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OBJECTIVE: Sphincter of Oddi dysfunction (SOD) has been used to describe patients with RUQ abdominal pain without an etiology. We conducted a systematic review and meta-analysis to evaluate the efficacy and safety of ES (endoscopic sphincterotomy) for SOD. METHODS: The study methodology follows the PRISMA guidelines. A comprehensive search was conducted using MEDLINE and EMBASE databases for RCTs with ES in patients with SOD. The primary outcome assessed was the improvement of abdominal pain after ES/sham. A random effects model was used to calculate pooled estimates for each outcome of interest. RESULTS: Of the initial 55 studies, 23 were screened and thoroughly reviewed. The final analysis included 3 studies. 340 patients (89.7% women) with SOD were included. All patients had a cholecystectomy. Most included patients had SOD type II and III. The pooled rate of technical success of ERCP was 100%. The average clinical success rate was 50%. The pooled cumulative rate of overall AEs related to all ERCP procedures was 14.6%. In the sensitivity analysis, only one study significantly affected the outcome or the heterogeneity. CONCLUSION: ES appears no better than placebo in patients with SOD type III. Sphincterotomy could be considered in patients with SOD type II and elevated SO basal pressure.
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Disfunção do Esfíncter da Ampola Hepatopancreática , Esfíncter da Ampola Hepatopancreática , Humanos , Feminino , Masculino , Esfinterotomia Endoscópica/efeitos adversos , Esfinterotomia Endoscópica/métodos , Disfunção do Esfíncter da Ampola Hepatopancreática/cirurgia , Disfunção do Esfíncter da Ampola Hepatopancreática/etiologia , Esfíncter da Ampola Hepatopancreática/cirurgia , Colangiopancreatografia Retrógrada Endoscópica/métodos , Manometria , Dor Abdominal/etiologiaRESUMO
INTRODUCTION: Significant concerns raise for the healthcare workers involved in airway management of patients diagnosed with coronavirus 2019 disease (COVID-19). Due to shortages of personal protective equipment (PPE), barrier enclosure systems such as aerosol box (AB) have been proposed worldwide. The aim of this study was to evaluate our experience using AB as protective equipment in patients with COVID-19 in a third-level center in Mexico. METHODS: A retrospective study of COVID-19 patients requiring airway management using an AB in the Hospital Central Sur de Alta Especialidad de Pemex in Mexico City from March 1 to June 1, 2020. Antropometric data, pre-intubation vital signs, and laboratory tests were recorded; the primary endpoints were intubation success rate and complications associated with AB and patients' mortality. As a secondary endpoint, AB subjective evaluation was explored by administering a survey after airway management procedures. RESULTS: Thirty-nine patients for a total of 40 intubations were documented. Thirty-one (77.5%) were men, with a mean age of 61.65 years; successful intubation occurred in 39 (97.55%) of the procedures, and AB was used in 36 (90%) of intubations, with success in 28 (70.0%); A Cormack-Lehane grade 3 view was recorded in 18 patients (46.2%), and during the procedure, the AB had to be removed in 8 (22.2%) cases, with migration documented in 91.6% of cases. The 30-day mortality was 48.71%, with 23.0% of patients discharged. 83.3% of surveyed anesthesiologists reported significant limitations in manipulating airway devices with AB used. CONCLUSION: Our data indicate that in clinical practice, the use of AB may hinder airway management and decrease the intubation success rate and may also result in patients' injury. Further studies are necessary to validate the use of AB in clinical practice, and they should not replace certified PPE.
