por cada estudio: U$ 76). Con la estrategia de uso único se hubieran utilizado: 144 papilótomos, 144 alambres guías, 24 canastillas de Dormia, 20 balones dilatadores, 72 balones extractores y 24 agujas de precorte. Esta estrategia hubiera generado un costo total de U$ 126 280 (promedio por estudio U$ 877). Al comparar los valores entre ambas estrategias observamos una minimización significativa en el costo (p< 0.001). No se registraron complicaciones. Conclusión: Con la estrategia de reutilización de los DM los costos se minimizaron significativamente sin generarse complicaciones

BACKGROUND: cost control is challenging endoscopic cholangiography in an area of constant technological advances. Reusing is using a medical device more times than what was specified by the manufacturer. This practice is preceded by reprocessing maneuvers and protected by the applicable laws. OBJECTIVES: to quantify the cost reduction of supplies and assess the complications. Method: a prospective descriptive study and an analysis of cost minimization by comparing the reuse and the single use of medical devices. Results: 144 studies were conducted during a period of three months. The reuse strategy included: 9 papillotomes, 12 hydrophilic guide wires, 3 Dormia baskets, 4 balloon extraction catheters, 5 balloon dilatation catheters and 2 pre-cut knives. It accounted for a total cost of USD 10,943 (average cost of materials per study: USD 76). The single-use strategy would have included: 144 papillotomes, 144 hydrophilic guide wires, 24 Dormia baskets, 20 balloon extraction catheters, 72 balloon dilatation catheters and 24 pre-cut needle knives. This strategy would have amounted to a total cost of USD 126,280 (average per study: USD 877). By comparing the values of both strategies, a significant minimization is seen in the cost (p< 0.001). No complications were seen. CONCLUSION: the strategy for reusing MD involveda significant minimization of costs without causing any complications.

[Endoscopic ultrasound-guided choledocho-duodenostomy in advanced pancreatic cancer with duodenal obstruction]. / Colédoco-duodenostomía guiada por ecoendoscopía en cáncer de páncreas avanzado con obstrucción duodenal.

Endoscopic retrograde cholangiopancreatography (ERCP) is considered the first-approach for biliary drainage. In cases of ERCP failure, patients are usually referred for percutaneous transhepatic biliary drainage or surgical biliary bypass. In the last decade, the indications of endoscopic ultrasound (EUS) in the management of patients with pancreatic cancer have increased, and numerous cases of EUS-guided biliary drainage have been reported in patients with failures during the ERCP. Our goal is to report a patient with locally advanced pancreatic cancer who presented with painless jaundice and cholestasis with biliary and duodenal obstruction. A EUS-guided choledochoduodenostomy was performed by placement of a self-expanding metal stent.

Colédoco-duodenostomía guiada por ecoendoscopia en cáncer de páncreas avanzado con obstrucción duodenal / Endoscopic ultrasound-guided choledocho-duodenostomy in advanced pancreatic cancer with duodenal obstruction

La colangiopancreatografía retrógrada endoscópica (CPRE) se considera el tratamiento de primera línea para el drenaje biliar en pacientes con cáncer de páncreas. En los casos de fracaso por CPRE, generalmente se realiza un drenaje biliar transparietohepático o una derivación biliar quirúrgica. En la última década, las indicaciones y la utilidad de la ecoendoscopia en pacientes con cáncer de páncreas han ido creciendo, y se han informado numerosos casos de drenajes biliares guiados por ecoendoscopia como una alternativa al drenaje biliar percutáneo o quirúrgico en fracasos en la CPRE. Nuestro objetivo es comunicar un caso con cáncer de páncreas localmente avanzado que se presentó con ictericia indolora y síndrome coledociano con obstrucción biliar y duodenal, en el que se realizó una colédoco-duodenostomía guiada por ecoendoscopia mediante la colocación de una prótesis metálica autoexpandible.

