Ignacio Fernandez-Urien

Gastroduodenal Injury After Radioembolization of Hepatic Tumors

BACKGROUND:Radioembolization is a new tool for the treatment of hepatic tumors that consists in the injection of biocompatible microspheres carrying radioisotopes into the hepatic artery or its branches.METHODS:We have performed radioembolization in 78 patients with hepatic tumors using resin-based microspheres loaded with yttrium-90. All patients were previously evaluated to minimize the risk of hazardous irradiation to nontarget organs and to obtain the data needed for dose calculation.RESULTS:We report a complication found in three cases (3.8%) that consists of abdominal pain resulting from gastroduodenal lesions and that had a chronic, insidious course. Microscopically, microspheres were detected in the specimens obtained from all affected gastric areas. Since these gastroduodenal lesions do not appear when nonradiating microspheres are injected in animals, lesions are likely to be due to radiation and not to an ischemic effect of vascular occlusion by spheres.CONCLUSIONS:We believe that a pretreatment evaluation that includes a more thorough scrutiny of the hepatic vascularization in search of small collaterals connecting to the gastroduodenal tract can help prevent this awkward complication.

Initial experience with EUS-guided cholangiopancreatography for biliary and pancreatic duct drainage: a Spanish national survey.

BACKGROUND EUS-guided cholangiopancreatography (ESCP) allows transmural access to biliopancreatic ducts when ERCP fails. Data regarding technical details, safety, and outcomes of ESCP are still unknown. OBJECTIVE To evaluate outcomes of ESCP in community and referral centers at the initial development phase of this procedure, to identify the ESCP stages with higher risk of failure, and to evaluate the influence on outcomes of factors related to the endoscopist. DESIGN Multicenter retrospective study. SETTING Public health system hospitals with experience in ESCP in Spain. PATIENTS A total of 125 patients underwent ESCP in 19 hospitals, with an experience of <20 procedures. INTERVENTION ESCP. MAIN OUTCOME MEASUREMENTS Technical success and complication rates in the initial phase of implantation of ESCP are described. The influence of technical characteristics and endoscopist features on outcomes was analyzed. RESULTS A total of 125 patients from 19 hospitals were included. Biliary ESCP was performed in 106 patients and pancreatic ESCP was performed in 19. Technical success was achieved in 84 patients (67.2%) followed by clinical success in 79 (63.2%). Complications occurred in 29 patients (23.2%). Unsuccessful manipulation of the guidewire was responsible for 68.2% of technical failures, and 58.6% of complications were related to problems with the transmural fistula. LIMITATIONS Retrospective study. CONCLUSION Outcomes of ESCP during its implantation stage reached a technical success rate of 67.2%, with a complication rate of 23.2%. Intraductal manipulation of the guidewire seems to be the most difficult stage of the procedure.

Evaluation of the short- and long-term effectiveness and safety of fully covered self-expandable metal stents for drainage of pancreatic fluid collections: results of a Spanish nationwide registry

BACKGROUND AND AIMS Initial reports suggest that fully covered self-expandable metal stents (FCSEMSs) may be better suited for drainage of dense pancreatic fluid collections (PFCs), such as walled-off pancreatic necrosis. The primary aim was to analyze the effectiveness and safety of FCSEMSs for drainage of different types of PFCs in a large cohort. The secondary aim was to investigate which type of FCSEMS is superior. METHODS This was a retrospective, noncomparative review of a nationwide database involving all hospitals in Spain performing EUS-guided PFC drainage. From April 2008 to August 2013, all patients undergoing PFC drainage with an FCSEMS were included in a database. The main outcome measurements were technical success, short-term (2 weeks) and long-term (6 months) effectiveness, adverse events, and need for surgery. RESULTS The study included 211 patients (pseudocyst/walled-off pancreatic necrosis, 53%/47%). The FCSEMSs used were straight biliary (66%) or lumen-apposing (34%). Technical success was achieved in 97% of patients (95% confidence interval [CI], 93%-99%). Short-term- and long-term clinical success was obtained in 94% (95% CI, 89%-97%) and 85% (95% CI, 79%-89%) of patients, respectively. Adverse events occurred in 21% of patients (95% CI, 16%-27%): infection (11%), bleeding (7%), and stent migration and/or perforation (3%). By multivariate analysis, patient age (>58 years) and previous failed drainage were the most important factors associated with negative outcome. CONCLUSIONS An FCSEMS is effective and safe for PFC drainage. Older patients with a history of unsuccessful drainage are more likely to fail EUS-guided drainage. The type of FCSEMS does not seem to influence patient outcome.

