Revista Española de Enfermedades Digestivas

Protecting renal function: a relevant decision for liver transplantation

Prevalence and progression of chronic kidney disease after liver transplant: a prospective, real-life, observational, two-year multicenter study

ABSTRACT Introduction: chronic kidney disease is a frequent complication after liver transplantation. The use of calcineurin inhibitors is one of the causes of this complication. Current immunsuppression regimens that reduce the use of calcineurin inhibitors may be associated with an improved preservation of renal function. Objective: the study aimed to assess the evolution of renal function after liver transplantation in the current routine clinical practice. Methods: an observational, prospective, multicenter study in adult liver transplant recipients was performed. Two hundred and thirty patients with a good renal function before transplantation were assessed six months post-transplantation (baseline) and every six months until month 30. Results: at baseline, 32% of the patients had a reduction in the glomerular filtration rate below 60 ml/min/1.73 m2. The mean glomerular filtration rate increased from 72.3 to 75.6 ml/min/1.73 m2 at baseline and month 30 respectively (p < 0.01). The mean serum creatinine levels (mg/dl) decreased from 1.13 to 1.09 (p < 0.01). The percentage of patients with stage 3 chronic kidney disease decreased from 31.7% to 26.4%, whereas the percentage of patients with stage 4 remained unchanged (0.4% at baseline and 0.5% at month 30). No patients progressed to end-stage kidney disease that required dialysis or renal transplantation. Conclusion: in the routine clinical practice, a moderate deterioration of renal function is frequent after liver transplantation. However, advanced chronic kidney disease is infrequent in patients with a good pre-transplant renal function.

Analysis of the diagnostic yield of endoscopic ultrasonography-guided fine-needle aspiration in patients with a suspected pancreatic malignancy

ABSTRACT Objectives: to determine the diagnostic yield of endoscopic ultrasonography-guided fine-needle aspiration (EUS-FNA) for suspected pancreatic malignancy. As well as to identify factors that affect the incidence of false-negative cases and evaluate the value of repeated EUS-FNA in patients with inconclusive results. Methods: we retrospectively evaluated the data of patients who underwent EUS-FNA due to a suspected pancreatic malignancy in our hospital from January 2015 to December 2016. Results: a total of 194 EUS-FNA procedures performed and 175 cases were analyzed. The overall sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV) and accuracy were 83.4% (151/181), 100% (13/13), 100% (151/151), 30.2% (13/43), and 84.5% (164/194), respectively. The combination of cytological and histological examination significantly increased the diagnostic performance compared to either method alone. The diagnostic sensitivity in metastatic tumors was significantly lower than that for adenocarcinoma. EUS-FNA performed using standard needles combined with the "slow-pull" technique had a lower sensitivity than other methods. According to the multivariate analysis, neither the combination of needle type and suction technique nor final diagnosis were independent factors that affected the diagnostic sensitivity. The sensitivity of repeated EUS-FNA was 50.0% (8/16). Definitive results after a repeated puncture were more likely for pancreatic body and tail masses, heterogeneous lesions and poorly demarcated lesions. However, the difference was not significant. Conclusions: EUS-FNA was accurate for the evaluation of a suspected pancreatic malignancy. Metastatic tumors and the use of a standard needle in combination with the slow-pull technique may increase the incidence of false-negative results. Repeated EUS-FNA has limited value but should be considered for selected cases where the suspicion of malignancy persists.