Endoscopic retrograde cholangiopancreatography (ERCP) is considered the first-approach for biliary drainage. In cases of ERCP failure, patients are usually referred for percutaneous transhepatic biliary drainage or surgical biliary bypass. In the last decade, the indications of endoscopic ultrasound (EUS) in the management of patients with pancreatic cancer have increased, and numerous cases of EUS-guided biliary drainage have been reported in patients with failures during the ERCP. Our goal is to report a patient with locally advanced pancreatic cancer who presented with painless jaundice and cholestasis with biliary and duodenal obstruction. A EUS-guided choledochoduodenostomy was performed by placement of a self-expanding metal stent.

[Quality and competence in endoscopic cholangiography. Towards certainty]. / Calidad y competencia en colangiografía endoscópica. Rumbo a lo seguro.

INTRODUCTION: The American Society of Gastroenterology (ASGE) and the American College of Gastroenterolog (ACG) have established indicators to recognize high-quality studies in endoscopic retrograde cholagiopancreatography (ERCP). The indicators were: a) Pre-procedure: adequate indication, informed consent, assessment of the degree of difficulty of the procedure and antibiotic prophylaxis. b) Intraprocedure: cannulation, choledocholithiasis extraction and stents placement rates. c) Postprocedure: full documentation and complications rates. METHODS: Between October 2010 and October 2012 we performed a retrospective, descriptive, observational and self-evaluative study to assess the compliance with ERCP quality indicators proposed by the ASGE. RESULTS: Preprocedural indicators were evaluated in 734 studies. Cannulation, choledocolithiasis extraction and stents placement under the hiliar bifurcation rates were 96.2%, 95.4% and 100%, respectively. The complication rate was 5.6% and the mortality was 0.27%. The severity of complications was evaluated according to the classification of Masci (30 mild, 7 moderate and 4 severe). CONCLUSIONS: Quality is a basic tool that allows the comparison between our actions and the indicators already predetermined as suitable. The appropriate indication is an indicator to improve. We believe that 12% of registered normal studies could be due to a difficult accessibility to magnetic resonance cholangiography in our health system. Achievement of the internationally validated indicators place us as a high-quality endoscopic cholagiography unit and as a training center with appropriate expertise.

Serological tests for celiac disease as indicators of long-term compliance with the gluten-free diet.

OBJECTIVES: The efficacy of celiac disease (CD)-related antibodies in monitoring clinical outcome of patients remains unclear. Our aims were to determine dynamics of antibodies after diagnosis and to assess their performances in monitoring patients' long-term compliance with the gluten-free diet (GFD). METHODS: We prospectively estimated the performance of seven celiac disease-related antibody tests at diagnosis and at 1 year and more than 4 years after treatment initiation in 53 adults. The ability of antibodies to identify patients partially compliant to treatment was explored by the receiver operating characteristic curve analysis. The derived cut-off values ('compliance' cutoffs) were compared with cut-off values used for diagnosis ('diagnostic' cutoffs). The degree of compliance with the GFD was assessed using a standardized, multidisciplinary approach. RESULTS: Concentrations of all antibodies decreased significantly at 1 year after diagnosis. The decline continued for more than 4 years in strictly compliant patients (P<0.05-0.001). The gap between 'compliance' and 'diagnostic' cut-offs values was wider at 1 year than at more than 4 years. The predictability of partial compliance determined by the area under receiver operating characteristic curves was relevant for most tests examined at 1 year (areas ranging: 0.64-0.72) and more than 4 years (0.58-0.78). Immunoglobulin A antibodies to deamidated gliadin peptides and tissue transglutaminase had the best performance for monitoring long-term compliance. CONCLUSION: Decreased concentrations of antibodies were significantly associated with the degree of compliance with the GFD. Immunoglobulin A antibodies to deamidated gliadin peptides and tissue transglutaminase had the best and more consistent performances. The serial measurement of antibody levels seems to be more reliable in monitoring compliance than the positive/negative expression of results.

