Revista Española de Enfermedades Digestivas

Precorte: dos (técnicas combinadas) mejor que una

Recidiva en cáncer de esófago tras cirugía R0: factores de riesgo y evolución

Introduction: despite advances in surgical and adjuvant therapy, recurrence in esophageal cancer submitted to R0 surgery remains high. The aim is to define risk factors and recurrence patterns. Additionally, to show the management carried out and the outcome of patients showing recurrence. Material and methods: observational and prospective study that included 61 patients. Neoadjuvancy therapy was indicated on T3, T4 and N+ tumors and every lymph node dissection was performed in two fields. Recurrence is defined at distance, regional or local, when, recurrence is detected after six months. According to clinical features and the recurrences, a palliative, chemotherapeutic or surgical management was indicated. Results: there were 54 men and the mean age was 59.7 years. The most frequent stage was the IIA and 17 (27.9%) had positive lymph nodes. Thirty (49.2%) had showed recurrence with a median disease-free interval of 10.5 months. The pTNM, the absence of response to the neoadjuvancy and the presence of compromised lymph nodes were found to be risk factors for recurrence. Only the presence of compromised lymph nodes was significant in the multivariate analysis. After diagnosis of the recurrence, median survival was 7 months and 6 subjects survived beyond 1 year. Conclusions: we confirmed the high incidence of recurrence in esophageal cancer, where the presence of compromised lymph nodes is probably the main risk factor. After the diagnosis of a relapse the prognosis would be bad, however there would be a small subsidiary group for treatment where outcomes would be better.

Introducción: pese a los avances quirúrgicos y en terapia complementaria, la recidiva en el cáncer de esófago sometido a cirugía R0 sigue siendo alta. El objetivo es definir factores de riesgo y patrones de recidiva. También mostrar el manejo realizado y la evolución de los pacientes con recidiva. Material y métodos: estudio observacional y prospectivo que incluye a 61 pacientes. La neoadyuvancia se indicó frente a tumores T3, T4 o N+ y se realiza a todos disección ganglionar en dos campos. Se define recidiva a distancia, regional o local, cuando después de 6 meses se detecta recurrencia. De acuerdo con las características clínicas y de las recidivas, se indica un manejo paliativo, quimioterápico o quirúrgico. Resultados: hubo 54 varones y la edad media fue de 59,7 años. El estadio más frecuente fue el IIA y 17 (27,9%) tenían ganglios positivos. Un total de 30 (49,2%) presentaron recidiva con una mediana de intervalo libre de enfermedad de 10,5 meses. El pTNM, la ausencia de respuesta a la neaodyuvancia y la presencia de ganglios comprometidos resultaron ser factores de riesgo para recidiva. Este último también fue significativo en el análisis multivariante. Tras el diagnóstico de recidiva, la mediana de supervivencia fue de 7 meses, y 6 pacientes alcanzaron una supervivencia superior a un año. Conclusiones: corroboramos la alta incidencia de recidiva del cáncer de esófago, siendo posiblemente el principal factor de riesgo la presencia de ganglios comprometidos. Tras el diagnóstico de una recidiva el pronóstico sería malo, sin embargo existiría un pequeño grupo subsidiario de tratamiento con mejores expectativas.

Dificultades endoscópicas e histológicas en el diagnóstico de la enfermedad celiaca: un estudio multicéntrico para valorar la práctica actual

Background and aims: the diagnosis of celiac disease requires small bowel biopsies to identify the characteristic mucosal changes. The current biopsy practice among endoscopists for celiac disease is in most part unknown. The aim of this study was to compare the different diagnostic policies in various centers in their current practice. Method: information from a total of 931 confirmed celiac disease patients was retrospectively obtained retrospectively from nine centers in European and Middle Eastern countries. The number of small-bowel biopsies obtained from the duodenal bulb and the second part of the duodenum was compared among different centers. Results: the most frequent stage of mucosal changes amongst Iranian subjects was Marsh IIIa whereas in the rest of the study population was Marsh IIIc. Marsh I and Marsh II were more prevalent in adults (P < 0.05) and Marsh IIIc was significantly higher in pediatric ages between 1 and 15 (P < 0.05). The most common number of biopsy specimens obtained from Romanian subjects was 1 (52% of cases), followed by 2 for Iranian (56%), 3 for Lithuanian (66.7%) and British patients (65%) and 4 for Italian patients (48.3%). For majority of cases, anemia was the most prevalent symptom (18.7%) followed by malabsorption (10.5%), diarrhea (9.3%) and dyspepsia (8.2%), respectively. Conclusions: despite the evidence-based recommendations, this study revealed a poor compliance with major guidelines on diagnosis of celiac disease. We emphasize that taking adequate number of duodenal biopsies should be implemented for an accurate diagnosis and also for the exclusion of celiac disease.