Comparing diagnostic yield of a novel pan-enteric video capsule endoscope with ileocolonoscopy in patients with active Crohn's disease: a feasibility study.

BACKGROUND AND AIMS Crohns disease (CD) is typically diagnosed with ileocolonoscopy (IC); however, when inflammation is localized solely in the small bowel, visualization of the entire small-bowel mucosa can be challenging. The aim of this study was to compare the diagnostic yield of a pan-enteric video capsule endoscope (small-bowel colon [SBC] capsule) versus IC in patients with active CD. METHODS This was a prospective, multicenter study. Patients with known active CD and proven bowel luminal patency underwent a standardized colon cleansing protocol followed by ingestion of the capsule. After passage of the capsule, IC was performed and recorded. Lesions indicative of active CD were assessed. RESULTS One hundred fourteen subjects were screened; 66 subjects completed both endoscopic procedures. The per-subject diagnostic yield rate for active CD lesions was 83.3% for SBC and 69.7% for IC (yield difference, 13.6%; 95% confidence interval [CI], 2.6%-24.7%); 65% of subjects had active CD lesions identified by both modalities. Of the 12 subjects who were positive for active CD by SBC only, 5 subjects were found to have active CD lesions in the terminal ileum. Three subjects were positive for active CD by IC only. Three hundred fifty-five classifying bowel segments were analyzed; the per-segment diagnostic yield rate was 40.6% for SBC and 32.7% for IC (yield difference 7.9%; 95% CI, 3.3%-12.4%). CONCLUSION This preliminary study shows that the diagnostic yields for SBC might be higher than IC; however, the magnitude of difference between the two is difficult to estimate. Further study is needed to confirm these findings.

Endoscopic and anesthetic feasibility of EUS and ERCP combined in a single session versus two different sessions.

AIM To discuss the feasibility of single session endoscopic ultrasonography (EUS) to discuss and endoscopic retrograde cholangiopancreatography (ERCP) execution. METHODS Retrospective endoscopic and anesthetic outcome comparison of performing both EUS and ERCP in a single endoscopic session (Group I) versus performing each procedure in two different sessions (Group II) was made. The following variables were evaluated: epidemiological variables, American Society of Anesthesiologists Physical Status Classification (ASA) level, procedural time, propofol dose, anesthetic complications, endoscopic complications and diagnostic yield, and therapeutic procedures on both groups. T-student, Chi-Square and Fisher test were used for comparison. RESULTS We included 39 patients in Group I (mean age: 69.85 ± 9.25; 27 men) and 46 in Group II (mean age: 67.46 ± 12.57; 25 men). Procedural time did not differ significantly between both groups (Group Ivs Group II: 93 ± 32.78 vs 98.98 ± 38.17; P >0.05) but the dose of propofol differed (Group I vs Group II: 322.28 ± 250.54 mg vs 516.96 ± 289.06 mg; P = 0.001). Three patients had normal findings on both explorations. Three anesthetic complications [O(2) desaturation (2), broncoaspiration (1)] and 9 endoscopic complications [pancreatitis (6), bleeding (1), perforation (1), cholangitis (1)] occurred without significant differences between both groups (P > 0.05). We did not find any significant difference regarding age, sex, ASA scale level, diagnostic yield or therapeutic maneuvers between both groups. CONCLUSION The performance of EUS and ERCP in a single session offers a similar diagnostic and therapeutic yield, does not entail a higher complication risk and requires a significantly smaller dose of propofol for sedation compared with performing each exploration in a different session.

Utilidad de la endoscopia en la hemorragia digestiva por vasculitis

Vasculitides constitute a heterogeneous group of diseases characterized by inflammation of blood vessels. The skin is mainly affected, although the gastrointestinal tract mucosa can also be involved. The contribution of endoscopy in these cases has not been clearly determined. We report three cases of systemic vasculitis (polyarteritis nodosa, Schonlein-Henoch purpura and Behcets disease) presenting with acute digestive bleeding. Endoscopy was an effective technique for completing the diagnosis and in establishing an effective nonsurgical therapeutic approach in these potentially lethal cases of gastrointestinal hemorrhage.