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BACKGROUND: During the COVID-19 pandemic, several questions have arisen about which endoscopic procedures (EPs) must be performed and which ones can be postponed. The aim of this study was to conduct a nationwide survey regarding the appropriate timing of EPs during the COVID-19 pandemic. METHODS: This prospective study was performed through a nationwide electronic survey. The survey consisted of 15 questions divided into three sections. The first evaluated the agreement for EPs classified as "time sensitive" and "not time sensitive". Two other sections assessed "high-priority" and "low-priority" scenarios. Agreement was considered when > 75% of respondents answered a question in the same direction. RESULTS: The response rate was 27.2% (214/784). Among the respondents, agreement for the need to perform EP in < 72 h was only reached for variceal bleeding (93.4%). Dysphagia with alarm symptoms was the scenario in which the highest percentage of physicians (95.9%) agreed that an EP needed to be performed within a month. Less than 30% of endoscopists would perform an EP within the first 72 h for patients with mild cholangitis, non-variceal upper gastrointestinal bleeding without hemodynamic instability, or severe anaemia without overt bleeding. In time-sensitive clinical scenarios suggestive of benign disease, none of the scenarios reached agreement in any sense. Among the time-sensitive clinical scenarios suggestive of malignancy, > 90% of the surveyed respondents considered that EP could not be postponed for > 8 weeks. CONCLUSIONS: There was no consensus among endoscopists about the timing of EPs in patients with pathologies considered time sensitive or in those with high-priority pathologies. Agreement was only reached in five (17%) of the evaluated clinical scenarios.
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COVID-19 , Varizes Esofágicas e Gástricas , Hemorragia Gastrointestinal/epidemiologia , Hemorragia Gastrointestinal/etiologia , Humanos , Pandemias , Estudos Prospectivos , SARS-CoV-2RESUMO
BACKGROUND AND STUDY AIMS: Post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis (PEP) is a complication associated with important morbidity, occasional mortality and high costs. Preventive strategies are suboptimal as PEP continues to affect 4% to 9% of patients. Spraying epinephrine on the papilla may decrease oedema and prevent PEP. This study aimed to compare rectal indomethacin plus epinephrine (EI) versus rectal indomethacin plus sterile water (WI) for the prevention of PEP. PATIENTS AND METHODS: This multicentre randomised controlled trial included patients aged >18 years with an indication for ERCP and naive major papilla. All patients received 100 mg of rectal indomethacin and 10 mL of sterile water or a 1:10 000 epinephrine dilution. Patients were asked about PEP symptoms via telephone 24 hours and 7 days after the procedure. The trial was stopped half way through after a new publication reported an increased incidence of PEP among patients receiving epinephrine. RESULTS: Of the 3602 patients deemed eligible, 3054 were excluded after screening. The remaining 548 patients were randomised to EI group (n=275) or WI group (n=273). The EI and WI groups had similar baseline characteristics. Patients in the EI group had a similar incidence of PEP to those in the WI group (3.6% (10/275) vs 5.12% (14/273), p=0.41). Pancreatic duct guidewire insertion was identified as a risk factor for PEP (OR 4.38, 95% CI (1.44 to 13.29), p=0.009). CONCLUSION: Spraying epinephrine on the papilla was no more effective than rectal indomethacin alone for the prevention of PEP. TRIAL REGISTRATION NUMBER: This study was registered with ClinicalTrials.gov (NCT02959112).
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Colangiopancreatografia Retrógrada Endoscópica , Pancreatite , Administração Retal , Anti-Inflamatórios não Esteroides/uso terapêutico , Colangiopancreatografia Retrógrada Endoscópica/efeitos adversos , Epinefrina , Humanos , Pancreatite/etiologiaRESUMO
INTRODUCTION: Patients with unexplained dilated common bile duct (CBD) and/or dilated main pancreatic duct (MPD) on noninvasive abdominal imaging tests are often referred for endoscopic ultrasound (EUS) in order to rule out biliopancreatic cancer. The aim of the study was to evaluate the diagnostic yield of EUS in this patient group. METHODS: A prospective study was conducted. Patients with unexplained dilated CBD and/or MPD on abdominal imaging, who underwent EUS, were enrolled. RESULTS: Fifty-four patients underwent EUS (CBD dilation n=38, MPD dilation n=5 or both n=11). In 31/54 patients (57.4%), EUS revealed pathologic findings. Sixteen patients (29.6%) had EUS evidence of biliopancreatic cancer and 15 patients (27.7%) had benign pathology. Ten (62.5%) of the patients with biliopancreatic cancer had MPD dilation. MPD dilation was significantly associated with malignancy (P=0.017). CONCLUSION: Patients with unexplained dilated MPD on noninvasive image have a high risk of biliopancreatic malignancy detected by EUS.
