RESUMO

BACKGROUND: Endoscopic therapy using multiple plastic stents (MPSs) is the standard therapy for postorthotopic liver transplantation (p-OLT) anastomotic biliary stricture (ABS). However, this approach demands repeated procedures. Recent studies using fully covered self-expandable metallic stents (FCSEMS) have shown encouraging results, but migration occurs in 10% to 40% of cases. The objective of this retrospective study was to evaluate the efficacy of endoscopic treatment using FCSEMS with an anti-migration system (Am-FCSEMS) in patients with p-OLT ABS. AIM: To evaluate the efficacy of endoscopic treatment using an Am-FCSEMS in patients with p-OLT ABS. METHODS: This study was conducted in a private tertiary care centre in São Paulo, Brazil and was approved by our institution's Human Research Committee. From April 2018 to October 2020, regardless of previous endoscopic treatment (MPS or FCSEMS), 17 patients with p-OLT ABS and indications for endoscopic therapy were included in this study. The exclusion criteria were pregnancy, nonanastomotic biliary or hilar stricture, hepatic artery stenosis/thrombosis, isolated biliary fistulae, a distance shorter than 2 cm from the stricture to the hepatic hilum, and patient refusal. The primary endpoint was the efficacy of p-OLT ABS endoscopic treatment using an Am-FCSEMS that remained in place for a 12-mo period. Biliary sphincterotomy was performed in patients with native papilla, and an Am-FCSEMS (10 mm in final diameter and 60 or 80 mm in length) was placed (HanarostentTM MI Tech, Co). Balloon stricture dilation was performed only if necessary to introduce the stent. RESULTS: Three patients were excluded due to loss to follow-up before stent removal. Among the 14 patients included and followed, 7 were women, and the average age was 56 years (range: 28-76). The average period of Am-FCSEMS placement was 362 ± 109 d. Technical success occurred in all 14 patients (100%). There were no cases of distal stent migration. Complete resolution of the stricture occurred in 13/14 patients (92.85%). Adverse events occurred in 3/14 patients (21.42%): 2 patients with mild acute pancreatitis (14.28%) and 1 patient (7.14%) with stent dysfunction (occlusion by biliary sludge and stones, which was treated endoscopically without the need for stent removal). No deaths occurred related to therapy. All stents were removed using foreign body forceps or snares without difficulty. After Am-FCSEMS removal, all 13 patients who had ABS resolution were followed-up for an average of 411 ± 172 d, and there was no stricture recurrence or need for further endoscopic therapy. CONCLUSION: In this retrospective study, endoscopy therapy using an Am-FCSEMS for p-OLT ABS was safe and effective, with a high stricture resolution rate that was probably due to the absence of stent migration.

RESUMO

OBJECTIVES: Pancreatic pseudocysts (PPC) are fluid collections with a well-defined wall that persist for more than 4 weeks inside or around the pancreas as a result of pancreatic inflammation and/or a ductal lesion. PPC have been successfully treated with endoscopic ultrasound (EUS)-guided drainage using different stents. This study aimed to evaluate the safety and efficacy of EUS-guided drainage of PPC using double-pigtail plastic stents in a tertiary hospital. METHODS: Patients with PPC referred for EUS-guided drainage between May 2015 and December 2019 were included in this case series. The primary endpoint was to evaluate the efficacy (clinical success) and safety (adverse events and mortality) of EUS-guided drainage of PPC. Secondary endpoints included technical success and pseudocyst recurrence. RESULTS: Eleven patients (mean age, 44.5±18.98 years) were included in this study. The etiologies for PPC were acute biliary pancreatitis, chronic alcoholic pancreatitis, and blunt abdominal trauma. The mean pseudocyst size was 9.4±2.69 cm. The clinical success rate was 91% (10/11). Adverse events occurred in three of 11 patients (27%). There were no cases of mortality. The technical success rate was 100%. Pseudocyst recurrence was identified in one of 11 patients (9%) at 12 weeks after successful clinical drainage and complete pseudocyst resolution. CONCLUSION: EUS-guided transmural drainage of PPC using double-pigtail plastic stents is safe and effective with high technical and clinical success rates.

Assuntos

Pseudocisto Pancreático , Adulto , Drenagem , Endossonografia , Humanos , Pessoa de Meia-Idade , Recidiva Local de Neoplasia , Pseudocisto Pancreático/diagnóstico por imagem , Pseudocisto Pancreático/cirurgia , Plásticos , Estudos Retrospectivos , Stents , Resultado do Tratamento , Ultrassonografia de Intervenção

RESUMO

OBJECTIVES: Pancreatic pseudocysts (PPC) are fluid collections with a well-defined wall that persist for more than 4 weeks inside or around the pancreas as a result of pancreatic inflammation and/or a ductal lesion. PPC have been successfully treated with endoscopic ultrasound (EUS)-guided drainage using different stents. This study aimed to evaluate the safety and efficacy of EUS-guided drainage of PPC using double-pigtail plastic stents in a tertiary hospital. METHODS: Patients with PPC referred for EUS-guided drainage between May 2015 and December 2019 were included in this case series. The primary endpoint was to evaluate the efficacy (clinical success) and safety (adverse events and mortality) of EUS-guided drainage of PPC. Secondary endpoints included technical success and pseudocyst recurrence. RESULTS: Eleven patients (mean age, 44.5±18.98 years) were included in this study. The etiologies for PPC were acute biliary pancreatitis, chronic alcoholic pancreatitis, and blunt abdominal trauma. The mean pseudocyst size was 9.4±2.69 cm. The clinical success rate was 91% (10/11). Adverse events occurred in three of 11 patients (27%). There were no cases of mortality. The technical success rate was 100%. Pseudocyst recurrence was identified in one of 11 patients (9%) at 12 weeks after successful clinical drainage and complete pseudocyst resolution. CONCLUSION: EUS-guided transmural drainage of PPC using double-pigtail plastic stents is safe and effective with high technical and clinical success rates.

