Jaume Boix

Portacaval shunt versus endoscopic sclerotherapy in the elective treatment of variceal hemorrhage.

Eighty-two consecutive Child-Campbell class A and B cirrhotic patients were included in a prospective controlled trial to assess the efficacy and safety of portacaval anastomosis vs. endoscopic sclerotherapy as elective treatment of variceal hemorrhage. Forty-one patients were randomized to portacaval anastomosis and 41 to sclerotherapy. After excluding dropouts, 34 patients were treated with portacaval anastomosis and 35 with sclerotherapy. The incidence of variceal rebleeding during follow-up (mean +/- SD, 20.6 +/- 14.2 months) was significantly higher in the sclerotherapy than in the portacaval groups, either considering the overall treated group or only patients completing sclerotherapy (40% and 25% vs. 2.9%; P = 0.0002 and P = 0.01, respectively). The 2-year probability of suffering from at least one episode of hepatic encephalopathy was significantly higher in patients submitted to portacaval anastomosis than in those treated with endoscopic sclerotherapy (40% vs. 12%; P = 0.04). However, disabling encephalopathy only appeared in 3 of 34 patients who underwent surgery (8.8%). Early and long-term mortality did not differ between the therapeutic groups; 2-year survival rates were 83% for portacaval anastomosis and 79% for sclerotherapy. It is concluded that portacaval anastomosis is more effective than endoscopic sclerotherapy in preventing variceal rebleeding in spite of the greater incidence of hepatic encephalopathy. The role of portacaval anastomosis in the elective treatment of variceal rebleeding should be reassessed.

Impact of azathioprine on the prevention of postoperative Crohn's disease recurrence: Results of a prospective, observational, long-term follow-up study

Background: Postoperative recurrence (PR) occurs early after intestinal resection in >75% of Crohns disease (CD) patients. No well‐established strategy for long‐term PR prevention is available. The aim was to prospectively evaluate the long‐term endoscopic and clinical outcomes of postoperative CD on maintenance treatment with azathioprine (AZA), especially in patients who developed endoscopic lesions confined to the ileocolic anastomosis. Methods: Long‐term AZA therapy (2–2.5 mg/kg/day) was initiated immediately after surgery in 56 consecutive patients who underwent a curative intestinal resection. Clinical and biological assessments every 3 months, as well as yearly endoscopic evaluation, were performed until the end of the study or clinical PR (CPR). Results: Thirty‐seven patients (70%) showed mucosal lesions at endoscopy after a median of 12 months (range 12–60); however, in 15 of these patients lesions were confined to the anastomosis and only 6 showed endoscopic progression, but none of them developed CPR. Among the remaining 22 patients with endoscopic PR (EPR), 23% suffered a CPR during follow‐up. Thirty percent of patients remained free of EPR after a median follow‐up of 33 months (range 12–84). The cumulative probability of EPR was 44%, 53%, 69%, and 82%, at 1, 2, 3, and 5 years, respectively. No predictive factors of EPR were found. Conclusions: Early postoperative use of AZA seems to delay EPR development in comparison to historical series or placebo groups in randomized controlled trials. Although usually considered as endoscopic recurrence, those lesions confined to the ileocolonic anastomosis are not likely to progress or to become symptomatic in the short term.

Impact of periampullary duodenal diverticula at endoscopic retrograde cholangiopancreatography: a proposed classification of periampullary duodenal diverticula.

Background/Aims To propose a classification schema to describe periampullary duodenal diverticula (PDD) found at endoscopic retrograde cholangiopancreatography (ERCP), and to study the characteristics of these diverticula. Materials and Methods Among 400 consecutive patients in whom an ERCP was performed, PDD were present in 131 (32.8%), being these patients significantly older than the remaining, served as controls. Results PDD were classified in 3 different types according to the position of the major duodenal papilla: type I (16.3%), inside the diverticulum; type II (10.2%), in the margin of the diverticulum; and type III (6.5%), near the diverticulum. PDD were not associated with a more difficult cannulation of the biliary tract. Conclusions PDD are common, especially in older patients, and do not significantly increase the difficulty of deep cannulation.

Addition of metronidazole to azathioprine for the prevention of postoperative recurrence of Crohn's disease: a randomized, double-blind, placebo-controlled trial.