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Endossonografia , Neoplasias Pancreáticas , Humanos , Ductos Pancreáticos/diagnóstico por imagem , Neoplasias Pancreáticas/diagnóstico por imagem , Estudos Prospectivos , Estudos RetrospectivosRESUMO
Idiopathic acute recurrent pancreatitis (IARP) is defined as at least two episodes of acute pancreatitis with the complete or near-complete resolution of symptoms and signs of pancreatitis between episodes, without an identified cause. There is a paucity of information about the usefulness of endoscopic ultrasound (EUS) in IARP. OBJECTIVES: To determine the diagnostic yield of EUS in IARP. DESIGN: A retrospective study was performed in patients with IARP evaluated by EUS between January 2009 and December 2016. Follow-up assessments of acute pancreatitis recurrence were carried out. RESULTS: Seventy-three patients with 102 EUS procedures were included. EUS was able to identify the cause of IARP in 55 patients (75.3%). The most common findings were chronic pancreatitis in 27 patients (49.1%), followed by lithiasic pathology in 24 patients (43.6%), and intraductal papillary mucinous neoplasm in four patients (7.3%). A directed treatment against EUS findings had a protective tendency associated with the final resolution of recurrence. There were no complications reported. CONCLUSION: EUS performed in patients with IARP helped to identify a possible cause in 2/3 of the cases. The majority of patients have a treatable disease.
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Endossonografia , Pancreatite Crônica , Doença Aguda , Humanos , Estudos RetrospectivosRESUMO
INTRODUCTION: Endoscopic retrograde cholangiopancreatography (ERCP) biliary drainage is considered the reference standard in patients with biliary obstruction, but it is not free of complications. EUS-guided biliary drainage (EUS-BD) is considered an alternative in patients with failed ERCP; however, data are scarce as to whether EUS-BD could be considered a first option. OBJECTIVE: The aim of our study was to compare the need for reintervention and cost between ERCP biliary drainage vs. EUS-BD. MATERIAL AND METHODS: We conducted a retrospective and comparative study of patients with distal malignant biliary obstruction with biliary drainage with ERCP + plastic stent (ERCP-PS) vs. ERCP + metal stent (ERCP-MS) vs. EUS-BD. RESULTS: 124 patients were included, divided into three groups: ERCP-PS, 60 (48.3%) patients; ERCP-MS, 40 (32.2%) patients; and EUS-BD, 24 (19.3%) patients. The need for reinterventions (67 vs. 37 vs. 4%, respectively), the number of procedures [3 (1-10) vs. 2 (1-7) vs. 1 (1-2)], and the costs (4550 ± 3130 vs. 5555 ± 3210 vs. 2375 ± 1020 USD) were lower in the EUS-BD group. No differences in terms of complications were detected. CONCLUSION: EUS-BD requires fewer reinterventions and has a lower cost compared to drainage by ERCP with metal or plastic stents.
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Colangiopancreatografia Retrógrada Endoscópica , Colestase , Colestase/etiologia , Colestase/cirurgia , Drenagem , Endossonografia , Humanos , Estudos Retrospectivos , Stents , Ultrassonografia de IntervençãoRESUMO
INTRODUCTION: Ectopic varices are those that appear in a different region of the gastroesophageal junction. Bleeding from ectopic varices is rare but is usually massive and deadly. AIM: To identify the possible factors that cause bleeding from ectopic varices in patients with portal hypertension. MATERIAL AND METHODS: A cross-sectional and retrospective study; the data were collected between January 2004 and June 2014. We included patients with portal hypertension and gastrointestinal ectopic varices diagnosed by endoscopy. RESULTS: We found 31 patients with gastrointestinal ectopic varices. Of these, 25 had liver cirrhosis, and six showed non-cirrhotic portal hypertension. There were 16 men and 15 women in the study. The median age of the patients was 60 years (range minimum-maximum of 27 to 80 years). Nineteen (61%) patients had rectal varices, 10 (32%) had duodenal varices, 1 (3%) had ileal varices, and 1 (3%) had colonic varices. We found bleeding in 4 (13%) of the 31 patients with ectopic varices; two belonged to the cirrhosis group, and the other two were from the non-cirrhotic portal hypertension group. Three of the 4 patients with bleeding from gastrointestinal ectopic varices had exhibited haemorrhage from oesophageal varices (odds ratio = 4.09, 95% CI: 0.37-44.78, p = 0.249), but none of them showed bleeding from gastric varices. CONCLUSIONS: Bleeding from gastrointestinal ectopic varices is not necessarily associated with bleeding from oesophageal or gastric varices.
