F. Chilovi

Major early complications from diagnostic and therapeutic ERCP: a prospective multicenter study

BACKGROUNDnThere is a lack of multicenter prospective studies on complications of diagnostic and therapeutic endoscopic retrograde cholangiopancreatography (ERCP).nnnMETHODSnWe studied 2769 consecutive patients undergoing ERCP at nine centers in the Triveneto region of Italy over a 2-year period. Six centers performed ERCP on less than 200 patients per year (small centers). General and ERCP-specific major complications were predefined. Data were collected at the time of ERCP, before discharge, and in cases of readmission within 30 days. ERCP was defined as therapeutic when endoscopic sphincterotomy (n = 1583), precut (n = 419), or drainage (n = 701) had been carried out, singularly or in combination.nnnRESULTSnOne hundred eleven major complications (4.0%) were recorded: moderate-severe pancreatitis 36 (1.3%), cholangitis 24 (0.87%), hemorrhage 21 (0.76%), duodenal perforation 16 (0.58%), others 14 (0.51%). Among 942 diagnostic ERCPs there were 13 major complications (1.38%) and 2 deaths (0.21%), whereas among 1827 therapeutic ERCPs there were 98 major complications (5.4%) and 9 deaths (0.49%). The difference in the incidence of complications between diagnostic and therapeutic ERCPs was statistically significant (p < 0.0001). Small center and precut were recognized as independent risk factors for overall major complications of therapeutic ERCP, whereas the following risk factors were identified in relation to specific complications: (1) pancreatitis: age less than 70 years, pancreatic duct opacification, and nondilated common bile duct; (2) cholangitis: small center, jaundice; (3) hemorrhage: small center; and (4) retroperitoneal duodenal perforation: precut, intramural injection of contrast medium, and Billroth II gastrectomy.nnnCONCLUSIONSnMajor complications are mostly associated with therapeutic procedures and low case volume. Present data support a policy of centralization of ERCP in referral centers. A more selected and safer use of precut may be expected to further limit the adverse events of ERCP.

Training with a computer-based simulator achieves basic manual skills required for upper endoscopy: A randomized controlled trial

BACKGROUNDnChanges in medical practice have constrained the time available for education and the availability of patients for training. Computer-based simulators have been devised that can be used to achieve manual skills without patient contact. This study prospectively compared, in a clinical setting, the efficacy of a computer-based simulator for training in upper endoscopy.nnnMETHODSnTwenty-two fellows with no experience in endoscopy were randomly assigned to two groups: one group underwent 10 hours of preclinical training with a computer-based simulator, and the other did not. Each trainee performed upper endoscopy in 19 or 20 patients. Performance parameters evaluated included the following: esophageal intubation, procedure duration and completeness, and request for assistance. The performance of the trainees also was evaluated by the endoscopy instructor.nnnRESULTSnA total of 420 upper endoscopies were performed; the computer pretrained group performed 212 and the non-pretrained group, 208. The pretrained group performed more complete procedures (87.8% vs. 70.0%; p < 0.0001), required less assistance (41.3% vs. 97.9%; p < 0.0001), and the instructor assessed performance as positive more often for this group (86.8% vs. 56.7%; p < 0.0001). The length of procedures was comparable for the two groups.nnnCONCLUSIONSnThe computer-based simulator is effective in providing novice trainees with the skills needed for identification of anatomical landmarks and basic endoscopic maneuvers, and in reducing the need for assistance by instructors.

Bovine lactoferrin for Helicobacter pylori eradication: an open, randomized, multicentre study.

Backgroundu2002 Cure rates for eradication of Helicobacter pylori appear to be decreasing, thus more effective therapies must be identified.

Digital clubbing in primary intestinal lymphangiectasia: a case report

ZusammenfassungDie primäre intestinale Lymphangiektasie ist eine seltene Erkrankung, die durch erweiterte Lymphgefäße der Dünndarmschleimhaut gekennzeichnet ist und zum Verlust von Lymphe in das Darmlumen führt. Die so entstehende Eiweiß-Verlust-Enteropathie ist labordiagnostisch durch Lymphopenie, Hypoalbuminämie und Hypogammaglobulinämie gekennzeichnet. Symptome beginnen für gewöhnlich in der frühen Kindheit. Hier berichten wir über einen Fall von Hypoalbuminämie und Hypogammaglobulinämie bei einem 57-jährigen Patienten mit 12-jähriger Anamnese von Diarrhoe, welche zu fehlender Gewichtszunahme, sekundärem Hyperparathyreoidismus mit Osteopenie, Beinödemen, monoklonaler Gammopathie, Trommelschlegelfingern und Uhrglasnägeln und zuletzt Gewichtsverlust geführt hat. Eine Fett-arme Diät ergänzt durch mittelkettige Triglyzeride war als therapeutische Intervention erfolgreich mit Reduktion von Diarrhoe, Verschwinden der Beinödeme und Gewichtszunahme. Dünndarm-Schleimhautbiopsien aus einer Doppel-Ballon-Endoskopie bestätigten die Diagnose mit der Darstellung erweiterter Lymphgefäße der Zotten. Uhrglasnägel und Trommelschlegelfinger wurden bislang in der medizinischen Literatur noch nicht mit primärer intestinaler Lymphangiektasie assoziiert und könnten auch hier mit chronischem Thrombozyten-Exzess in Zusammenhang stehen, der beim Patienten zumindest über die letzten 4 Jahre verfügbarer Beobachtungszeit nachweisbar war.SummaryPrimary intestinal lymphangiectasia (PIL), also known as Waldmanns disease, is a rare disorder characterized by dilated intestinal lacteals resulting in lymph leakage into the small bowel lumen and responsible for protein-losing enteropathy leading to lymphopenia, hypoalbuminemia and hypogammaglobulinemia. The symptoms usually start in early infancy. We report a case of secondary hyperparathyroidism, osteopenia, monoclonal gammopathy and digital clubbing in a 57-year-old patient with a 12-year history of discontinuous diarrhea. Malabsorption with inability to gain weight, and finally weight loss and formation of leg edema were associated with protein-losing enteropathy. A low-fat diet associated with medium-chain triglyceride supplementation was clinically effective as medical management in reducing diarrhea and leg edema, and promoting weight gain. Double-balloon enteroscopy and small bowel biopsy histopathology confirmed dilated intestinal lacteals. Digital clubbing associated with primary intestinal lymphangiectasia which may causally be related to chronic platelet excess has not been reported before.