Assuntos

Humanos , Adulto , Pessoa de Meia-Idade , Pseudocisto Pancreático/cirurgia , Pseudocisto Pancreático/diagnóstico por imagem , Plásticos , Stents , Drenagem , Estudos Retrospectivos , Resultado do Tratamento , Ultrassonografia de Intervenção , Endossonografia , Recidiva Local de Neoplasia

RESUMO

Antiretroviral therapy (ART) is typically composed of a combination of three antiretroviral drugs and is the treatment of choice for people with human immunodeficiency virus type 1/acquired immune deficiency syndrome (HIV-1/AIDS). However, it is unable to impact on viral reservoirs, which harbour latent HIV-1 genomes that are able to reignite the infection upon treatment suspension. The aim of this study was to provide an estimate of the safety of the disease-modifying antirheumatic agent auranofin and its impact on the HIV-1 reservoir in humans under intensified ART. For this purpose, an interim analysis was conducted of three of the six arms of the NCT02961829 clinical trial (five patients each) with: no intervention, i.e. continuation of first-line ART; intensified ART (ART + dolutegravir and maraviroc); and intensified ART plus auranofin. Auranofin treatment was found to be well tolerated. No major adverse events were detected apart from a transient decrease in CD4+ T-cell counts at Weeks 8 and 12. Auranofin decreased total viral DNA in peripheral blood mononuclear cells compared with ART-only regimens at Week 20 (P = 0.036) and induced a decrease in integrated viral DNA as quantified by Alu PCR. Despite the limited number of patient-derived sequences available in this study, phylogenetic analyses of nef sequences support the idea that auranofin may impact on the viral reservoir. [ClinicalTrials.gov ID: NCT02961829].

Assuntos

Antirreumáticos/uso terapêutico , Auranofina/uso terapêutico , HIV-1/genética , Provírus/efeitos dos fármacos , Provírus/genética , Latência Viral/efeitos dos fármacos , Terapia Antirretroviral de Alta Atividade , Contagem de Linfócito CD4 , DNA Viral/efeitos dos fármacos , DNA Viral/genética , Inibidores da Fusão de HIV/uso terapêutico , Infecções por HIV/tratamento farmacológico , Inibidores de Integrase de HIV/uso terapêutico , HIV-1/efeitos dos fármacos , Compostos Heterocíclicos com 3 Anéis/uso terapêutico , Humanos , Maraviroc/uso terapêutico , Oxazinas , Piperazinas , Piridonas

RESUMO

Chronic radiation proctopathy (CRP) is a troublesome complication of pelvic radiotherapy. The most common presentation is rectal bleeding. CRP symptoms interfere with daily activities and decrease quality of life. Rectal bleeding management in patients with CRP represents a conundrum for practitioners. Medical therapy is ineffective in general and surgical approach has a high morbid-mortality. Endoscopy has a role in the diagnosis, staging and treatment of this disease. Currently available endoscopic modalities are formalin, potassium titanyl phosphate laser, neodymium:yttrium-aluminum-garnet laser, argon laser, bipolar electrocoagulation (BiCAP), heater probe, band ligation, cryotherapy, radiofrequency ablation and argon plasma coagulation (APC). Among these options, APC is the most promising.

RESUMO

Background - Upper gastrointestinal bleeding implies significant clinical and economic repercussions. The correct establishment of the latest therapies for the upper gastrointestinal bleeding is associated with reduced in-hospital mortality. The use of clinical pathways for the upper gastrointestinal bleeding is associated with shorter hospital stay and lower hospital costs. Objective - The primary objective is the development of a clinical care pathway for the management of patients with upper gastrointestinal bleeding, to be used in tertiary hospital. Methods - It was conducted an extensive literature review on the management of upper gastrointestinal bleeding, contained in the primary and secondary information sources. Results - The result is a clinical care pathway for the upper gastrointestinal bleeding in patients with evidence of recent bleeding, diagnosed by melena or hematemesis in the last 12 hours, who are admitted in the emergency rooms and intensive care units of tertiary hospitals. In this compact and understandable pathway, it is well demonstrated the management since the admission, with definition of the inclusion and exclusion criteria, passing through the initial clinical treatment, posterior guidance for endoscopic therapy, and referral to rescue therapies in cases of persistent or rebleeding. It was also included the care that must be taken before hospital discharge for all patients who recover from an episode of bleeding. Conclusion - The introduction of a clinical care pathway for patients with upper gastrointestinal bleeding may contribute to standardization of medical practices, decrease in waiting time for medications and services, length of hospital stay and costs.

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Contexto - A hemorragia digestiva alta implica em significativas repercussões clínicas e econômicas. O estabelecimento correto das mais recentes terapêuticas para a hemorragia digestiva alta está associado à redução na mortalidade intra-hospitalar. O uso de algoritmos para atendimento da hemorragia digestiva alta está associado com menor tempo de internação e menores custos hospitalares. Objetivos - O objetivo primário é a criação de um protocolo de atendimento da hemorragia digestiva alta, para ser utilizado em hospital terciário. Métodos - Realizada extensa revisão da literatura sobre as condutas na hemorragia digestiva alta, contidas nas bases de dados primária e secundária. Resultados - O resultado é um modelo de atendimento para os pacientes com hemorragia digestiva alta e com evidência de sangramento recente, dado por melena ou hematêmese nas ultimas 24h, que são atendidos nas salas de emergência e unidades de terapia intensiva de hospitais terciários. Neste protocolo de atendimento, desenhado de forma compacta e compreensível, fica bem evidenciado o manejo dos pacientes desde a admissão, com definição dos critérios de inclusão e exclusão, passando considerações acerca do atendimento clínico inicial, posterior direcionamento para a terapêutica endoscópica, e encaminhamento às terapias de resgate em casos de sangramento persistente ou recorrente. Destacam-se também os cuidados que devem ser tomados antes da alta hospitalar para todos os pacientes que se recuperam de um episódio de sangramento. Conclusão - A introdução de um protocolo para atendimento e tratamento de pacientes com hemorragia digestiva alta pode contribuir para uniformização de condutas médicas, diminuição no tempo de espera por medicações e serviços, no tempo de internação e nos custos hospitalares.