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BACKGROUND: Burnout syndrome (BOS) is characterized by emotional exhaustion, depersonalization and reduced personal accomplishment. It affects doctors, patients and their inter-relationship. There is a lack of data on BOS in Mexico. The main objective of the present study is to evaluate the prevalence of BOS in physician members of the Mexican gastroenterological association (MGA) and Mexican association for gastrointestinal endoscopy (MAGE). MATERIALS AND METHODS: Cross sectional, prospective study through anonymous electronic survey via e-mail, sent to members of the MGA (n = 1192) and MAGE (n = 600). The survey included questions about basic sociodemographic information, Maslach Burnout Inventory, and factors potentially associated with BOS. Continuous variables were summarized as means and ANOVA or Kruskal-Wallis test were used to compare groups. Nominal variables were summarized as proportions and Fisher's exact test or Χ2 test were used, as appropriate. RESULTS: A total of 1792 e-mail invitations were delivered and 411 answers were received with a response rate of 22.9%. The prevalence of BOS according to the Maslach Burnout Inventory was 26.3% (108/411). The prevalence of BOS according to the single-item self-defined burnout question (SISDBOQ) was 32.6% (134/411). The Kappa coefficient for emotional exhaustion between the SISDBOQ and Maslach inventory was 0.48 (p = 0.0001). Factors associated with BOS included performing endoscopic procedures (OR 2.9 (1.2-6.6); p = 0.008), lack of support from colleagues upon complications (OR 0.2 (0.1-0.4); p = 0.0001), receiving frequent reprimands from superiors (OR 2.4 (1.5-3.8); p = 0.0001), work unrelated to medicine (OR 2.4 (1.4-3.9); p = 0.0001), work violence/harassment (OR 3.0 (1.9-4.9); p = 0.0001) and living in a big city (OR 1.9 (1.2-3); p = 0.005). CONCLUSION: BOS is a frequent entity in Mexican gastroenterologists and endoscopists. There are potentially modifiable factors associated with BOS.
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Esgotamento Profissional/epidemiologia , Endoscopia Gastrointestinal/psicologia , Gastroenterologistas/psicologia , Estudos Transversais , Humanos , Internato e Residência , México/epidemiologia , Complicações Pós-Operatórias/psicologia , Prevalência , Estudos Prospectivos , Apoio Social , Fatores Socioeconômicos , Violência no Trabalho/psicologiaRESUMO
BACKGROUND: The pre-colonoscopy diet traditionally involves 24 h of a clear liquid diet (CLD) in combination with a lavage solution; however, this preparation is poorly tolerated. AIM: To compare the impact on the quality of bowel cleansing and tolerability of a CLD versus a low-residue diet (LRD). METHODS: We performed a randomized trial. Subjects were randomized to CLD or LRD the day before of elective colonoscopy. All subjects received a 4-L preparation of single-dose PEG beginning 16 h prior to colonoscopy. The Boston bowel preparation scale was used to evaluate bowel cleansing; an adequate-quality preparation was defined as a score ≥ 2 per segment. RESULTS: A total of 205 subjects were included with a mean age (SD) of 55.6 (12.6) years; 133 (64.9%) of them were female. A total of 105 subjects were randomized to receive CLD and 100 to LRD. No significant differences in bowel preparation quality were observed between groups according to the section of colon: right colon (70% vs. 73%, p = 0.08), transverse colon (82% vs. 79%, p = 0.062), or left colon (80% vs. 78.7%, p = 0.28). There was a tendency toward less-frequent nausea (p = 0.08) and vomiting (p = 0.07) in patients with LRD. No differences between groups regarding ADR (12% vs. 10%) were noted. CONCLUSIONS: An LRD before colonoscopy resulted in a tendency toward improved tolerability by patients, with no differences in the quality of bowel preparation.