Asymptomatic bronchial aspiration of capsule endoscope: a significant complication

Capsule endoscopy is a safe and well-tolerated procedure allowing the direct, non-invasive mucosal investigation of the small bowel. There are, however, few limitations.

Influye el posible cansancio del endoscopista en la frecuencia de colonoscopias incompletas y de las lesiones polipoideas diagnosticadas

INTRODUCTION Nowadays, the possible effect of endoscopist fatigue on the results of colonoscopies is under discussion. We aimed to analyze possible differences in cecal intubation and the polyp and adenoma detection rate, depending on whether colonoscopies were performed at the beginning or at the end of the daily endoscopy session and to analyze the influence of the queue position on the detection rate. PATIENTS AND METHODS A retrospective study was performed with 1,000 ambulatory and consecutive colonoscopies, divided into 2 groups: «early» and «late» procedures. A total of 95 colonoscopies were excluded due to poor colon cleansing. After confirming that patient characteristics were homogenous in the two groups, we compared the frequency of complete colonoscopies and the polyp and adenoma detection rate. Possible differences between the 2 groups in the polyp detection rate according to the colonoscopy schedule were analyzed. RESULTS The overall polyp and adenoma detection rates were 44.2 and 30.5%, respectively, with no significant differences among 13 different endoscopists; polyps: p = 0.21; adenomas: p=0.63. No significant differences were found between the «early group» (n= 532) and the «late group» (n = 373) in the rates of complete colonoscopies [97.2 vs 99.4% (p=0.92)], the polyp detection rate [45.9 vs 41.8% (p=0.23)], the adenoma detection rate [30.8 vs 30% (p=0.80)] or the serrated adenoma rate [2.1% vs 1.6% (p=0.62)]. The lesion detection rate did not vary in relation to the «queue position»: polyps [p = 0.60, and adenomas: p = 0.83. CONCLUSIONS In our series, endoscopist fatigue at the end of the day had no influence on the complete colonoscopy rate or on the polyp and adenoma detection rate. There were no differences in the number of polypoid lesions detected according to the timing of the colonoscopy schedule.

Blue Rubber Bled Nevus syndrome: three cases

Syndrome (BRBNS) have been diagnosed in our center. In the younger patients (18 and 49-year old), endoscopic examinations were indicated because of the presence of iron deficiency anemia (IDA); in the older patient (77year old), endoscopy was performed because of hematochezia without laboratory or clinical involvement. In all patients, we observed nodular, bluish, tender, wrinkled or slightly depressed lesions at the skin and gastrointestinal (GI) tract. Most severe cutaneous lesions were observed on the upper limbs of the older patient (Fig. 1). On the other hand, endoscopic examinations of patients with IDA showed many of these lesions throughout the GI tract, and the greater ones were located in the colon (Figs. 2 and 3). Because of the symptoms of these three patients were mild, they were treated with conservative measures. Outcome was favorable in all cases. BRBNS, also known as Bean ́s syndrome, is a rare and probably inherited disorder characterized by the presence of cutaneous hemangiomas and vascular tumors of the GI tract (1,2). The lesions in the GI tract are usually multiple and may involve Blue Rubber Bled Nevus syndrome: three cases

A Rare Cause of Biliary Colics

Gastroe Question: A 63-yearold woman with a previous history of cholecystectomy 25 years ago presentedwith episodes of intermittent abdominal pain and abnormal liver biochemical tests in the last 2 years. Repeated transabdominal ultrasounds revealed no abnormalities. Under the suspicion of residual choledocholithiasis, she underwent to cholangiomagnetic resonance imaging; dilated biliary ducts (intrahepatic and extrahepatic) and an elongated and roundedfilling defect in the common hepatic duct was seen (Figure A). Because the first diagnostic option was choledocolitiasis subsequent endoscopic retrograde cholangiopancreatography plus biliary sphincterotomy was planned to retrieve the stone or stones (Figure B). However, it was not feasible because the filling defect was fixed to the ductal wall (some biliary sludge was removed). What is the most likely diagnosis? See the Gastroenterology web site (www.gastrojournal.org) for more information on submitting your favorite image to Clinical Challenges and Images in GI.