Efficacy and safety of transoral outlet reduction via endoscopic suturing in patients with weight regain after a surgical Roux-en-Y gastric bypass

RESUMEN Introducción: muchos de los pacientes sometidos a cirugía bariátrica (bypass gástrico en Y-de-Roux [RYGB]), con el tiempo, pueden recuperar parte del peso perdido. La reducción transoral del vaciamiento gástrico (TORe) con sutura endoscópica podría ser una alternativa válida en estos pacientes. Métodos: serie inicial retrospectiva que incluye a 13 pacientes consecutivos remitidos por reganancia ponderal tras RYGB y con anastomosis gastroyeyunal dilatada (> 15 mm). El TORe fue realizado mediante un dispositivo endoscópico de suturas transmurales (OverStitch-Apollo(r)), reduciendo el diámetro de la anastomosis y del reservorio gástrico. Se describen los datos iniciales de viabilidad técnica, seguridad y eficacia, con un seguimiento limitado a seis meses. Resultados: tras el RYGB, existía una pérdida media máxima de 37,69 kg y una posterior reganancia media de 21,62 kg. Se redujo el diámetro medio de la anastomosis de 36 mm (rango 20-45) a 9 mm (rango 5-12) (reducción del 75%) con una media de 2,5 suturas y el del reservorio de 7,2 cm (rango 2-10) a 4,7 cm (rango 4-5) (reducción del 34,72%) con una media de 2,7 suturas. La pérdida media de peso a los seis meses tras el TORe fue de 12,29 kg (pérdida del 56,85% del peso reganado tras RYGB). No se registraron complicaciones relacionadas con el procedimiento. Conclusiones: la reducción mediante sutura endoscópica de la anastomosis gastroyeyunal dilatada y del reservorio gástrico parece una opción viable y segura según nuestra limitada experiencia inicial. Dentro de un abordaje multidisciplinar y en un seguimiento a corto plazo, se presenta como una opción mínimamente invasiva y eficaz para controlar la reganancia ponderal tras RYGB.

ABSTRACT Introduction: many patients that undergo bariatric surgery (Roux-en-Y gastric bypass [RYGB]) may regain some of their weight lost over time. A transoral outlet reduction (TORe) with endoscopic suture could be a valid alternative in these patients. Methods: this was a retrospective initial series of 13 consecutive patients with weight regain after RYGB and a dilated gastro-jejunal anastomosis (> 15 mm). TORe was performed using an endoscopic transmural suture device (OverStitch-Apollo(r)), which was used to reduce the anastomosis aperture and also to treat the gastric pouch. The initial data of feasibility, safety and weight loss are described with a limited follow-up of six months. Results: there was a mean maximum weight loss of 37.69 kg after RYGB and a subsequent average regain of 21.62 kg. The mean anastomosis diameter was 36 mm (range 20-45) which was reduced to 9 mm (range 5-12) (75% reduction), with an average of 2.5 sutures. The mean pouch size was 7.2 cm (range 2-10), which decreased to 4.7 cm (range 4-5) (34.72% reduction), with an average of 2.7 sutures. The mean weight loss six months after TORe was 12.29 kg, a weight loss of 56.85% of the weight regained after RYGB. No complications related to the procedure were recorded. Conclusions: endoscopic suture reduction of the dilated gastro-jejunal anastomosis and the gastric pouch seems a feasible and safe option in our limited initial experience. With a multidisciplinary approach and a short term follow-up, this seems to be a minimally invasive and effective option to control weight regain after RYGB.

Efficacy and safety of fenofibrate add-on therapy for patients with primary biliary cholangitis and a suboptimal response to UDCA

