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RAPD 2011
VOL 34
N5 Septiembre - Octubre 2011

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XLII MEETING OF THE ANDALUSIAN SOCIETY OF DIGESTIVE DISEASES. JAEN 2011. Oral Comunications, Table 1


Oral Comunications, Table I

1. FULLY COVERED SELF-EXPANDABLE METAL STENTS IN BILIARY COMPLICATIONS AFTER LIVER TRANSPLANTATION

Jurado García, J.; Benítez Cantero, J.; Hervás Molina, A.; Marín Pedrosa, S.; Pleguezuelo Navarro, M.; García Sánchez, V.; de La Mata García, M.

REINA SOFIA HOSPITAL, CLINICAL MANAGEMENT UNIT, GASTROENTEROLOGY SERVICE. CORDOVA

Aims of this study

Efficacy and safety of fully covered metal stents by ERCP in the resolution of biliary strictures after liver transplantation.

Material and approaches

Prospective observational study including 5 patients who underwent liver transplant who developed biliary complications and who underwent ERCP with placement of metal stents. Demographic variables, transplantation variables, complications and follow-up features were recorded.

Results

The study included 4 men and 1 woman whose age was 60 ± 6.3, who had underwent orthotopic liver transplantation due to alcoholic cirrhosis, two associated hepatocellular carcinoma. Indication for transplantation: hepatocellular failure (3) and high-risk hepatocellular carcinoma (2). The patient underwent a duct-to-duct biliary anastomosis without using a Kehr tube. All patients showed anastomotic stenosis, with bile leak in one case. An ERCP was performed with sphincterotomy and dilatation using a catheter before placing the stent. No procedural complications were identified, except a slight migration of the stent without consequences. Mean time from the placement of the stent until its removal: 124.5 ± 10 days. The resolution of biliary complications after the placement of the metal stent was achieved in 3 cases with normalization of cholemia and cholestasis after a mean follow-up of 298 ± 70 days. In the other two patients, one showed ischemic biliary complications that required retransplantation, and in the other the stent could not be removed due to technical difficulties and it was necessary to perform a hepaticojejunostomy.

Conclusions

Biliary complications are a frequent cause of morbidity and mortality after liver transplantation. The placement of metal stents by ERCP may be a satisfactory alternative for the resolution of the stenosis. However, more cases are needed to endorse these results. 2.

2. TREATMENT WITH THALIDOMIDE IN PATIENTS WITH DISABLING GASTROINTESTINAL BLEEDING (GB) DUE TO GASTROINTESTINAL ANGIODYSPLASIA

Garrido, A.; López, J.; Bellido, F.; León, R.; Márquez, J.

VIRGEN DEL ROCIO HOSPITAL, GASTROENTEROLOGY SERVICE. SEVILLE.

Aims of this study

Assessing the efficacy of thalidomide in patients suffering from recurrent GB, who were also multi-transfused and refractory to conventional pharmacological therapy, with endoscopic or angiographic techniques.

Material and approaches

We performed a prospective study on 12 patients suffering from recurrent GB due to ectasia/vascular lesions refractory to conventional therapy who received treatment with thalidomide. The following variables were determined for each of the patients: age, sex, underlying disease, previous treatment with octreotide, pattern and duration of thalidomide treatment, mean hemoglobin concentration during the 6 months prior to initiation of treatment with thalidomide, mean hemoglobin concentration during treatment and increase in mean hemoglobin concentration. The reduction of transfusion requirements after initiation of treatment with thalidomide, as well as safety and adverse effects were also assessed for each patient. Patients with underlying liver disease were excluded from this study. Data were processed by descriptive statistics using version 16 of SPSS.