Assuntos

Adulto , Feminino , Humanos , Masculino , Protocolos Clínicos/normas , Hemorragia Gastrointestinal/terapia , Doença Aguda , Gerenciamento Clínico , Endoscopia Gastrointestinal , Tempo de Internação , Guias de Prática Clínica como Assunto

RESUMO

OBJECTIVE: The aim of this study was to compare the recurrence of esophageal varices (EVs) after endoscopic band ligation (EBL) associated with propranolol (PP) versus EBL alone. PATIENTS AND METHODS: Sixty-six cirrhotic outpatients (EBL group, n=32 and EBL+PP group, n=34) with high-risk EVs without previous bleeding were studied. MAIN OUTCOME MEASUREMENTS: The primary outcome was recurrence of EV. The secondary outcomes were EV eradication, bleeding before EV eradication, mortality, and adverse events. RESULTS: Demographic characteristics and the initial endoscopic findings were similar. EV eradication was achieved in all patients. Three patients presented gastrointestinal bleeding before variceal eradication, two in the EBL group and one in the EBL+PP group (P=0.13). Six patients died (liver failure), two in the EBL group and four in the EBL+PP group (P=0.27). Twelve (38%) patients in the EBL group and three (9%) patients in the EBL+PP group had variceal recurrence. The risk of recurrence of EVs after eradication was significantly higher among patients in the EBL group (P=0.003). CONCLUSION: EBL alone and EBL+PP were effective in the primary prophylaxis of bleeding from EVs in cirrhotic patients (EV eradication, bleeding before EV eradication, mortality, and adverse events were similar in both groups). However, variceal recurrence was lower in the EBL+PP group than band ligation alone.

Assuntos

Antagonistas Adrenérgicos beta/uso terapêutico , Varizes Esofágicas e Gástricas/terapia , Hemorragia Gastrointestinal/prevenção & controle , Propranolol/uso terapêutico , Prevenção Secundária/métodos , Antagonistas Adrenérgicos beta/efeitos adversos , Adulto , Terapia Combinada , Endoscopia Gastrointestinal , Varizes Esofágicas e Gástricas/complicações , Feminino , Hemorragia Gastrointestinal/etiologia , Humanos , Ligadura/efeitos adversos , Cirrose Hepática/complicações , Falência Hepática/etiologia , Falência Hepática/mortalidade , Masculino , Pessoa de Meia-Idade , Propranolol/efeitos adversos , Estudos Prospectivos , Recidiva , Método Simples-Cego , Resultado do Tratamento

RESUMO

BACKGROUND: Upper gastrointestinal bleeding implies significant clinical and economic repercussions. The correct establishment of the latest therapies for the upper gastrointestinal bleeding is associated with reduced in-hospital mortality. The use of clinical pathways for the upper gastrointestinal bleeding is associated with shorter hospital stay and lower hospital costs. OBJECTIVE: The primary objective is the development of a clinical care pathway for the management of patients with upper gastrointestinal bleeding, to be used in tertiary hospital. METHODS: It was conducted an extensive literature review on the management of upper gastrointestinal bleeding, contained in the primary and secondary information sources. RESULTS: The result is a clinical care pathway for the upper gastrointestinal bleeding in patients with evidence of recent bleeding, diagnosed by melena or hematemesis in the last 12 hours, who are admitted in the emergency rooms and intensive care units of tertiary hospitals. In this compact and understandable pathway, it is well demonstrated the management since the admission, with definition of the inclusion and exclusion criteria, passing through the initial clinical treatment, posterior guidance for endoscopic therapy, and referral to rescue therapies in cases of persistent or rebleeding. It was also included the care that must be taken before hospital discharge for all patients who recover from an episode of bleeding. CONCLUSION: The introduction of a clinical care pathway for patients with upper gastrointestinal bleeding may contribute to standardization of medical practices, decrease in waiting time for medications and services, length of hospital stay and costs.

Assuntos

Protocolos Clínicos/normas , Hemorragia Gastrointestinal/terapia , Doença Aguda , Adulto , Gerenciamento Clínico , Endoscopia Gastrointestinal , Feminino , Humanos , Tempo de Internação , Masculino , Guias de Prática Clínica como Assunto