ABSTRACT Background: primary biliary cholangitis (PBC) patients with a suboptimal response to ursodeoxycholic acid (UDCA) have a significantly worse survival rate. Fenofibrate has been shown to improve the short-term biochemical response in this group of patients. However, there is limited data available on the safety and efficacy of its long-term use, especially in patients with cirrhosis. Methods: in this retrospective cohort study, fenofibrate was given to PBC patients with a suboptimal response to at least 12 months of UDCA (13-15 mg/kg/d) therapy. Biochemistry data, GLOBE score and UK-PBC risk score at baseline and at different time points of treatment were compared. The safety profiles were also compared between cirrhotic and non-cirrhotic patient groups. Results: fenofibrate (200 mg/day) was given to 39 PBC patients with a suboptimal response to UDCA (15 cirrhotic and 24 non-cirrhotic patients). In the 26 patients who completed more than one year of combination therapy, the alkaline phosphatase (ALP) levels were 215 (185, 326) U/l, 122 (110, 202) U/l, 128 (106, 194) U/l, 124 (100, 181) U/l and 120 (82, 168) U/l, at baseline, three months, six months, 12 months and 24 months, respectively. All p values were < 0.01 when compared to baseline values. After two years of combination therapy, the UK-PBC risk score and GLOBE score did not significantly improve. The overall rates of adverse events were not significantly different between the cirrhotic and non-cirrhotic group. The elevation of liver enzymes was the most frequent side effect (n = 7), leading to a discontinuation in four patients. Furthermore, after two years of combination therapy, the serum creatinine levels and estimated glomerular filtration rates (eGFR) were significantly worse in both groups. Conclusion: fenofibrate add-on therapy could improve ALP and -GT levels in both non-cirrhotic and cirrhotic PBC patients with a suboptimal response to UDCA. However, patients need to be monitored carefully for a potential liver injury and nephrotoxicity.

Switching from reference infliximab to CT-P13 in patients with inflammatory bowel disease: results of a multicenter study after 12 months

ABSTRACT Background and aims: infliximab has changed the natural history of inﬂammatory bowel disease (IBD). The advent of biosimilar treatments such as CT-P13 will hopefully improve the availability of biological therapies. Data with regard to drug switching are currently limited. The objective of the study was to assess the effectiveness and safety of switching from the reference product (RP), infliximab, to CT-P13 in patients with IBD. Methods: this was a multicenter prospective observational study in patients with Crohn's disease (CD) and ulcerative colitis (UC). All patients had switched from infliximab RP (Remicade(r)) to CT-P13 treatment and were followed up for 12 months. The efficacy endpoint was the change in clinical remission assessed at 0 and 12 months, according to the Harvey-Bradshaw score and partial Mayo score for patients with CD and UC, respectively. Adverse events were monitored and recorded throughout the study. Results: a total of 167 patients (116 CD/51 UC) were included; 88.8% (103/116) of patients with CD were in remission at the time of the drug switch and 69.7% were in remission at 12 months. The Harvey-Bradshaw (HB) score significantly changed at 12 months (p = 0.001); 84.3% (43/51) of patients with UC were in remission at the time of the drug switch and 76.7% were in remission at 12 months. No significant changes in the median partial Mayo score (p = 0.87) were observed at 12 months. Serious adverse events related to medication were reported in 12/167 (7.2%) cases. Conclusion: switching from infliximab RP to CT-P13 is safe and effective at 12 months. The loss of efficacy at 12 months was 15.7%.

Routine lower gastrointestinal endoscopy for radiographically confirmed acute diverticulitis. In whom and when is it indicated?

ABSTRACT Introduction: international guidelines recommend a routine colonoscopy to rule out advanced neoplasm after an acute diverticulitis event. However, in recent years, this recommendation has been called into question following the advent of computerized tomography (CT), particularly with regard to uncomplicated diverticulitis. Furthermore, colonoscopy is associated with a risk and additional costs. Objective: to understand the diagnostic yield, quality and safety of colonoscopy in the setting of acute diverticulitis. Methods: this was a retrospective study of all patients diagnosed with acute diverticulitis via CT between 2005 and 2013, who subsequently underwent a colonoscopy. Results: two hundred and sixteen patients diagnosed with acute diverticulitis via CT were enrolled. These included 58 cases with complicated diverticulitis (27%) and 158 with uncomplicated diverticulitis (73%). An advanced neoplasm was found in 12 patients (5.6%); 11.7% were complicated and 3.2% were uncomplicated (p = 0.02). No major complications were identified. The quality was low but improved over time; the complete procedure rate was 88%, an effective preparation was achieved in 75% and excision of polyps < 2 cm was performed in 78% of cases. The optimum colonoscopy quality cu-off was 9.5 weeks. Conclusion: routine colonoscopy is advisable after a complicated diverticulitis event but its recommendation is unclear with regard to uncomplicated episodes. Colonoscopy is safe even when performed early. The overall quality is low but may be optimized via a subsequent endoscopy, two months after a diverticulitis diagnosis.