Gastroesophageal reflux symptoms in patients with celiac disease and the effects of a gluten-free diet.

BACKGROUND & AIMS: Celiac disease (CD) patients often complain of symptoms consistent with gastroesophageal reflux disease (GERD). We aimed to assess the prevalence of GERD symptoms at diagnosis and to determine the impact of the gluten-free diet (GFD). METHODS: We evaluated 133 adult CD patients at diagnosis and 70 healthy controls. Fifty-three patients completed questionnaires every 3 months during the first year and more than 4 years after diagnosis. GERD symptoms were evaluated using a subdimension of the Gastrointestinal Symptoms Rating Scale for heartburn and regurgitation domains. RESULTS: At diagnosis, celiac patients had a significantly higher reflux symptom mean score than healthy controls (P < .001). At baseline, 30.1% of CD patients had moderate to severe GERD (score >3) compared with 5.7% of controls (P < .01). Moderate to severe symptoms were significantly associated with the classical clinical presentation of CD (35.0%) compared with atypical/silent cases (15.2%; P < .03). A rapid improvement was evidenced at 3 months after initial treatment with a GFD (P < .0001) with reflux scores comparable to healthy controls from this time point onward. CONCLUSIONS: GERD symptoms are common in classically symptomatic untreated CD patients. The GFD is associated with a rapid and persistent improvement in reflux symptoms that resembles the healthy population.

New serology assays can detect gluten sensitivity among enteropathy patients seronegative for anti-tissue transglutaminase.

BACKGROUND: Some patients with celiac disease (CD) may be seronegative with the commonly used test for IgA anti-tissue transglutaminase (anti-tTG) antibodies. Our aim was to explore whether newer assays incorporating synthetic deamidated gliadin-related peptides (DGPs) or other TG isoenzymes as antigen are useful for detecting gluten sensitivity in IgA anti-tTG-seronegative patients. METHODS: We assayed serum samples obtained at diagnosis from (a) anti-tTG-seronegative patients with a CD-like enteropathy (n = 12), (b) skin biopsy-proven dermatitis herpetiformis (DH) patients (n = 26), and (c) IgA anti-tTG-positive CD patients (n = 26). All patients had typical total IgA concentrations. All patients underwent intestinal biopsy and serum testing for (a) detection of IgA and IgG isotypes of both anti-DGP and anti-tTG in a single assay (tTG/DGP Screen; INOVA Diagnostics), (b) simultaneous detection of both IgA and IgG anti-DGP antibody isotypes (DGP Dual; INOVA Diagnostics), and (c) detection of antibodies to transglutaminase 3 (TG3) or transglutaminase 6 (TG6). RESULTS: All anti-tTG-seropositive patients also tested positive in anti-DGP assays. Overall, tTG/DGP Screen detected 6 (31.6%) of the 19 anti-tTG seronegatives, and anti-DGP Dual produced positive results in 5 (26.3%) of these cases. Whereas both assays detected 2 anti-tTG-negative DH patients with partial villous atrophy, they were positive in only 2 of the 5 cases with no histologically discernible mucosal damage. Testing for antibodies to TG3 and TG6 identified 7 (36.8%) of the 19 anti-tTG-negative patients, 5 of which were also positive for anti-DGP. CONCLUSIONS: Detection of anti-DGP with tTG/DGP Screen or anti-DGP Dual, or detection of antibodies to other TG isoenzymes, enhances the sensitivity for detecting gluten sensitivity among non-IgA- deficient, anti-tTG-seronegative patients with CD-like enteropathy.

[Treatment of patients with squamous cell carcinoma of the anal canal in the last 20 years in a gastroenterology hospital]. / El tratamiento de los pacientes con carcinoma epidermoide del canal anal en los últimos 20 años en nuestro hospital.