RESUMO

AIM: To evaluate the efficacy and safety of undiluted N-butyl-2 cyanoacrylate plus methacryloxysulfolane (NBCM) as a prophylactic treatment for gastric varices (GV) bleeding. METHODS: This prospective study was conducted at a single tertiary-care teaching hospital between October 2009 and March 2013. Patients with portal hypertension (PH) and GV, with no active gastrointestinal bleeding, were enrolled in primary prophylactic treatment with NBCM injection without lipiodol dilution. Initial diagnosis of GV was based on endoscopy and confirmed with endosonography (EUS); the same procedure was used after treatment to confirm eradication of GV. After puncturing the GV with a regular injection needle, 1 mL of undiluted NBCM was injected intranasally into GV. The injection was repeated as necessary to achieve eradication or until a maximum total volume of 3 mL of NBCM had been injected. Patients were followed clinically and evaluated with endoscopy at 3, 6 and 12 mo. Later follow-ups were performed yearly. The main outcome measures were efficacy (GV eradication), safety (adverse events related to cyanoacrylate injection), recurrence, bleeding from GV and mortality related to GV treatment. RESULTS: A total of 20 patients (15 male) with PH and GV were enrolled in the study and treated with undiluted NBCM injection. Only 2 (10%) patients had no esophageal varices (EV); 18 (90%) patients were treated with endoscopic band ligation to eradicate EV before inclusion in the study. The patients were followed clinically and endoscopically for a median of 31 mo (range: 6-40 mo). Eradication of GV was observed in all patients (13 patients were treated with 1 session and 7 patients with 2 sessions), with a maximum injected volume of 2 mL NBCM. One patient had GV recurrence, confirmed by EUS, at 6-mo follow-up, and another had late recurrence with GV bleeding after 35 mo of follow-up; overall, GV recurrence was observed in 2 patients (10%), after 6 and 35 mo of follow-up, and GV bleeding rate was 5% (1 patient). Mild epigastric pain was reported by 3 patients (15%). No mortality or major complications, including embolism, or damage to equipment were observed. CONCLUSION: Endoscopic injection with NBCM, without lipiodol, may be a safe and effective treatment for primary prophylaxis of gastric variceal bleeding.

RESUMO

OBJECTIVE: To investigate the impact of transgastric peritoneal access on plasma biomarkers of acute inflammatory response in comparison to laparoscopy. METHODS: This was a prospective and comparative study in a porcine model. Transgastric peritoneal access performed by natural orifice transluminal endoscopic surgery was compared with laparoscopy. Laparotomy and sham groups were used as positive and negative controls, respectively. Thirty-four pigs were assigned to receive transgastric natural orifice transluminal endoscopic surgery (n = 12), laparoscopy (n = 8), laparotomy (n = 8) or a sham procedure involving only anesthesia (n = 6). In the natural orifice transluminal endoscopic surgery group, peritoneoscopy was performed with a gastroscope via transgastric access. Blood samples were collected at baseline and 1, 3, 6, 9 and 24 h after the surgical procedure for measurement of interleukins 1ß, 6 and 10 and tumor necrosis factor-α. A complete blood count was performed, and C-reactive protein levels were measured at baseline and at 24 h. RESULTS: All surgical and endoscopic procedures were performed without major complications. Peritoneal cavity inventory showed no signs of peritonitis in any animal. Interleukin 1ß, interleukin 10 and tumor necrosis factor-α levels were below the threshold of detection. The mean level of interleukin 6 was statistically significantly higher in the laparotomy group than in the other groups (p<0.05), with no significant differences among the sham, laparoscopy and natural orifice transluminal endoscopic surgery groups (p>0.05). C-reactive protein analysis indicated significant increases in all groups, with no differences among the groups. Complete blood count analysis showed no differences among the groups. CONCLUSIONS: Based on the observed interleukin 6 patterns, the systemic inflammatory response resulting from transgastric peritoneal access by natural orifice transluminal endoscopic surgery is similar in intensity to the response that occurs after laparoscopy.

Assuntos

Gastroscopia/métodos , Laparoscopia/métodos , Cirurgia Endoscópica por Orifício Natural/métodos , Síndrome de Resposta Inflamatória Sistêmica/etiologia , Animais , Biomarcadores/sangue , Proteína C-Reativa/análise , Citocinas/sangue , Modelos Animais de Doenças , Ensaio de Imunoadsorção Enzimática , Masculino , Duração da Cirurgia , Cavidade Peritoneal/cirurgia , Peritonite/etiologia , Estudos Prospectivos , Reprodutibilidade dos Testes , Suínos , Fatores de Tempo

RESUMO

OBJECTIVE: To investigate the impact of transgastric peritoneal access on plasma biomarkers of acute inflammatory response in comparison to laparoscopy. METHODS: This was a prospective and comparative study in a porcine model. Transgastric peritoneal access performed by natural orifice transluminal endoscopic surgery was compared with laparoscopy. Laparotomy and sham groups were used as positive and negative controls, respectively. Thirty-four pigs were assigned to receive transgastric natural orifice transluminal endoscopic surgery (n = 12), laparoscopy (n = 8), laparotomy (n = 8) or a sham procedure involving only anesthesia (n = 6). In the natural orifice transluminal endoscopic surgery group, peritoneoscopy was performed with a gastroscope via transgastric access. Blood samples were collected at baseline and 1, 3, 6, 9 and 24 h after the surgical procedure for measurement of interleukins 1β, 6 and 10 and tumor necrosis factor-α. A complete blood count was performed, and C-reactive protein levels were measured at baseline and at 24 h. RESULTS: All surgical and endoscopic procedures were performed without major complications. Peritoneal cavity inventory showed no signs of peritonitis in any animal. Interleukin 1β, interleukin 10 and tumor necrosis factor-α levels were below the threshold of detection. The mean level of interleukin 6 was statistically significantly higher in the laparotomy group than in the other groups (p<0.05), with no significant differences among the sham, laparoscopy and natural orifice transluminal endoscopic surgery groups (p>0.05). C-reactive protein analysis indicated significant increases in all groups, with no differences among the groups. Complete blood count analysis showed no differences among the groups. CONCLUSIONS: Based on the observed interleukin 6 patterns, the systemic inflammatory response resulting from transgastric ...