Posterior tibial nerve stimulation in the treatment of fecal incontinence: a systematic review

RESUMEN La incontinencia fecal supone un importante impacto en la calidad de vida, produciendo estigmatización y exclusión social. La electroestimulación del nervio tibial posterior se emplea como técnica de tratamiento de la misma. La presente revisión sistemática tiene por objeto evaluar la eficacia de esta técnica en el tratamiento de la incontinencia fecal. La búsqueda bibliográfica en PubMed, Scopus, Web of Knowledge y PEDro se desarrolló siguiendo la declaración Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA), e incluyó ensayos clínicos aleatorizados y series de casos. Las medidas de resultado fueron la eficacia del tratamiento, la severidad de la incontinencia y la calidad de vida, tanto para la estimulación percutánea como transcutánea a corto, medio y largo plazo. Veintitrés estudios reunieron los criterios de selección. Dos ensayos clínicos obtuvieron diferencias significativas respecto al placebo, en términos de eficacia del tratamiento. Quince series de casos concluyeron con mejoras significativas en términos de eficacia, severidad y calidad de vida. Todos los ensayos clínicos y series de casos consiguieron reducir los episodios incontinentes y aumentar el tiempo de aplazamiento de la defecación. Programas de una o dos sesiones por semana, de 30 a 60 minutos, con anchura de pulso de 200 microsegundos y frecuencias de 10-20 hertzios son los óptimos para obtener estos resultados. No se ha demostrado superioridad de la estimulación percutánea frente a la transcutánea. La ENTP resulta efectiva en el tratamiento de la incontinencia fecal aunque se requieren tratamientos a largo plazo para consolidar los efectos de la técnica.

ABSTRACT Fecal incontinence severely impacts on quality of life, causing stigmatization and social exclusion. Posterior tibial nerve stimulation (PTNS) is one technique used for treatment. This systematic review aims to assess the effectiveness of PTNS for the treatment of fecal incontinence. A literature review was performed in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) declaration. Pubmed, Scopus, Web of Knowledge and PEDro databases were searched for both randomized clinical trials and cases series. The outcome variables were treatment effectiveness, severity of incontinence and quality of life; all were measured in the short, mid and long-term after performing both percutaneous and transcutaneous PTNS. Twenty-three studies met the selection criteria. Two clinical trials found significant differences in treatment effectiveness compared to the placebo response. Fifteen cases series observed significant differences in terms of effectiveness, severity and quality of life. All clinical trials achieved a reduction in the number of incontinence episodes and an increase in the deferral time for defecation. Optimal results were achieved by interventions consisting of one or two weekly sessions of a 30-60 minutes duration and the use of pulse widths of 200 µs and frequencies of 10-20 Hz. Percutaneous stimulation did not demonstrate better results compared to transcutaneous application. PTNS is an effective technique for the treatment of fecal incontinence, although long-term interventions are required in order to prolong its effects in the long-term.

Giant intra-abdominal liposarcoma

Effects of mesalazine enemas on lymphoid follicular proctitis

ABSTRACT Lymphoid follicular proctitis (LFP) is an uncommon inflammatory disease that is characterized by rectal bleeding, congested and granular mucosa without ulceration and abnormal and coalescing hyperplastic lymphoid follicles without acute inflammatory changes. The lesions are usually confined to the rectal mucosa. LFP therapy is not well defined. Herein, we present a case of LFP that was resolved with a rapid administration of mesalazine enemas. A 35-year-old male was admitted to our hospital due to intermittent rectal bleeding associated with stools. Total colonoscopy revealed nodular mucosa with top pinpoint-like ulcers from the rectum to the border between the sigmoid flexure and the rectum. The nodules congested together on the lower rectal segment and occupied 2/3 of the rectal lumina. Endoscopic submucosal dissection was performed in order to obtain more specimens for histologic examination, which revealed marked lymphoid follicular hyperplasia with prominent germinal centers and a conserved mantle zone. Treatment was started with mesalazine enemas of 4 g q.d. and the patient was asymptomatic after three days. All the lesions disappeared two months later. Mesalazine enemas could be a promising and effective therapeutic option for LFP therapy.