Results

12 patients (7 men and 5 women) with recurrent GB were included in this study. The mean age of the population under study was 77; 4/12 patients had underlying heart disease and 1/12 had stage II renal disease. 100% of the patients had been treated with octreotide or APC, and they were considered non-responsive to these treatments. The dose used was 200 mg/24 hours, and the treatment for most patients lasted four months. The mean hemoglobin concentration before the initiation of treatment was 6.5 g/dl, after two months it was 11.3 g/dl and at the end of the treatment it was 12.1 g/dl (p=0.0731); during treatment no transfusions of red blood cells were required by any of the patients. 1/12 patients had sensory axonal polyneuropathy that did not require withdrawing thalidomide. Thalidomide was withdrawn in two cases: in 1 patient who showed a gastrointestinal intolerance to the medicine and in another patient who showed fever and thrombophlebitis of the leg after a cat scratch.

Conclusions

Treatment with thalidomide is safe and effective in patients with GB due to angiodysplasia/vascular lesions of the gastrointestinal tract. Since there is currently no clearly effective medical treatment for these type of patients, thalidomide is a therapeutic alternative to consider when conventional lines of treatment run out.

3. ARE THERE ALTERNATIVES TO SURGERY WHEN AN ENDOSCOPIC CAPSULE IS RETAINED IN THE SMALL BOWEL?

López Higueras, A.; Pérez-cuadrado Martínez, E.

J.M. MORALES MESEGUER UNIVERSITY HOSPITAL, GASTROENTEROLOGY SERVICE. MURCIA.

Aims of this study

Capsule endoscopy (CE) is a first line technique in the diagnosis and monitoring of small bowel diseases. Although complications from its use are rare, the most frequent one is the retention of the capsule in any of the sections of the digestive tract; retention is considered when, after 14 days, there is radiological evidence that the capsule has not been expelled. Capsules retained in the second portion of the duodenum and colon are easily removable by conventional upper or lower endoscopy, but for those retained in the distal portions of the small bowel, the gold standard for their removal until now was surgery (needed in 30% of cases). In this study, we postulate that the double-balloon enteroscopy (DBE) via oral/anal approaches can be a less aggressive and very effective alternative.

Approach

Retrospective analysis of a series of 1200 capsule endoscopies of the small bowel performed in our unit between October 2004 and July 2011, assessing the number of retentions that took place and the number of removals made by DBE.

Results

We found 7 cases with capsule retention (0.6%), lower percentage than that of most published series despite not using the patency capsule. As in other series, the most common causes of retention were NSAID strictures (43%), IBD (28.5%) and tumors (28.5%). Recovery by oral DBE was successful in 4 cases (57%).

Conclusions

DBE is a valid alternative to surgery for the removal of retained CE in the small bowel and it showed to be less aggressive and very effective.

4. ENDOSCOPIC ULTRASOUND-GUIDED CYSTOGASTROSTOMY FOR THE TREATMENT OF LARGE PANCREATIC PSEUDOCYSTS. INITIAL EXPERIENCE AND TECHNICAL PECULIARITIES WITH RESPECT TO PUBLISHED EXPERIENCE.

Martos-ruiz, V.; Ojeda Hinojosa, M.; Matas Cobos, A.; González Artacho, C.; Redondo-cerezo, E.; de Teresa Galván, J.

VIRGEN DE LAS NIEVES UNIVERSITY HOSPITAL, GASTROENTEROLOGY SERVICE. GRANADA.

Introduction

Large pancreatic pseudocysts represent a clinical problem with complex surgical management. Endoscopic fenestration of the gastrointestinal tract is a significant advance, with excellent results and few complications.

Aims of this study

Analyzing our initial experience and technical details.

Patients and approaches

Between January 2010 - 2011, we conducted 6 of these procedures. All patients were men, and their mean age was 49. The mean diameter of pseudocysts was 20 cm. The procedure was initiated by linear endoscopic ultrasound, locating an avascular area with less than 1 cm wall thickness. We attempted to pass a 0.35" probe in all cases using a 19g needle, being successful in 5 cases (83.3%). A needle sphincterotome was used in 4 patients (66.7%), and it was needed to dilate the fistula before passing a pneumatic balloon using a Soehendra stent extractor in all cases. Later, between 3 (33%) and 1 (33%) stents were inserted according to the characteristics of the liquid, the size of the pseudocyst and the caliber of the fistula. The adequate drainage of the zone was achieved in 100% of patients. During follow-up the resolution of the pseudocyst could be confirmed. The only complication to be highlighted is an hemorrhage after using the sphincterotome (solved with an hemostatic clip). The stents were removed 9-12 months later of their insertion.