Assuntos

Animais , Masculino , Gastroscopia/métodos , Laparoscopia/métodos , Cirurgia Endoscópica por Orifício Natural/métodos , Síndrome de Resposta Inflamatória Sistêmica/etiologia , Biomarcadores/sangue , Proteína C-Reativa/análise , Citocinas/sangue , Modelos Animais de Doenças , Ensaio de Imunoadsorção Enzimática , Duração da Cirurgia , Estudos Prospectivos , Cavidade Peritoneal/cirurgia , Peritonite/etiologia , Reprodutibilidade dos Testes , Suínos , Fatores de Tempo

RESUMO

Brunner's gland hamartoma (BGH) is an extremely rare benign digestive tumor, generally located in the duodenal bulb. We report the case of a 51-year-old asymptomatic man with a large pedunculated BGH arising from the pylorus. It was successfully removed en bloc by endoscopic resection.

RESUMO

CONTEXT: Band ligation (BL) is the most appropriate endoscopic treatment for acute bleeding or prophylaxis of esophageal variceal bleeding. Sclerotherapy with N-butyl-2-cyanoacrylate (CY) can be an alternative for patients with advanced liver disease. Bacteremia is an infrequent complication after BL while the bacteremia rate following treatment with CY for esophageal varices remains unknown. OBJECTIVES: To evaluate and compare the incidence of transient bacteremia between cirrhotic patients submitted to diagnostic endoscopy, CY and BL for treatment of esophageal varices. METHODS: A prospective study comprising the period from 2004 to 2007 was conducted at Hospital of Universidade Federal de São Paulo, UNIFESP, SP, Brazil. Cirrhotic patients with advanced liver disease (Child-Pugh B or C) were enrolled. The patients were divided into two groups according treatment: BL Group (patients undergoing band ligation, n = 20) and CY Group (patients receiving cyanoacrylate injection for esophageal variceal, n = 18). Cirrhotic patients with no esophageal varices or without indication for endoscopic treatment were recruited as control (diagnostic group n = 20). Bacteremia was evaluated by blood culture at baseline and 30 minutes after the procedure. RESULTS: After 137 scheduled endoscopic procedures, none of the 58 patients had fever or any sign suggestive of infection. All baseline cultures were negative. No positive cultures were observed after CY or in the control group - diagnostic endoscopy. Three (4.6 %) positive cultures were found out of the 65 sessions of band ligation (P = 0.187). Two of these samples were positive for coagulase-negative staphylococcus, which could be regarded as a contaminant. The isolated microorganism in the other case was Klebsiella oxytoca. The patient in this case presented no evidence of immunodeficiency except liver disease. CONCLUSIONS: There was no significant difference in bacteremia rate between these three groups. BL or CY injection for non-bleeding esophageal varices may be considered as low-risk procedures regarding bacteremia even when performed on patients with advanced liver disease.

Assuntos

Bacteriemia/etiologia , Embucrilato/uso terapêutico , Varizes Esofágicas e Gástricas/tratamento farmacológico , Varizes Esofágicas e Gástricas/cirurgia , Cirrose Hepática/complicações , Escleroterapia/métodos , Adolescente , Adulto , Idoso , Bacteriemia/epidemiologia , Estudos de Casos e Controles , Varizes Esofágicas e Gástricas/etiologia , Esofagoscopia , Feminino , Humanos , Ligadura/efeitos adversos , Ligadura/métodos , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Escleroterapia/efeitos adversos , Índice de Gravidade de Doença , Resultado do Tratamento , Adulto Jovem

RESUMO

CONTEXT: Band ligation (BL) is the most appropriate endoscopic treatment for acute bleeding or prophylaxis of esophageal variceal bleeding. Sclerotherapy with N-butyl-2-cyanoacrylate (CY) can be an alternative for patients with advanced liver disease. Bacteremia is an infrequent complication after BL while the bacteremia rate following treatment with CY for esophageal varices remains unknown. OBJECTIVES: To evaluate and compare the incidence of transient bacteremia between cirrhotic patients submitted to diagnostic endoscopy, CY and BL for treatment of esophageal varices. METHODS: A prospective study comprising the period from 2004 to 2007 was conducted at Hospital of Universidade Federal de São Paulo, UNIFESP, SP, Brazil. Cirrhotic patients with advanced liver disease (Child-Pugh B or C) were enrolled. The patients were divided into two groups according treatment: BL Group (patients undergoing band ligation, n = 20) and CY Group (patients receiving cyanoacrylate injection for esophageal variceal, n = 18). Cirrhotic patients with no esophageal varices or without indication for endoscopic treatment were recruited as control (diagnostic group n = 20). Bacteremia was evaluated by blood culture at baseline and 30 minutes after the procedure. RESULTS: After 137 scheduled endoscopic procedures, none of the 58 patients had fever or any sign suggestive of infection. All baseline cultures were negative. No positive cultures were observed after CY or in the control group - diagnostic endoscopy. Three (4.6 percent) positive cultures were found out of the 65 sessions of band ligation (P = 0.187). Two of these samples were positive for coagulase-negative staphylococcus, which could be regarded as a contaminant. The isolated microorganism in the other case was Klebsiella oxytoca. The patient in this case presented no evidence of immunodeficiency except liver disease. CONCLUSIONS: There was no significant difference in bacteremia rate between these three groups. BL or CY injection for non-bleeding esophageal varices may be considered as low-risk procedures regarding bacteremia even when performed on patients with advanced liver disease.