Endoscopic closure of tracheoesophageal fistula for tuberculosis with an over-the-scope-clip

RESUMEN Las fístulas enterales siempre han sido entidades de manejo quirúrgico y su abordaje suele ser difícil debido a las comorbilidades, el estado nutricional deteriorado y las dificultades anatómicas relacionadas con múltiples intervenciones en estos pacientes. Por estas razones viene aumentando la utilización de métodos endoscópicos como los clips, los stent autoexpandibles y, más recientemente, el over the scope clip (OTSC(r)). Presentamos el caso de un paciente con infección por VIH, que ingresó por síntomas respiratorios. En los estudios se le documenta una fístula traqueoesofágica cuya patología demuestra infección por tuberculosis (TB) y citomegalovirus (CMV), por lo cual se decidió inicialmente colocar un stent esofágico; sin embargo, este migró hacia el estómago. Cirugía de tórax consideró llevarlo a esofagectomía con ascenso gástrico y parche muscular en la tráquea, pero por su mal estado nutricional y comorbilidad decidimos colocar un OTSC(r), con lo cual se corrigió la fistula. Además, se le dio tratamiento antituberculoso y antirretroviral.

ABSTRACT Surgical management has been the main approach for enteral fistulae. This approach is usually complex due to comorbidities, a wasted nutritional state and anatomical difficulties related to prior multiple interventions. Therefore, endoscopic methods such as clips, self-expanding metal stent (SEMS) and recently, the over scope clip (OTSC(r)) are increasing in popularity and use. Herein, we present the case of a patient with a HIV infection who was admitted due to respiratory symptoms. Radiological and microbiological studies documented a tracheoesophageal fistula due to tuberculosis (TB) and cytomegalovirus (CMV) infection. Therefore, an esophageal fully-covered stent was placed, which migrated into the stomach. The thoracic surgeons considered an esophagectomy with gastric ascent and muscle patch in the trachea. However, due to his poor nutritional status and comorbidity, an OTSC was placed to treat the fistulae. The patient also received medical treatment with anti-tuberculotics and anti-retrovirals.

Revista Española de Enfermedades Digestivas

Protecting renal function: a relevant decision for liver transplantation

Prevalence and progression of chronic kidney disease after liver transplant: a prospective, real-life, observational, two-year multicenter study

Analysis of the diagnostic yield of endoscopic ultrasonography-guided fine-needle aspiration in patients with a suspected pancreatic malignancy

Efficacy and safety of transoral outlet reduction via endoscopic suturing in patients with weight regain after a surgical Roux-en-Y gastric bypass

Efficacy and safety of fenofibrate add-on therapy for patients with primary biliary cholangitis and a suboptimal response to UDCA

Switching from reference infliximab to CT-P13 in patients with inflammatory bowel disease: results of a multicenter study after 12 months

Routine lower gastrointestinal endoscopy for radiographically confirmed acute diverticulitis. In whom and when is it indicated?

Posterior tibial nerve stimulation in the treatment of fecal incontinence: a systematic review

Giant intra-abdominal liposarcoma

Effects of mesalazine enemas on lymphoid follicular proctitis

Endoscopic closure of tracheoesophageal fistula for tuberculosis with an over-the-scope-clip

Retroperitoneal schwannoma

Rectal syphilitic ulcer

Giant hepatobiliary cystadenoma: clinic-pathological findings

Why anal cytology is not enough in a dysplasia screening program

Dysphagia lusoria: uncommon cause of dysphagia in children

Bacterial endogenous endophthalmitis after colonoscopy