UNLABELLED: Anal cancers compromise only 1.5% of all digestive tumors. At present, concurrent radiochemotherapy (RT-CT) is the treatment of choice for most of these lesions. OBJECTIVE: To collect and analyze clinical data from the medical records of all consecutive patients with squamous cell carcinoma of the anal canal (SCCAC) treated by the Oncology Section in 20 years. PATIENTS AND METHODS: The medical records of 108 patients with SCCAC were reviewed: 64% were women, mean age was 57.6 years (27-85), only 1 patient was HIV(+). RESULTS: Initial treatment: 87 patients were treated with RT-CT (81%), 5 CT only, 2 RT only, 8 local resection and 6 abdominoperineal resection (APR). 1) Patients initially treated with RT-CT: cobalt therapy was given to 76% of pts and linear accelerator was used in 24% of patients. 24% of patients received Mitomycin C based CT (modified Nigro), 66% Cisplatin based CT and 10% 5FU alone; 66% had clinical complete response (CCR) (26% of them relapsed). Median follow up was 2.16 years (1 month-15.5 years), median time to progression was 11.8 months and overall survival was 76.7% at 3 years (CI 95%: 65.2-87.7). 2) Patients initially treated with local resection: 6 patients NED and 2 relapsed (1 had CCR after RT-CT). 3) Patients initially treated with APR: 5 with curative intent (4 had local recurrence), and 1 was palliative. 4) Surgical rescue after RT-CT in 6 patients with curative intent (4 APR and 2 local resections), and in 15 patients was palliative (2 APR and other surgeries in 13). CONCLUSIONS: Our group is pioneer in the use of Cisplatin based RT-CT for the treatment of patients with SCCAC. Complete response rate and overall survival at 3 years, were similar to those reported by international data. As this is probably one of the largest series of SCCAC in Argentina, we hope that this analysis of our data would be a starting point to develop prospective clinical trials.

El tratamiento de los pacientes con carcinoma epidermoide del canal anal en los últimos 20 años en nuestro hospital. / [Treatment of patients with squamous cell carcinoma of the anal canal in the last 20 years in a gastroenterology hospital]

Anal cancers compromise only 1.5

of all digestive tumors. At present, concurrent radiochemotherapy (RT-CT) is the treatment of choice for most of these lesions. OBJECTIVE: To collect and analyze clinical data from the medical records of all consecutive patients with squamous cell carcinoma of the anal canal (SCCAC) treated by the Oncology Section in 20 years. PATIENTS AND METHODS: The medical records of 108 patients with SCCAC were reviewed: 64

were women, mean age was 57.6 years (27-85), only 1 patient was HIV(+). RESULTS: Initial treatment: 87 patients were treated with RT-CT (81

), 5 CT only, 2 RT only, 8 local resection and 6 abdominoperineal resection (APR). 1) Patients initially treated with RT-CT: cobalt therapy was given to 76

of pts and linear accelerator was used in 24

of patients. 24

of patients received Mitomycin C based CT (modified Nigro), 66

Cisplatin based CT and 10

5FU alone; 66

had clinical complete response (CCR) (26

of them relapsed). Median follow up was 2.16 years (1 month-15.5 years), median time to progression was 11.8 months and overall survival was 76.7

at 3 years (CI 95

: 65.2-87.7). 2) Patients initially treated with local resection: 6 patients NED and 2 relapsed (1 had CCR after RT-CT). 3) Patients initially treated with APR: 5 with curative intent (4 had local recurrence), and 1 was palliative. 4) Surgical rescue after RT-CT in 6 patients with curative intent (4 APR and 2 local resections), and in 15 patients was palliative (2 APR and other surgeries in 13). CONCLUSIONS: Our group is pioneer in the use of Cisplatin based RT-CT for the treatment of patients with SCCAC. Complete response rate and overall survival at 3 years, were similar to those reported by international data. As this is probably one of the largest series of SCCAC in Argentina, we hope that this analysis of our data would be a starting point to develop prospective clinical trials.