Revista Española de Enfermedades Digestivas

Colorectal cancer screening and survival

Screening-detected colorectal cancers show better long-term survival compared with stage-matched symptomatic cancers

ABSTRACT Purpose: the aim of this study was to compare overall and disease-free survival among patients with colorectal cancer detected via a screening program as compared to those with symptomatic cancer. Material and methods: patients diagnosed via colonoscopy (screening group) and those with clinical symptoms (non-screening) were identified from 1995 to 2014. Demographic, clinical, surgical and pathologic variables were recorded. Stage I, II and III cancers were included. Overall and disease-free survival were calculated at five and ten years after tumor resection and survival was calculated by matching both groups for cancers at stage I, II and III. Results: two hundred and fifty patients were identified as a result of screening procedures and 1,330 patients presented with symptomatic cancers. There were no significant differences in the baseline characteristics between the two groups. Pathologic stage, degree of differentiation, perineural invasion and lymphovascular invasion were lower in the screening group (p < 0.01). Overall and disease-free survival at five and ten years were higher in the screening group (p < 0.01). However, when the subjects were matched for pathologic stage, significant differences were found between the two groups with regard to stage I and III tumors. Disease-free survival in stage III at five years (79.1 vs 61.7%; p < 0.001) and ten years (79.1% vs 58.5%; p < 0.001) were significantly higher in the screening group. Conclusions: patients with stage I and III tumors that were diagnosed via a screening program have a higher overall and disease-free survival at five and ten years.

A clinical trial comparing propofol versus propofol plus midazolam in diagnostic endoscopy of patients with a low anesthetic risk

RESUMEN Antecedentes y objetivos: propofol y midazolam son dos de los fármacos más utilizados en la endoscopia digestiva alta (EDA). El objetivo del estudio fue evaluar dos protocolos de sedación utilizando estos fármacos en pacientes sometidos a una EDA en términos de seguridad, eficiencia, calidad de la exploración y aceptación del paciente. Pacientes y métodos: estudio prospectivo, randomizado y a doble ciego, en el que se incluyó a 83 pacientes de 18-80 años, de bajo riesgo anestésico (ASA I-II) sometidos a EDA diagnóstica, aleatorizados a recibir propofol más placebo (grupo A) o midazolam más propofol (grupo B). Resultados: en el grupo A, 42 pacientes recibieron un bolo de placebo (suero salino) y propofol en bolos de 20 mg hasta una media de 115 mg; en el grupo B, 41 pacientes recibieron 3 mg de midazolam y bolos de 20 mg de propofol hasta una media 83 mg. No hubo diferencias significativas en los efectos adversos en ambos grupos y los que se presentaron se trataron de forma conservadora. Los pacientes en el grupo B (midazolam más propofol) alcanzaron de forma más rápida la sedación deseada sin variar el tiempo global de la exploración. La calidad en la evaluación endoscópica fue similar en ambos grupos y los pacientes se sintieron igualmente satisfechos con ambos regímenes de sedación. Conclusiones: la sedación con midazolam más propofol no afecta al tiempo global de la exploración, utiliza menos dosis de propofol, es tan segura como la administración del propofol en monoterapia, proporciona igual calidad de exploración y similar aceptación por los pacientes.

ABSTRACT Background and objectives: propofol and midazolam are two of the most commonly used sedatives in upper gastrointestinal endoscopy (UGE). The objective of this study was to evaluate these two sedation regimens administered to patients who underwent an UGE with regard to security, efficiency, quality of exploration and patient response. Patients and methods: a prospective, randomized and double-blind study was performed which included 83 patients between 18 and 80 years of age of a low anesthetic risk (ASA - American Society of Anesthesiologists- I-II) who underwent a diagnostic UGE. Patients were randomized to receive sedation with either placebo plus propofol (group A) or midazolam plus propofol (group B). Results: in group A, 42 patients received a placebo bolus (saline solution) and on average up to 115 mg of propofol in boluses of 20 mg. In group B, 41 patients received 3 mg of midazolam and an average of up to 83 mg of propofol in boluses of 20 mg. There were no significant differences in the adverse effects observed in either group and all adverse events were treated conservatively. The patients in group B (midazolam plus propofol) entered the desired sedated state more quickly with no variation in the overall time of the exploration. The quality of the endoscopic evaluation was similar in both groups and the patients were equally satisfied regardless of the sedatives they received. Conclusions: the use of midazolam plus propofol as a sedative does not affect the overall exploration time, a lower dose of propofol can be used and it is as safe as administering propofol as a monotherapy while providing the same level of both exploration quality and patient approval.