Discussion

The drainage of pancreatic fluid collections by endoscopic ultrasound-guided cystogastrostomy is safe and efficient. The key is the insertion of the probe into the cavity and the dilatation of the fistula; many times it is necessary to use other techniques previously.

5. ACCEPTANCE OF SCREENING COLONOSCOPIES IN A SERIES OF FIRST DEGREE RELATIVES OF PATIENTS WITH COLORECTAL CANCER

Puente Gutiérrez, J.; Marín Moreno, M.; Bueno del Pino, P.; Domínguez Jiménez, J.; Bernal Blanco, E.

ALTO GUADALQUIVIR HOSPITAL, GASTROENTEROLOGY SERVICE. JAEN.

Aims of this study

Knowing the acceptance rate of colonoscopy in our screening program in first degree relatives (FDR) of patients with colorectal cancer (CRC) and analyzing the related variables.

Approach

Retrospective longitudinal study on 462 FDR who were offered the possibility to undergo a colonoscopy between March 2008 and November 2010. After diagnosing a case of CRC, a family interview was scheduled to identify individuals at risk and they were proposed to undergo a colonoscopy by letter on a personal basis. Relatives older than 75 were excluded from the study, those who were already under control and those who were below the recommended age to start screening (AEG 2009). The variables analyzed were: acceptance, sex, age, parentage, place of residence, family phenotype, attendance at the interview and screening results.

Results

Screening was offered to 462 FDR (258 were women) whose age was 53.0 ± 10.9 (range 29-75). 214 of them accepted to undergo a colonoscopy (46.3%). Acceptance predictor variables were attending the family interview (OR 4.95, CI 95% 2.99-8.19) and having a relative with cancer or high-grade dysplasia during screening (OR 6.15, CI 95% 2.50-15.16); and non-acceptance predictor variables were older than 60 (OR 2.87, CI 95% 1.74-4.75), residing in another province (OR 2.38, CI 95% 1.23-4.60) and belonging to a family with ≥ 6 relatives at risk (OR 1.99, CI 95% 1.11-3.59).

Conclusions

The colonoscopy acceptance rate was modest, raising the advisability of implementing strategies to improve it. Assisting the family interview, age, living far away and belonging to a large family are variables that can have a decisive influence.

6. ENDOSCOPIC DRAINAGE OF PANCREATIC FLUID COLLECTIONS GUIDED BY ENDOSONOGRAPHY. EXPERIENCES FROM OUR SERVICE

Medina Cruz, M.; Romero Castro, R.; Argüelles Arias, F.; Jiménez Sáenz, M.; Pellicer Bautista, F.

VIRGEN MACARENA UNIVERSITY HOSPITAL, GASTROENTEROLOGY SERVICE. SEVILLE.

History and aims of this study

Endoscopic drainage guided by endoscopic ultrasonography is a recent efficient and safe technique, used for the treatment of pancreatic fluid collections. This retrospective study evaluates in the short and long term the results obtained with this technique in our center.

Aims of this study

To determine whether indigo carmine staining allows the detection of epithelial lesions that go unnoticed by the conventional endoscopic view, allowing to reduce the appearance of dangerous neoplastic epithelial lesions during follow-up in these patients. Patients and approaches All patients who underwent endoscopic drainage of these collections in our hospital between 2005 and 2010 were included in this study. They were followed up in outpatient clinics on a quarterly basis and through telephone contact on the long-term; this follow-up period ended in January 2011.