Precorte combinado en la canulación biliar difícil

Aim: precut sphincterotomy refers to a variety of endoscopic techniques that are used in order to access the bile duct when conventional methods of cannulation have failed. There are not significant data (such as efficacy, safety) about the use of different techniques of precutting at the same session. We have described our experience with combined precut sphincterotomy (CPS) and we have compared our results to the use of an isolated precut. Patients and methods: we have performed 247 precuts of a total of 2.390 ERCPs. Patients were distributed according to the type of precut practiced: Needle-knife, transpancreatic and combined precut sphincterotomies. "Combined precut" consisted in performing first a transpancreatic sphincterotomy and, if the access was not achieved, then performing a needle-knife sphincterotomy in the same session. The data about safety and efficacy were prospectively collected. The complications were defined according to the consensus criteria. Results: we performed precutting techniques in 247 patients. Needle-knife, transpancreatic, and combined precuts were performed in 125 (6.9%), 74 (4.1%) and 48 (2.6%) patients, respectively. Bile duct cannulation was successful in 48 patients (100%) in the group of combined precut, 121 patients (96.8%) in the transpancreatic group, and 67 patients (90.5%) in the needle-knife group (p = 0.03). There were not differences in complications rates between the three groups. There was no pancreatitis in the combined precut group. The complications were successfully managed with conservative treatment. Conclusions: combined precut sphincterotomy seems to be a safe and successful technique in those cases of difficult bile duct cannulation.

Impacto de las técnicas combinadas de precorte sobre la canulación selectiva biliar

Introduction: simple biliary cannulation techniques obtain a success rate of 80-95%. Advanced precut techniques are not immediately successful in 10-40% of cases. Between extreme options such as a second attempt a few days later or an immediate attempt by the transparietal route, an alternative precut technique may be used as a rescue strategy for the initially failed procedure. The purpose of this study was to assess the efficacy and safety of the combined use of two precut techniques when immediate biliary access is not granted by an initial procedure. Patients and method: a retrospective analysis of a personal series of precut (needle-knife and transpancreatic) sphincterotomies, both alone and in combination. Results: five hundred sixty nine ERCPs (endocopic retrograde cholangio-pancreatography) met the inclusion criteria for the analysis. Simple cannulation was obtained in 444 (78%) of them. In all, 119 (21%) precuts were attempted and 110 (92.4%) were successful, which raised the overall cannulation rate to 97.4%. Ninety-five (80%) precuts were successful with the initial technique. Rescue with the alternative technique was attempted for 20 failures with a successful outcome in 15, which raised the overall success rate to 92%. The combination of needle-knife precut plus transpancreatic precut raised the success rate from 87% to 94%. The combination of transpancreatic precut plus needle-knife precut raised the success rate from 70% to 90%. Among all 96 patients with available follow-up data, 17 (18%) complications were recorded: 9 bleeding episodes, 4 pancreatitis cases, and 4 retroperitoneal perforations. No mortality was recorded. Conclusions: a combination of precut techniques is effective for biliary cannulation when simple cannulation and initial precut approaches fail. The safety profile differs from that in the delayed strategy, hence both should be considered alternatives, their use depending on the technical and clinical conditions prevailing for each patient, as well as endoscopist experience.

Introducción: las técnicas simples de canulación biliar consiguen un porcentaje de éxitos del 80-95%. Las técnicas avanzadas de precorte no logran el éxito inmediato en un porcentaje del 10-40%. Entre las opciones extremas de un segundo intento diferido varios días o un intento de acceso inmediato por vía transparietal, existe el recurso a una técnica alternativa de precorte como rescate de la inicial fallida. El objetivo del presente estudio es evaluar la eficacia y seguridad del empleo combinado de dos técnicas de precorte cuando la inicial no permite el acceso biliar inmediato. Pacientes y método: análisis retrospectivo de una serie personal de esfinterotomías de precorte (de aguja y transpancreático) simples y combinadas. Resultados: un total de 569 colangio-pancreatografías retrógradas endoscópicas (CPRE) cumplen los criterios de inclusión en el análisis. En 444 (78%) se obtuvo la canulación simple. Se intentaron 119 (21%) precortes, con éxito en 110 (92,4%), lo que elevó la tasa global de canulación al 97,4%. Noventa y cinco (80%) de los precortes tuvieron éxito con la técnica inicial. En 20 fracasos se intentó el rescate con la técnica alternativa, con éxito en 15, elevando la tasa global de éxito al 92%. La combinación precorte de aguja más precorte transpancreático elevó la tasa de éxito del 87% al 94%. La combinación precorte transpancreático más precorte de aguja elevó la tasa de éxito del 70% al 90%. Entre los 96 pacientes con seguimiento disponible se registraron 17 (18%) complicaciones: 9 hemorragias, 4 pancreatitis y 4 perforaciones retroperitoneales. No se registró mortalidad. Conclusiones: la combinación de técnicas de precorte es eficaz para alcanzar la canulación biliar cuando las técnicas simples de canulación y el precorte inicial fracasan. El perfil de seguridad difiere del de la estrategia moratoria, por lo que ambas deben considerarse alternativas y emplearse dependiendo de las condiciones técnicas y clínicas de cada paciente y de la experiencia del endoscopista.