Switching from endoscopic submucosal dissection to salvage piecemeal knife-assisted snare resection to remove a lesion: a preoperative risk score from the beginning

ABSTRACT Background and aims: endoscopic submucosal dissection (ESD) in the Western setting remains a challenge. Therefore, other simplified techniques such as knife-assisted snare resection (KAR) have been reported to overcome this issue. Methods: patients who underwent an ESD for the treatment of gastrointestinal neoplasms were included in a retrospective cross-sectional observational study. Factors associated with the end of ESD as a salvage p-KAR were identified and a logistic regression model was developed. Results: a total of 136 lesions in 133 patients were analyzed. Operator experience of under 50 cases and the combination of lesion size > 30 mm and colorectal location were independent predictive factors for switching to a salvage p-KAR according to the multivariate logistic regression analysis. We developed a risk scoring system based on these four variables (experience, size, location and the combination of size and location) with a receiver operating characteristic curve of 0.81 (95% CI: 0.74-0.89). The diagnostic accuracy of the score for a cut-off point ≥ 5 had a sensitivity of 0.79 (95% CI: 0.66-0.93) and a specificity of 0.71 (95% CI: 0.61-0.80). Conclusion: a simple predictive score system that includes four preoperative factors accurately predicts ESD to finish as a p-KAR. A careful selection of cases considering these variables could be useful to achieve better outcomes in the Western setting.

Assessment of the esophagogastric junction (EGJ) using the EGJ contractile integral (EGJ-CI) following per-oral endoscopic myotomy (POEM) in achalasia

ABSTRACT Background: the esophagogastric junction contractile integral (EGJ-CI) is a novel high-resolution manometry (HRM) tool designed to assess EGJ barrier function. This study assessed whether changes in EGJ-CI values reflect a disruption of the EGJ in achalasia patients undergoing per-oral endoscopic myotomy (POEM). Methods: patients with HRM performed both before and after POEM were identified over a three year period and were compared to healthy controls. EGJ-CI was calculated using the St Louis method, where EGJ vigor is assessed independently of respiration and referenced to the gastric baseline. It is reported as mmHg.cm. Pre- and post-POEM EGJ-CI, conventional lower esophageal sphincter pressure (LESP) metrics (end expiratory LESP and mean basal LESP) and integrated relaxation pressure (IRP) were compared between groups. The correlation between EGJ-CI and conventional LESP metrics was also assessed and compared to controls. Results: fifteen achalasia patients (35.2 ± 2.5 years, 73% female) fulfilled the inclusion criteria and were compared to 20 healthy volunteers (26.6 ± 1.1 years, 50% female). The Eckardt score was significant lower after POEM (1.5 ± 0.3 vs 7.0 ± 0.5, p < 0.001). Baseline conventional LESP metrics, EGJ-CI and IRP were higher in achalasia cases compared to controls (p < 0.001). Both conventional LESP metrics and EGJ-CI decreased significantly following POEM (p < 0.001) and approximated the values recorded in controls (p ≥ 0.1). However, IRP remained higher post-POEM compared to controls (p = 0.011). EGJ-CI correlated with conventional LESP metrics at baseline (Pearson's r = 0.75-0.79; Spearman's rho = 0.84-0.85, p < 0.001) and following POEM (0.55-0.70 and 0.5-0.77, respectively; p ≤ 0.03). Conclusions: EGJ-CI complements the assessment of the EGJ barrier and may be a useful metric to follow barrier function after per-oral myotomy.

Prevalence of the need for sodium intake restriction and the use of laxatives in palliative patients

RESUMEN Antecedentes: la población paliativa suele sufrir patologías que requieren una restricción de sodio en su dieta, aunque se desconoce la prevalencia de este requerimiento. Estas patologías, junto al estreñimiento, hacen que pueda desaconsejarse el uso de laxantes con electrolitos. Objetivo: conocer la prevalencia de la necesidad de restringir la ingesta de sodio en pacientes paliativos y analizar la prevalencia de estreñimiento y del uso de laxantes, incluidos los que contienen sodio. Método: estudio epidemiológico, multicéntrico, descriptivo, transversal y retrospectivo en pacientes mayores de 18 años recibidos en la consulta hospitalaria de paliativos (junio 2015-marzo 2016) tanto externos como hospitalizados. Se recogieron las características demográficas y antropométricas, enfermedades asociadas a la restricción de sodio en la dieta y tratamientos usados. Resultados: se incluyeron 400 pacientes paliativos (edad 77,8 ± 13,0 años, hombres 52,2%). El 68,3% fueron pacientes hospitalizados y el 31,8%, externos. En el 87,0% (IC95%: 83,3-90,0) existía comorbilidad que precisaba una dieta baja o ausente de sodio. Solo el 46,5% (IC95%: 41,5-51,5) tenía una recomendación de dieta baja en sal. Cabe resaltar que el 50,5% (IC95%: 45,5-55,5) de los pacientes presentó la necesidad de dieta baja en sodio y sufría estreñimiento. Un 53,8% (IC95%: 48,7-58,7) de los pacientes tomaba laxantes (54% productos ricos en lactulosa o polietilenglicol [PEG] con electrolitos), el 52,1% debido a estreñimiento y el 42,3% como prevención al tratamiento con opioides. Conclusiones: un alto porcentaje de la población estudiada (87%) padece algún trastorno que requiere la limitación de sodio en su dieta y al menos la mitad presenta estreñimiento. El uso de laxantes, como tratamiento o como prevención del estreñimiento, es frecuente en los pacientes paliativos. Por tanto, la elección de un laxante sin sodio será preferible en este tipo de pacientes.