Results

The pancreatic collections found in a total of 38 patients were classified as pancreatic pseudocysts (n=23), abscess (n=13) and necrosis (n=2). 66% of them were men with a mean age of 55 (34% of them). The mean diameter of the collections drained was 11.2 cm. The techniques and treatment used were successful in 87% of the patients with pseudocysts cases, in 77% of the patients with abscesses and in 50% of the patients with pancreatic necrosis cases. The drainage failure rate was 18%, using elective surgery 7 days after the endoscopic therapy. The complication rate in this series was 28%. After the first three months follow-up, up to 82% of the patients were asymptomatic, with reduction or disappearance of the collection observed in the CT scan. This percentage of patients remained asymptomatic during the entire follow-up.

Conclusions

The endoscopic drainage of pancreatic fluid collections is a safe and effective technique for the treatment of the said collections, with an acceptable complication rate.

7. SAFETY OF PROPOFOL SEDATION IN ASA IV PATIENTS UNDERGOING ENDOSCOPIC ULTRASONOGRAPHY

Ojeda Hinojosa, M.; Martos Ruiz, V.; González Artacho, C.; Redondo Cerezo, E.; de Teresa Galván, J.

VIRGEN DE LAS NIEVES UNIVERSITY HOSPITAL, GASTROENTEROLOGY SERVICE. GRANADA.

Aims of this study

Propofol sedation administered by nurses is a widely discussed issue in the medical literature. However, there are hardly any studies focused on patients at high anesthetic risk (ASA IV, in our case). The aim of our study is to assess the implementation of a propofol sedation protocol in patients at high risk.

Approach

This is a subanalysis of a prospective observational study including 47 patients at high anesthetic risk (ASA IV). Demographic variables (age and sex), procedure-related variables (total dose of propofol, induction dose, use of atropine and dose) and the presence of complications were analyzed.

Results

The mean age of patients was 72.83 ± 9.41 and 61.7% of them were men. The mean dose of propofol was 104.44 ± 83.95 mg, being the induction dose of propofol 45.11 ± 16.13 mg. 31.9% of patients received atropine, with a mean dose of 0.46 ± 0.43 mg. There were no major complications during the development of procedures. In 17.02% of the patients there was a minor complication, the most frequent one being desaturation (SatO2<90%) in 12.8% of the patients, and bradycardia (<50lpm) in 4.3% of the patients.

Conclusions

In elderly and high anesthetic risk patients (ASA IV) propofol sedation guided by endoscopists is a safe procedure.

8. OBSERVATIONAL, PROSPECTIVE AND MULTICENTER STUDY ON NON-VARICEAL UPPER GASTROINTESTINAL BLEEDING IN ANDALUSIA

San Juan Acosta, M.1; Argüelles Arias, F.1; Vega Sanz, J.2; Gómez, M.3; García Fernández, F.3; Caunedo Alvarez, A.1; Herrerías Gutiérrez, J.1

1VIRGEN MACARENA UNIVERSITY HOSPITAL, GASTROENTEROLOGY SERVICE. SEVILLE; 2TORRECARDENAS HOSPITAL, GASTROENTEROLOGY SERVICE. ALMERÍA; 3SAN JUAN DE DIOS HOSPITAL, GASTROENTEROLOGY SERVICE. SEVILLE.

Introduction

The non-variceal upper gastrointestinal bleeding (UGIB) is one of the most common causes of admittance to hospital emergency departments. There are no updated data available on the incidence of UGIB in Andalusia, nor on its mortality and rebleeding rates or on the need for surgery.

Aims of this study

Primary Objectives: To analyze the incidence of UGIB, as well as the rebleeding and mortality rates, and the need for surgery per month. Secondary Objectives: To analyze the types of lesions, the endoscopic and doctor prescribed treatments and the mean length of hospital stay in patients suffering from UGIB and its possible correlation with triggering factors.

