Claudio Navarrete

Choledocholithiasis: Percutaneous Treatment

Abstract. The percutaneous approach to retained biliary duct stones is most reasonable in the presence of a T-tube because of the low morbidity and mortality as well as its low cost. We report our experience with 353 patients, emphasizing the technique and the solutions to some frequent problems.

Treatment of Common Bile Duct Injuries After Surgery

The treatment of common biliary duct injuries after surgery is a permanent challenge for physicians, and management by a multidisciplinary team is often required. The endoscopic approach is a valuable tool because it is able to assess the problem and also provide a therapeutic option for both fistulas and stenosis of the biliary tree. This article discusses the endoscopic management of postsurgical injuries of the common bile duct and discusses the application of practical tools.

Inverted Colonic Diverticulum: An Infrequent and Dangerous Endoscopic Finding

Inverted Colonic Diverticulum: An Infrequent and Dangerous Endoscopic Finding R. Merino, T. Kinney, R. Santander, R. Yazigi, C. Navarrete, M. Saenz, R. Saenz Background: Inverted Colonic Diverticula (ICD) can be misinterpreted as elevated polypoid lesions, and biopsy or endoscopic resection of these lesions can lead to severe complications. These important lesions are rarely reported in the medical literature and marginally mentioned in classic texts. The aim of this study is to describe the endoscopic characteristics of ICD to avoid misdiagnosis and to report the frequency of these lesions in a large endoscopic series. Materials and Methods: A retrospective analysis was performed of all patients undergoing colonoscopy at our institution between July 2001 and July 2004 using Medicaps 2.0 InfoCYS endoscopic database and selecting patients diagnosed with ICD. Patient characteristics as well as lesion characteristics were recorded, including location, endoscopic characteristics, and the presence of synchronous polypoid lesions.The following endoscopic characteristics were considered in diagnosing ICD: 1) elevated sessile appearance with fine concentric folds surrounding the lesion, 2) mucosal pattern on lesion is similar to surrounding mucosa, 3) umbilicated appearance, 4) found in an area of diverticula, 5) surrounding fine concentric folds enhance with Methylene Blue, and 6) lesion reverts to typical diverticular appearance with direct water infusion, air insufflation, or gentle pressure with biopsy forceps. Results: Among 4508 colonoscopies performed in the selected period, 33 (0.7%) were diagnosed with ICD according to the endoscopic criteria above. Mean patient age was 62.3 years, with 7/9 male/female ratio. 89% of ICD were in an area of multiple colonic diverticula, and 75% were located in the sigmoid colon. One had active bleeding from the inverted diverticulum and was treated with injection therapy. 2 cases required gentle pressure with the biopsy forceps for diagnosis and the remaining were diagnosed according to the other referred endoscopic criteria. No biopsies or resections were performed. There were no complications in this series. Conclusion: ICD is a rare endoscopic finding (0.7%) that is occasionally complicated by local bleeding. Misdiagnosis could be dangerous as these lesions appear similar to sessile polyps, and biopsy or endoscopic resection could lead to serious complications. The endoscopic criteria described should be considered to avoid complications.

Divertículo colónico invertido: un hallazgo endoscópico infrecuente

Resumen Introduccion El diverticulo colonico invertido (DCI) tiene una apariencia similar a las lesiones polipoideas elevadas. El objetivo del presente estudio es describir las caracteristicas endoscopicas del DCI a fin de evitar errores en el diagnostico y reportar la frecuencia de estas lesiones. Material y metodo Se realizo un analisis retrospectivo de todos los pacientes que se sometieron a una colonoscopia entre julio de 2001 y julio de 2004, usando una base de datos endoscopicos. Se incluyeron los pacientes con diagnostico de DCI y se analizaron sus caracteristicas. Con respecto al DCI, se registro la localizacion, las caracteristicas endoscopicas y la presencia de polipos colonicos sincronicos. Resultados Entre las 4.508 colonoscopias realizadas, 33 pacientes (0,7%) tuvieron el diagnostico de DCI. La edad promedio de los pacientes fue de 62,3 anos, y hubo un leve predominio del sexo femenino con una relacion 1:1,2. El 89 % de los DCI se localizo en un area de diverticulosis, y el 75% se localizo en el colon sigmoides. Un paciente presento una hemorragia digestiva activa con su origen en el diverticulo invertido y se trato con inyectoterapia. Se describieron las caracteristicas endoscopicas del DCI. No se reportaron complicaciones en esta serie. Conclusiones El DCI es un hallazgo endoscopico raro que puede complicarse por el sangrado local. El error diagnostico puede ser peligroso y su biopsia o reseccion conllevarian graves complicaciones. Los criterios diagnosticos descritos deberian considerarse para evitar la aparicion de complicaciones.