ABSTRACT Background: palliative patients usually have diseases that require a restriction of dietary sodium, although the prevalence of this requirement is unknown. Such conditions, combined with constipation, may mean that the use of laxatives with electrolytes should be avoided. Objectives: to ascertain the prevalence of the need to restrict sodium intake in palliative patients and to analyze the prevalence of constipation and the use of laxatives, including those containing sodium. Method: this was a multicenter retrospective, descriptive, cross-sectional, epidemiological study of both inpatients and outpatients over 18 years of age treated at the palliative care clinic (June 2015-March 2016). Demographic and anthropometric characteristics, diseases associated with dietary sodium restriction and treatments administered were recorded. Results: the study sample consisted of 400 palliative patients, with a mean age of 77.8 ± 13.0 years and 52.2% were male. Of these, 68.3% were inpatients and 31.8% were outpatients. Comorbidities requiring low sodium or a sodium-free diet were found in 87.0% (95% CI: 83.3-90.0) of cases. Only 46.5% (95% CI: 41.5-51.5) of patients had been prescribed a low salt diet. It should be noted that 50.5% (95% CI: 45.5-55.5) of patients required a low sodium diet and suffered from constipation. Laxatives (polyethylene glycol or lactulose-rich products [PEG] with electrolytes in 54% of cases) were taken by 53.8% (95% CI: 48.7-58.7) of patients, 52.1% due to constipation and 42.3% as a prevention due to opioid treatment. Conclusions: a high proportion of the study cohort (87%) had some condition that required dietary sodium restriction and at least half the patients had constipation. The use of laxatives to treat or prevent constipation is common in palliative patients. A sodium-free laxative is therefore preferred in these patients.

The long-term recurrence rate and survival of obstructive left-sided colon cancer patients: a stent as a bridge to surgery

RESUMEN Introducción: la endoprótesis como puente a cirugía curativa en pacientes con cáncer de colon izquierdo obstructivo es una alternativa al tratamiento clásico. El objetivo de nuestro estudio es evaluar la recidiva de la enfermedad así como la morbimortalidad del tratamiento. Pacientes y métodos: estudio retrospectivo observacional donde se analizan los pacientes que acudieron al Servicio de Urgencias con cuadro de obstrucción intestinal por tumoración en colon izquierdo entre junio de 2006 y enero de 2014. Se incluyó a los pacientes a los cuales se les colocó una endoprótesis por vía endoscópica y posteriormente fueron intervenidos con intención curativa. El periodo de observación fue hasta mayo de 2017. Resultados: cincuenta y tres pacientes fueron tratados con endoprótesis; de ellos, nueve fallecieron en el postoperatorio. Los pacientes fallecidos eran más frecuentemente varones (100% en fallecidos vs. 62% en no fallecidos, p = 0,02), con más edad (81,4 ± 5,1 vs. 71,6 ± 10,8, p < 0,001) y tenían hemoglobinas más bajas al ingreso (12,9 vs. 13,6, p < 0,001), mayor número de leucocitos (12.918 vs. 9.437, p < 0,001) y mayor coagulopatía (INR 1,6 vs. 1, p < 0,001). Tuvieron una recidiva a distancia ocho pacientes con una mediana de supervivencia libre de enfermedad de 19,1 meses. Se compararon las variables en función de la aparición de enfermedad a distancia y la media de edad fue menor en los pacientes que presentaron recidiva (65,9 ± 11,3 vs. 74,9 ± 9,9 p < 0,001). Conclusiones: el uso de endoprótesis como puente a cirugía curativa en los pacientes con cáncer de colon izquierdo obstructivo en nuestro hospital ha presentado unos resultados comparables a estudios previos.