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CONTEXTO: A ligadura elástica é considerada o melhor tratamento endoscópico para o sangramento agudo por varizes esofágicas ou para profilaxia do sangramento varicoso, sendo a escleroterapia com N-2-butil-cianoacrilato uma alternativa para os pacientes com doença hepática avançada e distúrbio de coagulação. Bacteriemia é uma complicação rara associada à ligadura elástica, por outro lado, a incidência de bacteriemia relacionada com o uso de N-2-butil-cianoacrilato permanece desconhecida. OBJETIVOS: Avaliar e comparar a incidência de bacteriemia transitória entre os pacientes cirróticos submetidos a endoscopia digestiva alta diagnóstica, escleroterapia com N-2-butil-cianoacrilato ou ligadura elástica para tratamento das varizes esofágicas. MÉTODOS: Estudo prospectivo realizado entre 2004 e 2007 foi conduzido no Hospital da Universidade Federal de São Paulo, UNIFESP, Brasil. Cirróticos com doença hepática avançada (Child B ou C) foram incluídos. Os pacientes foram divididos em dois grupos de acordo com o tratamento: grupo ligadura elástica (pacientes submetidos a ligadura elástica, n = 20) e grupo N-2-butil-cianoacrilato (pacientes submetidos a injeção de N-2-butil-cianoacrilato, n = 18). Cirróticos sem varizes esofágicas ou com varizes esofágicas sem indicação de tratamento endoscópico foram recrutados como controles (grupo endoscopia diagnóstica, n = 20). Bacteriemia foi avaliada por hemocultura basal e 30 minutos após o procedimento. RESULTADOS: Dos 137 procedimentos endoscópicos realizados, nenhum dos 58 pacientes apresentou febre ou qualquer sinal sugestivo de infecção. Todas as hemoculturas de base foram negativas. Nenhuma cultura positiva foi observada após o uso de N-2-butil-cianoacrilato ou no grupo controle. Três (4,6 por cento) culturas positivas foram encontradas após as 65 sessões de ligadura elástica (P = 0,187). Duas dessas foram positivas para Staphylococcus coagulase-negativo, provavelmente relacionadas à contaminação. O microorganismo isolado no terceiro caso foi Klebsiella oxytoca. Nesse caso, o paciente apresentava a própria doença hepática como única situação relacionada à imunodeficiência. CONCLUSÕES: Não houve diferença significante na incidência de bacteriemia entre os três grupos de pacientes. Ligadura elástica ou injeção de N-2-butil-cianoacrilato para profilaxia do sangramento varicoso podem ser considerados procedimentos de baixo risco quanto ao surgimento de bacteriemia, mesmo em pacientes com doença hepática avançada.

Assuntos

Adolescente , Adulto , Idoso , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Adulto Jovem , Bacteriemia/etiologia , Embucrilato/uso terapêutico , Varizes Esofágicas e Gástricas/tratamento farmacológico , Varizes Esofágicas e Gástricas/cirurgia , Cirrose Hepática/complicações , Escleroterapia/métodos , Bacteriemia/epidemiologia , Estudos de Casos e Controles , Esofagoscopia , Varizes Esofágicas e Gástricas/etiologia , Ligadura/efeitos adversos , Ligadura/métodos , Estudos Prospectivos , Índice de Gravidade de Doença , Escleroterapia/efeitos adversos , Resultado do Tratamento

RESUMO

OBJECTIVE: To determine whether Model for End-stage Liver Disease (MELD) Child-Turcotte-Pugh (CTP) classification, AST to platelet ratio index (APRI), and laboratory tests could predict the presence of esophageal varices (EV) or varices which need prophylactic therapy (medium or large size EV). METHODS: Three hundred patients with cirrhosis (193 men; mean age 53.1 years; majority with chronic C hepatitis) were prospectively analyzed. The presence of EV (any size and medium or large EV) was correlated with patients' characteristics (MELD, CTP classification, APRI, platelets count, and liver tests). RESULTS: One hundred and seventy-one patients (57%) had EV, of whom 35% (105) had varices which need prophylactic therapy (VPT). The distribution of EV according to CTP classification was as follows: A, 49%; B, 75.3% and C, 80%. Independent predictors of EV were: MELD higher than 8 (P=0.02); APRI higher than 1.64 (P=0.01); platelet count lower than 93,000/mm³ (P<0.01); aspartate aminotransferase higher than 1.34 × UNL (P=0.01), and total bilirubin higher than 1 mg/dl (P=0.04). MELD higher than 8 had the highest discriminative value for presence of EV (sensitivity=80.1%; specificity=51.2%; area under receiver operating characteristics=0.68). Factors independently associated with VPT were: thrombocytopenia (<92,000/mm³; P<0.01) and aspartate aminotransferase higher than 1.47 × UNL (P=0.03). Platelet count lower than 92,000/mm³ had sensitivity of 65.7%, specificity of 57.9%, and an area under receiver operating characteristics of 0.62 for the presence of VPT. CONCLUSION: High values on MELD are associated with EV and thrombocytopenia, with varices which need prophylactic therapy. As a result of their low sensitivity and specificity, it is suggested to maintain the recommendation of upper gastrointestinal endoscopy for all patients with cirhosis.