Background:Endoscopic recurrence occurs in up to 80% of patients with Crohn’s disease 1 year after intestinal resection. Imidazole antibiotics, thiopurines, and particularly their combination have proven efficacy in preventing endoscopic recurrence. The aim of the study was to compare the efficacy of the addition of metronidazole (for 3 months after the surgical treatment) to azathioprine for the prevention of postsurgical endoscopic recurrence. Methods:A pilot study was made of 50 patients with Crohn’s disease undergoing intestinal resection with ileocolic anastomosis and treated with 2 to 2.5 mg/kg of azathioprine per day for 1 year. The patients were randomized to receive additional 15 to 20 mg/kg of metronidazole per day or placebo for the first 3 months (n = 25 per arm). Endoscopic assessment was performed 6 and 12 months after the surgical resection. The primary end point was the prevention of endoscopic recurrence as defined by a Rutgeerts score of <2 at 6 months. The initial sample size had an 80% statistical power in detecting an absolute risk reduction of ≥30%. Results:Endoscopic recurrence occurred in 28% and 44% of the patients at 6 months (P = 0.19) and in 36% and 56% (P = 0.15) at 12 months in the metronidazole and placebo groups, respectively. No statistically significant differences were found between the treatment groups regarding severe endoscopic recurrence (Rutgeerts score ≥ 3) at 6 and 12 months. Likewise, there were no differences in the rate of adverse events between the treatment groups. Conclusions:The addition of metronidazole to azathioprine did not significantly reduce the risk of endoscopic recurrence beyond azathioprine alone in this study but does not worsen its safety profile.

Endoscopist experience as a risk factor for colonoscopic complications

Aim  We aimed to determine the incidence of colonic perforation (CP) following colonoscopy and postpolypectomy bleeding (PPB) in a teaching hospital, assessing the influence of endoscopist experience as a risk factor.

Radiation dose to patients during endoscopic retrograde cholangiopancreatography.

Endoscopic retrograde cholangiopancreatography (ERCP) is an important tool for the diagnosis and treatment of the hepatobiliary system. The use of fluoroscopy to aid ERCP places both the patient and the endoscopy staff at risk of radiation-induced injury. Radiation dose to patients during ERCP depends on many factors, and the endoscopist cannot control some variables, such as patient size, procedure type, or fluoroscopic equipment used. Previous reports have demonstrated a linear relationship between radiation dose and fluoroscopy duration. When fluoroscopy is used to assist ERCP, the shortest fluoroscopy time possible is recommended. Pulsed fluoroscopy and monitoring the length of fluoroscopy have been suggested for an overall reduction in both radiation exposure and fluoroscopy times. Fluoroscopy time is shorter when ERCP is performed by an endoscopist who has many years experience of performing ERCP and carried out a large number of ERCPs in the preceding year. In general, radiation exposure is greater during therapeutic ERCP than during diagnostic ERCP. Factors associated with prolonged fluoroscopy have been delineated recently, but these have not been validated.

Does methotrexate induce mucosal healing in Crohn's disease?

To the Editor: Mucosal healing has been claimed to be 1 of the most relevant therapeutic endpoints in Crohn’s disease (CD) as far as it seems to be associated with a longer clinical remission and lower likelihood of diseaserelated hospitalizations and intestinal resection. However, clinical indexes poorly correlate with endoscopic lesions. For this reason, endoscopic monitoring to assess mucosal healing has been proposed as an important tool in order to establish the real efficacy of drug therapies in IBD. Among the available maintenance therapies for CD, mucosal healing has only been assessed for infliximab and thiopurines. Methotrexate (MTX) has proven to be effective in inducing and maintaining clinical remission in chronic active CD. Despite that its efficacy seems to be similar to that of azathioprine, it remains a second-line drug. The lack of data showing its potential in inducing mucosal healing may be 1 of the reasons for its limited use in CD. In this perspective, we aimed to assess mucosal healing among patients with clinical response to MTX. CD patients treated with MTX for steroiddependency who entered into clinical remission free of steroids after starting MTX were identified. Eight patients from whom 2 colonoscopies—before and after MTX—were available were included. Disease location was colonic in 4 patients, ileal in 2, and ileocolonic in the remaining 2. Three patients had undergone ileocecal resection in the past. Azathioprine had been initially prescribed for steroid-dependency, but had to be discontinued because of intolerance in 4 and therapeutic failure in the remaining 4 patients. No patient received biological agents. MTX was administered subcutaneously or intramuscularly at an initial dose of 25 mg/ week, for a total 16 weeks; then the dosage was decreased to 15 mg/week as a long-term maintenance treatment. Patients were clinically inactive at the moment MTX was started, as far as they also received prednisone. Endoscopic reports of IBD patients in our center routinely describe the severity of Crohn’s lesions by specifying the presence and location of ulcers, erosions, aphtae, stenosis, and mucosal friability and erythema. As previously used elsewhere, total endoscopic healing was defined by the disappearance of all endoscopic lesions, whereas persistence of minor aphthous ulcers or erosions in the setting of a clear endoscopic improvement was considered partial mucosal healing. Individual characteristics and endoscopic features of patients are shown in Table 1. After