ABSTRACT Background: a colonic stent as a bridge to elective surgery for left-sided malignant colonic obstruction is an alternative to the classical treatment. The aim of our study was to evaluate the recurrence rate as well as the morbidity and mortality of this treatment. Patients and methods: patients admitted to the Emergency Department with left-sided malignant colonic obstruction between June 2006 and January 2014 were analyzed in a retrospective observational study. Patients who underwent self-expanding metallic stent placement via endoscopy as a bridge to surgery were included. The observation period was performed until May 2017. Results: fifty-three patients were treated with a colonic stent as a bridge to surgery; nine patients died during the postoperative period. The deceased patients were more frequently male (100% in the deceased vs 62% in the non-deceased, p = 0.02), with a more advanced age (81.4 ± 5.1 vs 71.6 ± 10.8, p < 0.001), lower hemoglobin levels on admission (12.9 vs 13.6 p < 0.001), a greater number of leukocytes (12,918 vs 9,437, p < 0.001) and greater coagulopathy (INR 1.6 vs 1, p < 0.001). Eight patients had a distant relapse with a median disease-free survival of 19.1 months. The variables were compared according to the appearance of distant disease and the mean age was lower in patients with a recurrence (65.9 ± 11.3 vs 74.9 ± 9.9, p < 0.001). Conclusions: the results of the use of a stent as a bridge to curative surgery in patients with obstructive left colon cancer in our hospital is comparable to previous studies.

Meckel's diverticulum: clinical features, diagnosis and management

ABSTRACT Meckel's diverticulum is the most common anomalous development of the gastrointestinal system that results from an incomplete vitelline canal. A diagnosis is usually made during the clinical examination of presentations such as unexplained gastrointestinal bleeding, obstruction, inflammation or perforation. The purpose of this review is to provide an adequate level of knowledge of the clinical and diagnostic features as well as the management of Meckel's diverticulum. Diagnosis of Meckel's diverticulum may be challenging as the condition remains asymptomatic or may mimic various diseases and obscure the clinical picture. Life-threatening complications include bleeding, obstruction, inflammation and perforation. Therefore, it is essential that anatomical and pathophysiological characteristics are known in detail in order to prevent complications which will result in morbidity and mortality.

String sign of Kantor in a patient with Crohn's disease

Treatment of graft-versus-host disease with mesenchymal cells as a complication of a liver transplantation

RESUMEN Presentamos el caso de un paciente trasplantado hepático (TH) de donante cadáver que desarrolló una enfermedad de injerto contra huésped (EICH) agudo, cuyas manifestaciones fundamentales fueron rash cutáneo, diarrea y pancitopenia. Como parte del tratamiento se administraron células mesenquimales. Hasta la fecha no se han descrito en la literatura casos de EICH post-TH tratados con células mesenquimales. A pesar del tratamiento, no se produjo mejoría en la aplasia ni en la clínica gastrointestinal y el paciente falleció por una infección diseminada.

ABSTRACT We present the case of a liver transplant (LT) recipient donor who developed graft versus host disease (GVHD). The main features were cutaneous rash, diarrhea and pancytopenia. Mesenchymal cells were administered as part of the treatment. This is the first case of a patient with GVHD after LT reported to date. Despite the treatment, there was no improvement in aplasia or gastrointestinal symptoms and the patient died due to a disseminated infection.

Topical mesalazine as a cause of Stevens-Johnson syndrome

RESUMEN La mesalazina es un fármaco usado habitualmente en la colitis ulcerosa que suele cursar con pocos efectos secundarios. Se han descrito casos infrecuentes de lesiones mucocutáneas graves como el síndrome de Stevens-Johnson (SSJ) y la necrólisis epidérmica tóxica (NET) secundarias a salicilatos. Es importante su diagnóstico precoz por su alta morbimortalidad. Presentamos el caso de una mujer de 46 años con proctitis ulcerosa que desarrolló un SSJ tras la administración tópica de mesalazina. La evolución de las lesiones fue favorable tras la suspensión del fármaco e inicio de corticoides intravenosos.

ABSTRACT Mesalazine is a drug routinely used in ulcerative colitis and usually has few side effects. There have been reports of uncommon cases of severe mucocutaneous damage, such as Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN), induced by salicylates. It is important to diagnose these promptly due to the high morbidity and mortality rates. We describe the case of a 46-year-old female with ulcerative proctitis, who developed SJS following topical mesalazine use. The lesions responded well to intravenous corticosteroids after discontinuation of the drug.

An unusual case report of inflammatory fibrous polyps in the upper gastrointestinal tract

The sedation issue: accumulating data while failing to advance towards a solution?

Biliary bleeding due to a hepatic artery pseudoaneurysm rupture

Obstructive jaundice secondary to a hepatic hydatid cyst

Iatrogenic superior mesenteric artery syndrome

Symptomatic exfoliative esophagitis induced by dabigatran