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Colonoscopia/métodos , Dieta/métodos , Cuidados Pré-Operatórios/métodos , Idoso , Colo/diagnóstico por imagem , Colonoscopia/efeitos adversos , Fibras na Dieta/administração & dosagem , Ingestão de Energia , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Polietilenoglicóis/administração & dosagem , Cuidados Pré-Operatórios/efeitos adversos , Resultado do TratamentoRESUMO
INTRODUCTION: Hemostatic powder (TC-325) is a new tool for treatment of gastrointestinal bleeding that allows the treatment of large surfaces with active bleeding. The aim was to describe the initial success of TC-325 for the control of GI bleeding. MATERIALS AND METHODS: We did a multicenter cohort study with patients admitted to the endoscopy service for GI bleeding. A format was generated to standardize the information obtained in each center. It was determined whether this treatment had been used as a single therapy or as a combination therapy. Descriptive statistics with medians and ranges, or averages with SD according to distribution. RESULTS: Eighty-one patients with 104 endoscopic procedures were included. The median number of endoscopic procedures was 1 (1-3). In the first procedure, the initial success rate was 98.8% (n = 80), failure rate was 1.2% (n = 1), and rebleeding rate was 20% (n = 16). The majority of rebleeding cases occurred within the first 3 days (12/16, 75%). There was no association between rebleeding and etiology (malignant or benign; P = 0.6). In first procedure, 44 (54%) cases had monotherapy with TC-325 and 37 (46%) cases had a combined endoscopic therapy. There were no differences in initial success or rebleeding rates when TC-325 was used as monotherapy versus combined therapy (P = 0.7). The mortality rate was 4% (3/81). CONCLUSION: TC-325 is effective for achieving initial control of bleeding in patients with different GI etiologies. The rate of bleeding recurrence is considerable in both patients with benign and malignant etiology.
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Hemorragia Gastrointestinal/terapia , Hemostase Endoscópica/métodos , Hemostáticos/uso terapêutico , Minerais/uso terapêutico , Adulto , Idoso , Idoso de 80 Anos ou mais , Terapia Combinada , Feminino , Hemorragia Gastrointestinal/etiologia , Hemostase Endoscópica/efeitos adversos , Hemostáticos/efeitos adversos , Humanos , Masculino , Pessoa de Meia-Idade , Minerais/efeitos adversos , Recidiva , Estudos RetrospectivosRESUMO
Background and study aim Different techniques have been introduced to improve the endoscopist's view and enhance the detection of polyps. The endocuff is a polymer sleeve cap that is connected to the tip of the colonoscope in order to improve visualization of the mucosa during colonoscopy. The aim of the study was to compare adenoma detection rates (ADR) of endocuff-assisted colonoscopy and conventional colonoscopy. Patients and methods Patients 50 years or older were randomized into two groups: an endocuff-assisted colonoscopy group and a conventional colonoscopy group without the endocuff. Results A total of 337 patients were included: 174 in the endocuff group and 163 in the conventional group. The median age was 61 years (interquartile range 55â-â70 years), and 74â% were women. The ADR was higher in the endocuff group than in the conventional group (22.4â% vs. 13.5â%; Pâ=â0.02). The mean number of adenomas was 0.30 (SD 0.25) in the endocuff group and 0.21 (SD 0.26) in the conventional group (P â=â0.02). The rate of ileal intubation was lower in the endocuff group (73â% vs. 87â%; Pâ<â0.001). No serious adverse events occurred with the use of the endocuff. Conclusions Endocuff colonoscopy achieved a greater ADR than conventional colonoscopy.Trial registered at ClinicalTrials.gov (NTC02387593).