OC.01.2: THE “PROMETEO” STUDY PHASE 1 & 2: CLINICAL FEATURES AND OUTCOME OF ITALIAN PATIENTS ADMITTED TO HOSPITAL FOR ACUTE NON VARICEAL UPPER GASTROINTESTINAL BLEEDING

TIMING OF ENDOSCOPY ANDMORTALITY FROM NONVARICEAL UPPER GASTROINTESTINAL BLEEDING (NVUGIB): THE SOONER IS NOT ALWAYS THE BETTER R. Marmo1, G. Rotondano∗ ,2, M. Koch3, M. Del Piano4, M.A. Bianco2, A. Zambelli 5 , G. Di Matteo6 , L. Cipolletta 2 1Ospedale Curto, Polla, Italy; 2Ospedale Maresca, Torre Del Greco, Italy; 3Aco San Filippo Neri, Roma, Italy; 4Ao Maggiore della Carita, Novara, Italy; 5Ao Ospedale Maggiore, Crema, Italy; 6Irccs De Bellis, Castellana Grotte, Italy

T1069 Appropriateness for Ordinary Hospital Admission of Patients With Nonvariceal Upper Gastrointestinal Haemorrhage

GIB was matched in 77.2% (3057/3960) of cases. Mean age was 58.5y (range 12-103y) and 66.5% were males. Upper GIB (UGIB) accounted for 1911 (66.7%) cases. The top 3 causes were: 1. Peptic ulcer disease (54.1%), 2. Gastroduodenitis (16.3%) and 3. Mallory Weiss Tear (13.4%). Variceal UGIB (VUGIB) accounted for 7.5% of UGIB events. The proportion of UGIB fell from 69.4% in 2004 to 67.0% in 2008 (p=0.038,R2=0.96). Mortality rates for non-VUGIB fell from 2.5% to 2.1% (p=0.356,R2=0.28) while VUGIB mortality rates fell from 14.9% to 9.0% (p=0.356,R2=0.28). Endoscopic hemostasis rates rose from 97.6% to 99.0% (p=0.093,R2=0.67). Angiotherapy rate was 0.9% with no change over the 5 years. Significant risk factors for mortality among UGIB were: age (odds ratio (OR):1.04; 95% confidence interval (CI):1.02-1.06), number of comorbidities (OR:1.59; 95% CI:1.32-1.90) and ICU admission (OR:17.0; 95% CI:6.5-44.4). Lower GIB (LGIB) accounted for 954 (33.3%) cases. The top 3 causes were: 1. Piles (39.6%), 2. Diverticular disease (29.8%) and 3. Colorectal cancer (14.0%). The proportion of LGIB cases rose from 30.6% in 2004 to 33.0% in 2008 (p=0.032,R2=0.83) and this was contributed by a rise in ischemic colitis cases from 1.2% to 5.9% (p=0.024,R2=0.98). Mortality rate for LGIB was 2.3% with no significant change over the 5 years. Therapeutic colonoscopy rates dropped from 15.2% to 10.3% (p=0.043,R2=0.96) while angiotherapy rates rose from 1.8% to 4.9% (p=0.278,R2= 0.37). Surgical rate was 4.7% without significant change over the 5 years. Significant risk factors for mortality among LGIB were: age (OR:1.07; 95% CI:1.03-1.12), number of comorbidities (OR:1.52, 95% CI:1.14-2.03) and surgery (OR:4.51; 95% CI:1.20-17.0). Conclusions: ED admission diagnosis of acute GIB was correctly matched by in-patient discharge diagnosis in 77.2% of cases. Trend of UGIB was falling with reduction in mortality and surgical rates. There was a rising trend in LGIB, contributed by a rise in ischemic colitis events over the same period. Mortality and surgical rates remained unchanged for LGIB while colonoscopic intervention rates fell and angiotherapy rates rose.

Shock Wave for Main Bile Duct Stones

The introduction of endoscopic sphincterotomy by Demling and Kawai in 1974 [1, 2] with or without mechanical lithotripsy followed by stone extraction with a Dormia basket or with a Fogarty-type balloon has gained wide acceptance as a standard non-operative modality for the removal of common bile duct (CBD) stones [3, 4, 5]. The rate of successful stone removal has been reported to be more than 92% [5, 6, 7, 8, 9]. The most frequent causes that can hinder the endoscopic extraction of bile duct stones are the presence of impacted or large stones, bile duct strictures, unusual anatomy, or the presence of intrahepatic stones.