Material and approaches

This is an observational, prospective, multicenter study which included all patients admitted to emergency departments for non-variceal UGIB in four Andalusian hospitals during a period of 1 month with another month follow-up. The study included the collection of data regarding age, medication before the UGIB episode, comorbidities, hemoglobin levels, need for transfusions, mean length of hospital stay, type of medication administered, need for endoscopic therapy, rebleeding and mortality one month after the UGIB episode. Results 49 patients were included in the study (19 men and 30 women with a mean age of 67.54). The incidence was 31.8/100000 habitants/year, the mortality rate of 6.1% and the rebleeding rate of 8.1%. No patient required surgery. The decrease in hemoglobin in 46.9% cases made blood transfusion necessary. The mean length of hospital stay was 6 days. 26.5% of patients were taking NSAIDs and 14.2% anticoagulants (Table 1). Table 2 shows patients' comorbidities. In 16.3% of cases it was detected a gastroduodenal ulcer (Forrest IA 2/8, IIC 1/8 and III 5/8), in 12.2% of cases a papular-erosive gastroduodenopathy and in 8.2% of cases acute lesions of the gastric mucosa. In 4% of cases traces of blood were observed with no evidence of lesion and in 18.3% of cases no alterations were observed. 16.3% of cases required endoscopic therapy. 91.8% of patients received intravenous treatment with PPIs (22.4% omeprazole/ 71.4% pantoprazole). The mean duration of the intravenous therapy was 4.5 days. No correlation was found between potential triggering factors and the need for endoscopic therapy or the mean length of hospital stay. No statistically significant association between the mean length of hospital stay and the age of patients was found.

Conclusions

In our area the incidence of non-variceal UGIB is similar to that described in literature, as well as the mortality and rebleeding rate. The medical treatment administered is consistent with the guidelines, but not the time of application.

9. RESULTS AND SAFETY OF THE ANTIANGIOGENIC THERAPY IN CIRRHOTIC PATIENTS WITH GASTROINTESTINAL BLEEDING (GB)

Garrido, A.; León, R.; Bellido, F.; López, J.; Márquez, J.

VIRGEN DEL ROCIO HOSPITAL, GASTROENTEROLOGY SERVICE.

Aims of this study

Assessing the efficacy of thalidomide in cirrhotic patients suffering from recurrent GIB, who were also multi-transfused and refractory to conventional pharmacological therapy, with endoscopic or angiographic techniques.

Material and approaches

We performed a prospective study on 19 patients suffering from recurrent GB due to ectasia/vascular lesions/PHT gastropathy refractory to conventional therapy who received treatment with thalidomide. The following variables were determined for each of the patients: age, sex, etiology and classification of cirrhosis, previous treatment with octreotide, pattern and duration of thalidomide treatment, mean hemoglobin concentration during the 6 months prior to initiation of treatment with thalidomide, mean hemoglobin concentration during treatment and increase in mean hemoglobin concentration. The reduction of transfusion requirements after initiation of treatment with thalidomide, as well as safety and adverse effects were also assessed for each patient. Data were processed by descriptive statistics using version 16 of SPSS.

Results

19 patients (12 men and 7 women) with recurrent GB were included in this study. The mean age of the population under study was 71; etiology of cirrhosis: 8 alcohol, 7 HCV, 1 HBV, 1 autoimmune, 1 NASH, 1 cryptogenic.Child A 8/19 (42.1%), Child B 5/19 (26.6%), Child C 6/19 (31.3%). 100% of the patients had been treated with octreotide or APC, and they were considered non-responsive to these treatments. The dose used was 200 mg/24 hours, and the treatment for most patients lasted four months. The mean hemoglobin concentration before initiation of treatment was 7 g/dl, two months later it was 9.7 g/dl and at the end of treatment it was 10 g/dl (p=0.0471). 8/19 patients (42%) had episodes of hepatic encephalopathy during treatment, two of the cases requiring treatment withdrawal, and 1 patient left after one month treatment due to "general complications"; another patient showed axonal sensory polyneuropathy that that did not make necessary to withdraw thalidomide and was solved when treatment came to an end. 2 patients, classified as Child-Pough class C, died during the study.

Conclusions

Treatment with thalidomide is effective in cirrhotic patients with GB due to ectasias/vascular lesions/PHT gastropathy, although at the cost of a significant risk of decompensation in the form of hepatic encephalopathy, which had not been informed to date. Since there is currently no clearly effective medical treatment for these type of patients, thalidomide is a therapeutic alternative to consider when conventional lines of treatment run out.

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