Utilidad de la cápsula endoscópica como método diagnóstico en el estudio de patología de intestino delgado

Background: Wireless capsule endoscopy (CE) is a relatively new method to evaluate the small intestine. Aim: To evaluate the indications of CE in our center and assess whether specific indications are associated with best results during CE studies. Material and Methods: Retrospective analysis of 69 patients aged 9 to 85 years (36 males) subjected to a CE at our institution between April 2004 and October 2007. Results: The most common indications for CE were overt gastrointestinal bleeding in 43.5% of patients, iron deficiency anemia in 39.1 %, suspicion of a small bowel tumor in 4.3%, chronic diarrhea in 4.3% and abdominalpain in 2.9%. CE was normal in 23.2% and was able to find lesions in 76.8% of the studies. Gastrointestinal bleeding, followed by iron deficiency anemia were the indications associated with the higher rates of positive findings during CE. Conclusions: Gastrointestinal bleeding and iron deficiency anemia were the indications that obtained the best diagnostic y ield for CE.

Is There a Different Outcome Between Endoscopic Treatment of Intrahepatic (IHBL) Versus Extrahepatic Biliary Leak (EHBL)

Is There a Different Outcome Between Endoscopic Treatment of Intrahepatic (IHBL) Versus Extrahepatic Biliary Leak (EHBL)? Susana Escalante-Glorsky, Hashim Khandawalla, Claudio Navarrete, Marc Catalano, Isaac Raijman Sr. Introduction: Endoscopic stenting with or without sphincterotomy is the optimal non-surgical therapy for BL. Placing a short stent in the bile duct without bypassing the leak may be enough for healing. The validity of this statement in IHBL is unknown. We compared the outcome of pts with IHBL with that of EHBL after endoscopic therapy. Patients andMethods: EHBLwas defined as that located below the biliary confluence. A total of 233 pts with BLwere treated. In the IHBL group, there were 27 pts: 3 with right hepatic duct (RHD) leak, 12 duct of Luschka leak, 4 left hepatic duct (LHD) leak, and 8 intrahepatic leaks posttrauma. Of the post-traumatic BL (5 left lobe, 3 right lobe). The mean time from injury to diagnosis of the BL was 4 days. In the EHBL, there were 206 pts. The BL was at the cystic stump in 198 and from an OLT anastomosis in 8. The mean time from surgery to diagnosis of the BL was 4 days. Treatment included a biliary sphincterotomy and placement of a 7-10 Fr straight polyethylene stent bypassing the site of leakage or in the leaking intrahepatic duct. A 7 Fr stent was used in 3 pts with peripheral IHDL and the stent was placed just above the ampulla. Results: Of the pts with EHBL, the BL resolved in 194 of 206, for an overall success rate of 94%. Failures included 1 post-OLT and 11 post-LC. Complications occurred in 1 pt after OLT who developed cholangitis that resolved promptly after therapy, acute pancreatitis in 1 pt after LC, and stent migration in 1 after LC. In the IHBL group, the BL resolved in 23 of 27 pts, for an overall success rate of 85%. Failures included 1 pt after right hepatectomy and 3 post-trauma BL who received 7 Fr stents placed just above the ampulla. After the stent was replaced for a 10 Fr into the leaking branch, the BL leak resolved. Thus, overall 26 of 27 pts resolved (96%). During a mean follow up of 23 months, there has been no recurrence of the BL in either patient’s group. Conclusion: 1. Endoscopic therapy with biliary sphincterotomy and stent placement is successful in the majority of pts with IHBL and EHBL; 2. for pts with IHBL, it is recommended that a stent be placed in the feeding bile duct of the leak; 3. Large bore stents (10 Fr) are preferred over smaller stents (7 Fr); 4. Endoscopic therapy is the intervention of first choice in pts with IHBL or EHBL; 5. Surgery is needed when BL does not resolve after endoscopic therapy; 6. A prospective multicenter trial would be useful in establishing the best possible treatment in these pts.