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Adenocarcinoma/diagnóstico por imagem , Adenoma/diagnóstico por imagem , Pólipos do Colo/diagnóstico por imagem , Colonoscopia/instrumentação , Neoplasias Colorretais/diagnóstico por imagem , Idoso , Colonoscopia/efeitos adversos , Detecção Precoce de Câncer/instrumentação , Feminino , Humanos , Íleo , Intubação Gastrointestinal , Masculino , Pessoa de Meia-Idade , Estudos ProspectivosRESUMO
Background. The Rockall, Glasgow-Blatchford, and AIMS65 are useful and validated scoring systems for predicting the outcomes of patients with nonvariceal gastrointestinal bleeding. However, there are no validated evidence for using them to predict outcomes on variceal bleeding. The aim of this study was to evaluate and compare the prognostic accuracy of different nonvariceal bleeding scores with other liver-specific scoring systems in cirrhotic patients. MATERIAL AND METHODS: A retrospective multicenter study that included 160 cirrhotic patients with acute variceal bleeding. The AUROC's to predict in-hospital mortality, and rebleeding, were analyzed for each scoring system. RESULTS: Overall in-hospital mortality occurred in 13% and in-hospital rebleeding in 12% of patients. The systems with the best AUROC value for predicting mortality were MELD (0.828; 95% CI 0.748-0.909), and AIMS65 (0.817; 95% CI 0.724-0.909). The best score systems for predicting rebleeding were Glasgow-Blatchford (0.756; 95% CI 0.640- 0.827), and Rockall (0.691; 95% CI 0.580-0.802). CONCLUSIONS: In addition to liver-specific scores, the AIMS65 score is accurate for predicting in-hospital mortality in cirrhotic patients with acute variceal bleeding. Other scoring systems might be useful for predicting significant clinical outcomes in these patients.
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Técnicas de Apoio para a Decisão , Varizes Esofágicas e Gástricas/etiologia , Hemorragia Gastrointestinal/etiologia , Cirrose Hepática/complicações , Adulto , Idoso , Área Sob a Curva , Varizes Esofágicas e Gástricas/diagnóstico , Varizes Esofágicas e Gástricas/mortalidade , Feminino , Hemorragia Gastrointestinal/diagnóstico , Hemorragia Gastrointestinal/mortalidade , Mortalidade Hospitalar , Humanos , Cirrose Hepática/diagnóstico , Cirrose Hepática/mortalidade , Masculino , México , Pessoa de Meia-Idade , Valor Preditivo dos Testes , Prognóstico , Curva ROC , Recidiva , Reprodutibilidade dos Testes , Estudos Retrospectivos , Medição de Risco , Fatores de Risco , Fatores de TempoRESUMO
BACKGROUND AND OBJECTIVES: There is no consensus about the ideal method for diagnosis in patients who have already undergone endoscopic ultrasound fine needle aspiration (EUS-FNA), and the inconclusive material is often obtained. The aim was to evaluate the diagnostic yield of the second EUS-FNA of pancreatic lesions. MATERIALS AND METHODS: A retrospective analysis of prospectively collected data of patients with EUS-FNA of pancreatic lesions is performed. All patients who underwent more than one EUS-FNA for the evaluation of suspected pancreatic cancer over a 7-year period were included in the analysis. RESULTS: A total of 296 EUS-FNAs of the pancreas were performed in 257 patients. The diagnostic yield with the first EUS-FNA was 78.6% (202/257). Thirty-nine (13.3%) FNAs were repeated in 34 patients; 17 (50%) patients were women. The mean ± standard deviation (SD) age was 58.8 ± 16.1 years. The location of the lesions in the pancreatic gland, from which the second biopsies were taken, was head of the pancreas, n = 28 (82.4%), body of the pancreas, n = 3 (8.8%), and tail, n = 3 (8.8%). The mean ± SD of the size of the lesion was 36.3 ± 14.6 mm. The second EUS-FNA was more likely to be positive for diagnosis in patients with an "atypical" histological result in the first EUS-FNA (odds ratio [OR]: 4.04; 95% confidence interval [CI]: 0.9-18.3), in contrast to patients with a first EUS-FNA reported as "normal" (OR: 0.21; 95% CI: 0.06-0.71). Overall, the diagnostic yield of the second EUS-FNA was 58.8% (20/34) with an increase to 86.3% overall (222/257). CONCLUSION: Repeat EUS-FNA in pancreatic lesions is necessary in patients with a negative first EUS-FNA because it improves the diagnostic yield.