Linaclotida en el tratamiento de pacientes con síndrome del intestino irritable con estreñimiento: análisis de una oportunidad

Linaclotide is a secretagogue that provides a combined effect on visceral pain. The European Medicines Agency has authorized its indication for the symptomatic treatment of moderate to severe irritable bowel syndrome with constipation in adults. The purpose of this review is to discuss the clinical framework for linaclotide use in our setting, the drug's characteristics and pre-clinical development, and the clinical studies supporting its use in order to establish relevant views regarding its validity and clinical applicability. The results suggest that the only -non-severe- adverse effect associated with this drug is diarrhea. As regards effectiveness, linaclotide consistently shows favorable, significant differences in absolute risk versus placebo for all objective outcome variables described by regulatory agencies, with a combined pain and constipation response between 12.6% and 22.8% according to the variable and trial under consideration. This response is sustained and drug-related, as it goes away upon discontinuation. To conclude, linaclotide has a safety and efficacy profile that, from a clinical perspective, warrants its use for patients meeting irritable bowel syndrome and constipation criteria, with significant symptoms that cannot be relieved with other less specific measures. In the absence of predictive rules for response, it is recommended that, should the patient fail to respond, he or she should be considered not eligible for linaclotide therapy, and both indication and treatment continuity should be reserved for objective responders alone.

La linaclotida es un secretagogo que asocia un efecto combinado sobre el dolor visceral. La European Medicines Agency ha aprobado su indicación en el tratamiento sintomático en adultos del síndrome del intestino irritable con estreñimiento moderado o grave. El objetivo de esta revisión es analizar el marco clínico de aplicación de linaclotida en nuestro medio, las características del fármaco, su desarrollo preclínico y los estudios clínicos que apoyan su uso, con el fin de establecer los correspondientes juicios de validez y aplicabilidad clínica. Los resultados indican que el único efecto adverso, no grave, del fármaco es la diarrea. En cuanto a su eficacia, linaclotida presenta consistentemente favorables y significativas diferencias de riesgo absolutas frente a placebo en todas las variables resultado objetivas marcadas por las agencias reguladoras, con una respuesta combinada a dolor y estreñimiento entre el 12,6% y el 22,8%, según la variable y el ensayo considerados. Esta respuesta es sostenida y vinculada al fármaco, pues desaparece tras su retirada. Se concluye que linaclotida presenta un perfil de seguridad y eficacia que justifica, desde una perspectiva clínica, su uso en pacientes que cumplan criterios de síndrome del intestino irritable con estreñimiento con sintomatología de intensidad significativa que no pueda resolverse con otros tratamientos menos específicos. En ausencia de reglas de predicción de respuesta se recomienda que, si tras un periodo de prueba el paciente no responde, debe considerarse que no es candidato a tratamiento con linaclotida, reservando indicación y continuidad del tratamiento solo a los respondedores objetivos.

Tumor rectal de crecimiento lateral tipo no granular resecado mediante disección endoscópica submucosa pura: un tratamiento inusual para una lesión atípica

Peritonitis biliar secundaria a la perforación espontánea de hamartoma mesenquimal hepático

Síndrome de Budd-Chiari secundario a pseudotumor inflamatorio hepático: seguimiento durante 10 años

Inflammatory pseudotumor (IPT) of the liver is a rare benign tumor of unknown origin, it has the appearance of a malignant tumor but has a benign histology and clinical course. We report a case of a 63-year-old man diagnosed of IPT of the liver and followed for 10 years. During the clinical course, he developed a secondary Budd-Chiari syndrome, with a successful response to a transjugular intrahepatic portosystemic shunt over a 5-year follow-up period.

El pseudotumor inflamatorio (PTI) hepático es una entidad rara, de origen desconocido y aunque puede tener apariencia maligna, su naturaleza es benigna. Presentamos el caso de un varón de 63 años diagnosticado de PTI hepático en seguimiento durante 10 años. En su evolución desarrolló un síndrome de Budd-Chiari, con buena respuesta tras la colocación de una derivación porto-sistémica transyugular, a los cinco años.

Drenaje biliar transhepático anterógrado usando una prótesis metálica autoexpandible: una alternativa terapéutica tras la hepaticoyeyunostomía con reconstrucción en Y en Roux

Endoscopic drainage is the procedure of choice in cases of obstructive jaundice. However, in patients with a surgical biliary reconstruction, this technique cannot be often satisfactorily used. In these cases, the best alternative has usually been the percutaneous biliary drainage. Since the introduction of endoscopic ultrasound-guided therapy, some new techniques have been proposed to solve these technical problems related to postsurgical disturbed anatomy. In this case report, we describe our successful experience in the performance of a transhepatic anterograde biliary drainage using a self-expandable metallic stent in the context of a patient who previously had undergone a hepaticojejunostomy with Roux-en-Y reconstruction because of a resected hilar cholangiocarcinoma.

Síndrome hepatopulmonar

Quiste hidatídico hepático gigante con extensión al mediastino

Divertículo duodenal perforado por cuerpo extraño

Perforación rectal asociada al tratamiento con sunitinib

Enfermedad de Ménétrier y sarcoma de Kaposi en un paciente VIH positivo

El uso inadecuado de inhibidores de la bomba de protones, las guías y la investigación clínica