Assuntos

Biomarcadores/sangue , Varizes Esofágicas e Gástricas/etiologia , Cirrose Hepática/complicações , Contagem de Plaquetas , Adulto , Idoso , Aspartato Aminotransferases/sangue , Métodos Epidemiológicos , Varizes Esofágicas e Gástricas/diagnóstico , Varizes Esofágicas e Gástricas/prevenção & controle , Esofagoscopia , Feminino , Hepatite C Crônica/sangue , Hepatite C Crônica/complicações , Humanos , Cirrose Hepática/sangue , Masculino , Pessoa de Meia-Idade , Prognóstico , Trombocitopenia/etiologia

RESUMO

BACKGROUND: Patients with liver cirrhosis frequently undergo diagnostic or therapeutic upper GI endoscopy (UGIE), and the liver disease might impair the metabolism of drugs usually administered for sedation. OBJECTIVE AND SETTING: To compare sedation with a combination of propofol plus fentanyl and midazolam plus fentanyl in cirrhotic outpatients undergoing UGIE. DESIGN: A prospective, randomized, controlled trial was conducted between February 2008 and February 2009. MAIN OUTCOMES MEASUREMENTS: Efficacy (proportion of complete procedures using the initial proposed sedation scheme), safety (occurrence of sedation-related complications), and recovery time were measured. RESULTS: Two hundred ten cirrhotic patients referred for UGIE were randomized to 2 groups: midazolam group (0.05 mg/kg plus fentanyl 50 µg intravenously) or propofol group (0.25 mg/kg plus fentanyl 50 µg intravenously). There were no differences between groups regarding age, sex, weight, etiology of cirrhosis, and Child-Pugh or American Society of Anesthesiologists classification. Sedation with propofol was more efficacious (100% vs 88.2%; P < .001) and had a shorter recovery time than sedation with midazolam (16.23 ± 6.84 minutes and 27.40 ± 17.19 minutes, respectively; P < .001). Complication rates were similar in both groups (14% vs 7.3%; P = .172). LIMITATIONS: Single-blind study; sample size. CONCLUSION: Both sedation schemes were safe in this setting. Sedation with propofol plus fentanyl was more efficacious with a shorter recovery time compared with midazolam plus fentanyl. Therefore, the former scheme is an alternative when sedating cirrhotic patients undergoing UGIE.

Assuntos

Analgésicos Opioides/farmacocinética , Período de Recuperação da Anestesia , Sedação Consciente/métodos , Sedação Profunda/métodos , Endoscopia Gastrointestinal , Hipnóticos e Sedativos/farmacocinética , Cirrose Hepática/metabolismo , Analgésicos Opioides/administração & dosagem , Analgésicos Opioides/efeitos adversos , Bradicardia/etiologia , Sedação Consciente/efeitos adversos , Sedação Profunda/efeitos adversos , Feminino , Fentanila/administração & dosagem , Fentanila/efeitos adversos , Humanos , Hipnóticos e Sedativos/administração & dosagem , Hipnóticos e Sedativos/efeitos adversos , Hipotensão/etiologia , Hipóxia/etiologia , Masculino , Midazolam/administração & dosagem , Midazolam/efeitos adversos , Pessoa de Meia-Idade , Propofol/administração & dosagem , Propofol/efeitos adversos , Método Simples-Cego , Estatísticas não Paramétricas

RESUMO

BACKGROUND: The results of variceal band ligation (VBL) in patients with advanced liver disease are unknown. Cyanoacrylate injection (CI) might have a better outcome than VBL in the treatment of esophageal varices (EV) in these patients. AIM: To compare VBL and CI in the treatment of EV in patients with advanced liver disease. PATIENTS AND METHODS: Thirty-eight patients with medium or large EV and Child-Pugh index of at least eight were randomized into two groups: VBL (n=20) and CI (n=18). The patients were followed-up for at least 6 months after the end of treatment. Main outcomes were eradication, bleeding, mortality, complication, and recurrence rates. RESULTS: Variceal eradication rates were similar in the VBL and CI groups (90 vs. 72%, P=0.39). Mean number of sessions until eradication was 3.17 and 3, respectively. Bleeding episodes until eradication were equally observed in both groups (P=0.17). Mortality (55 vs. 56%, P=0.52) and major complication rates (5 and 17%, P=0.32) were similar. Chest pain with dysphagia was more frequent in the CI group (55.6 vs. 10%, P=0.004). A higher risk of variceal recurrence was observed in the CI group (33 vs. 57%, P=0.04). CONCLUSION: No significant differences between the VBL and CI groups were observed in the treatment of EV in patients with advanced liver disease regarding mortality, variceal eradication, and major complications rates. However, minor complications and variceal recurrence were significantly more common in the CI group. In addition, there was a clear trend toward more bleeding episodes in patients included in the CI group.

Assuntos

Cianoacrilatos/uso terapêutico , Endoscopia/métodos , Varizes Esofágicas e Gástricas/etiologia , Varizes Esofágicas e Gástricas/cirurgia , Hepatopatias/complicações , Adulto , Cianoacrilatos/efeitos adversos , Feminino , Hemorragia Gastrointestinal/terapia , Humanos , Injeções/efeitos adversos , Ligadura/efeitos adversos , Masculino , Pessoa de Meia-Idade , Recidiva , Resultado do Tratamento

RESUMO

OBJECTIVE: To evaluate and to compare the diagnostic yield of ERCP brush cytology (ERCP) and EUS-FNA in patients with biliary strictures and evaluates the agreement between general pathologists (GP) and expert GI pathologists (GIP) in the final diagnosis of biliary strictures. METHODS: Patients with biliary strictures documented by ERCP were included. Brush cytology was performed and during EUS, only visible mass lesions or localized bile duct wall thickening were aspirated. The gold standard method for diagnosis was surgical histology and/or follow-up. Tissue sampling results were: malignant, suspicious, atypical, insufficiently or benign. Specimens were interpreted by GP and GIP, blinded for prior tests results. RESULTS: 46 patients were included. Final diagnosis was malignancy in 37 (26 pancreatic--11 biliary) and benign in 9 (8 chronic pancreatitis--1 common bile duct inflammatory stricture). Sensitivity and accuracy for ERCP brush cytology were 43.2% and 52.2% for GP and 51.4% and 58.7% for GIP. Sensitivity and accuracy for EUS-FNA were 52.8% and 58.5%, respectively for GP and 69.4% e 73.2% for GIP. In comparison, the combination of brush cytology and EUS-FNA demonstrated higher sensitivity and accuracy for both GP (64.9% and 69.6%, respectively) and GIP (83.8% and 84.8%, respectively) and improved agreement with final diagnosis for both (mostly for GIP). CONCLUSION: Both, ERCP brush cytology and EUS-FNA has a similar yield for the diagnosis of biliary strictures. However, the combination of these methods results in an improved diagnostic accuracy. In addition, GIP might be expected to interpret specimens with greater accuracy than GP.