Biodegradable stents in gastrointestinal endoscopy

Biodegradable stents (BDSs) are an attractive option to avoid ongoing dilation or surgery in patients with benign stenoses of the small and large intestines. The experience with the currently the only BDS for endoscopic placement, made of Poly-dioxanone, have shown promising results. However some aspects should be improved as are the fact that BDSs lose their radial force over time due to the degradable material, and that can cause stent-induced mucosal or parenchymal injury. This complication rate and modest clinical efficacy has to be carefully considered in individual patients prior to placement of BDSs. Otherwise, the price of these stents therefore it is nowadays an important limitation.

Changes in mucosal fatty acid profile in inflammatory bowel disease and in experimental colitis: a common response to bowel inflammation

BACKGROUND AND AIMS Plasma polyunsaturated fatty acid profile in patients with inflammatory bowel disease is abnormal. We aimed to assess the mucosal fatty acid pattern in patients with ulcerative colitis and Crohns disease, and in rats with trinitrobenzene-sulfonic acid (TNB) induced colitis. METHODS Fatty acids were measured in colonic mucosa of patients with ulcerative colitis (n = 30), Crohns disease (n = 21), and healthy controls (n = 13). Likewise, they were assessed in the colonic mucosa of rats with TNB- and sham-colitis. RESULTS There was an increase of the end-products (C22:5n3, C22:6n3, C20:4n6, C22:5n6) and a decrease of the precursors (C18:3n3, C18:2n6) of both n3 and n6 polyunsaturated fatty acids in the mucosa of active ulcerative colitis and TNB-colitis. Also, high values of saturated (C16:0, C18:0) and low values of monounsaturated fatty acids (C18:1n9) were observed. Furthermore, the mucosa of active Crohns disease showed substantial changes in saturated, monounsaturated and essential fatty acids, but not in polyunsaturated fatty acids. Mucosa of patients with inactive disease showed intermediate fatty acid values between the mucosa of active patients and healthy controls. CONCLUSIONS Colonic inflammation causes a characteristic modification of the mucosal fatty acid profile which appears to be common to different aetiologies and seems to be related to the degree of inflammation.

Azatioprina y mesalazina en la prevención de la recurrencia posquirúrgica en la enfermedad de Crohn: estudio retrospectivo

Objetivos La reseccion quirurgica todavia es un pilar fundamental en el tratamiento de la enfermedad de Crohn (EC); sin embargo, la recurrencia es la norma. El objetivo del presente estudio es evaluar la aparicion de recurrencia de EC en una serie de pacientes a quienes se practico una reseccion quirurgica, tratados posteriormente con azatioprina (AZA) o mesalazina (5-ASA), e identificar los factores asociados a la recurrencia. Metodos Se revisaron las historias clinicas de los pacientes con EC, a quienes se practico una reseccion intestinal, durante un periodo de 4 anos. Solo fueron incluidos en el estudio los que recibieron AZA o 5-ASA como profilaxis de la recurrencia. Resultados Se incluyeron 33 pacientes tratados con AZA y 16 con 5-ASA. Se constato una recurrencia endoscopica en el 8,6 y el 87,5% de los pacientes del grupo AZA y 5-ASA, respectivamente (p Conclusion AZA parece ser mas eficaz que 5-ASA en la prevencion de la recurrencia endoscopica posquirurgica en la EC. Son necesarios estudios prospectivos con seguimiento a largo plazo para establecer la verdadera utilidad de AZA en esta situacion clinica.