Assuntos

Doenças Biliares/diagnóstico , Neoplasias do Sistema Biliar/diagnóstico , Colangiopancreatografia Retrógrada Endoscópica , Endossonografia , Adulto , Idoso , Idoso de 80 Anos ou mais , Biópsia por Agulha Fina , Diagnóstico Diferencial , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos

RESUMO

OBJETIVO: Avaliar o desempenho diagnóstico da citologia obtida pela CPER, aquele obtido pela EE-PAAF e a concordância entre patologistas gerais (PG) e especialistas (PE) em pacientes com estenose biliar. MÉTODOS: Incluímos pacientes com estenose biliar identificados pela CPER. A EE-PAAF foi realizada apenas em áreas com efeito de massa ou da parede espessada do ducto biliar. O padrão-ouro foi a cirurgia, histologia e/ou o seguimento. As amostras teciduais foram consideradas: malignas, suspeitas, atípicas, insuficientes ou benignas. Os espécimes obtidos por cada método foi interpretado (cego) por um PG e outro PE. RESULTADO: 46 pacientes foram incluídos (37 malignos e 9 benignos). O diagnóstico final foi de tumor pancreático (26), biliar (11), pancreatite crônica (8) e estenose inflamatória do ducto biliar (1). Sensibilidade e acurácia da CPER foram 43,2 por cento e 52,2 por cento para o PG e 51,4 por cento e 58,7 por cento para o PE. Sensibilidade e acurácia da EE-PAAF foi 52,8 por cento e 58,5 por cento para o PG e 69,4 por cento e 73,2 por cento para o PE. A combinação entre a CPER e EE-PAAF demonstrou maior sensibilidade e acurácia para ambos PG (64,9 por cento e 69,6 por cento) e PE (83,8 por cento e 84,8 por cento), respectivamente. CONCLUSÃO: A citologia obtida pelo escovado da via biliar durante a CPER e as amostras teciduais colhidas pela EE-PAAF tem rendimento semelhante para o diagnóstico das estenoses biliares. No entanto, a combinação dos métodos resulta em uma maior acurácia. Além disso, espera-se que a interpretação das amostras ocorra com maior precisão pelo PE se comparado ao PG.

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OBJECTIVE: To evaluate and to compare the diagnostic yield of ERCP brush cytology (ERCP) and EUS-FNA in patients with biliary strictures and evaluates the agreement between general pathologists (GP) and expert GI pathologists (GIP) in the final diagnosis of biliary strictures. METHODS: Patients with biliary strictures documented by ERCP were included. Brush cytology was performed and during EUS, only visible mass lesions or localized bile duct wall thickening were aspirated. The gold standard method for diagnosis was surgical histology and/or follow-up. Tissue sampling results were: malignant, suspicious, atypical, insufficiently or benign. Specimens were interpreted by GP and GIP, blinded for prior tests results. RESULTS: 46 patients were included. Final diagnosis was malignancy in 37 (26 pancreatic - 11 biliary) and benign in 9 (8 chronic pancreatitis - 1 common bile duct inflammatory stricture). Sensitivity and accuracy for ERCP brush cytology were 43.2 percent and 52.2 percent for GP and 51.4 percent and 58.7 percent for GIP. Sensitivity and accuracy for EUS-FNA were 52.8 percent and 58.5 percent, respectively for GP and 69.4 percent e 73.2 percent for GIP. In comparison, the combination of brush cytology and EUS-FNA demonstrated higher sensitivity and accuracy for both GP (64.9 percent and 69.6 percent, respectively) and GIP (83.8 percent and 84.8 percent, respectively) and improved agreement with final diagnosis for both (mostly for GIP). CONCLUSION: Both, ERCP brush cytology and EUS-FNA has a similar yield for the diagnosis of biliary strictures. However, the combination of these methods results in an improved diagnostic accuracy. In addition, GIP might be expected to interpret specimens with greater accuracy than GP.

Assuntos

Adulto , Idoso , Idoso de 80 Anos ou mais , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Doenças Biliares/diagnóstico , Neoplasias do Sistema Biliar/diagnóstico , Colangiopancreatografia Retrógrada Endoscópica , Endossonografia , Biópsia por Agulha Fina , Diagnóstico Diferencial , Estudos Prospectivos

RESUMO

Retroperitoneal perforation during therapeutic endoscopic retrograde cholangiopancreatography (ERCP) is uncommon and is usually manifested by abdominal pain, fever and leukocytosis. We report the case of a patient with post-ERCP subcutaneous emphysema, pneumomediastinum and pneumothorax treated conservatively. A 79-year-old woman with a diagnosis of choledocholitiasis was referred to our institution for an elective outpatient therapeutic ERCP. At the end of the procedure, subcutaneous emphysema was observed, and a thoracic computed tomography revealed a right pneumothorax and pneumomediastinum. Supportive care was instituted and she was discharged asymptomatic after 10 days of hospitalization. Subcutaneous emphysema, pneumothorax and pneumomediastinum are potencial complications of ERCP and sphincterotomy. We review the other cases previously reported and discuss the management.