Júlio Carlos Pereira-Lima

Long-term results (7 to 10 years) of endoscopic papillotomy for choledocholithiasis. Multivariate analysis of prognostic factors for the recurrence of biliary symptoms

BACKGROUNDnThe long-term outcome after endoscopic papillotomy is poorly defined. The aim of this study was to determine the long-term results of this method in the treatment of common duct calculi and to determine which prognostic factors are associated with the relapse of biliary symptoms.nnnMETHODSnBetween 1985 and 1988, 223 consecutive (149 women, mean age 67.9 years) patients underwent endoscopic papillotomy for duct stones; 127 had already undergone cholecystectomy or underwent this operation during the same hospitalization. Follow-up data were obtained retrospectively from the patients and patients relatives and general practitioners.nnnRESULTSnThe procedure was successful in 217 of 223 cases (97%), of which 203 were followed-up; 2 patients died in the first month after treatment (0.89%). Mean follow-up for the 201 patients was 6.2 years, during which 31 relapsed (15%). Three significant prognostic factors for late complications were identified in a multivariate analysis. The recurrence rate of biliary symptoms in patients who were left with an in situ gallbladder was 20.2%, and 11% for those whose gallbladder was removed (p = 0.04). Patients with a bile duct 15 mm or greater in diameter were more prone to recurrence of symptoms than those with a bile duct 10 mm or less in diameter (41% vs. 10%, p = 0.025) and were especially at higher risk to develop recurrent stones (19.5% vs. 4.9%, p = 0.019). Stone recurrence, but not biliary symptoms as a whole, was more frequent in patients with a peripapillary diverticulum (p = 0.035).nnnCONCLUSIONSnThe long-term results of endoscopic papillotomy are comparable with those of surgical techniques. The prognostic factors associated with relapse of biliary symptoms as a whole are gallbladder left in situ and choledochal diameter. Bile duct size and peripapillary diverticula are associated with recurrent bile duct stones.

Platelet count/spleen diameter ratio: analysis of its capacity as a predictor of the existence of esophageal varices

CONTEXTnUpper gastrointestinal bleeding associated to esophageal varices is the most dramatic complication of cirrhosis. It is recommended screening every cirrhotic for esophageal varices with endoscopy.nnnOBJECTIVESnTo evaluate the capacity of the platelet count/spleen diameter ratio in non-invasively predicting esophageal varices in a population of cirrhotics originated in an independent center from the one in which it was developed.nnnMETHODSnThe study included patients from the ambulatory care clinic of cirrhosis of a Brazilian hospital and studied platelet count, spleen diameter and presence of esophageal varices, as well as Child and MELD scores. It used a cutoff value of 909 for the platelet count/spleen diameter ratio, as previously published. A sample of 139 patients was needed to grant results a 95% confidence level.nnnRESULTSnThe study included 164 cirrhotics, 56.7% male, with a mean age of 56.6 ± 11.6 years. In the univariate analysis, platelet count, spleen diameter, presence of ascites, Child and MELD scores and the platelet count/spleen diameter ratio were related to esophageal varices (P<0.05). The platelet count/spleen diameter ratio had sensitivity of 77.5% (95% CI = 0.700-0.850), specificity of 45.5% (95% CI = 0.307-0.602), positive predictive value of 79.5% (95% CI = 0.722-0.868), negative predictive value of 42.6% (95% CI = 0.284-0.567) and accuracy of 68.9% (95% CI = 0.618-0.760). In the multivariate analysis, platelet count was the only variable which related to esophageal varices (P<0.05).nnnCONCLUSIONnPlatelet count/ spleen diameter ratio is not adequate to predict esophageal varices in cirrhotics.

Large Colorectal Lesions: Evaluation and Management

In the last years, a distinctive interest has been raised on large polypoid and non-polypoid colorectal tumors, and specially on flat neoplastic lesions ≥20 mm tending to grow laterally, the so called laterally spreading tumors (LST). Real or virtual chromoendoscopy, endoscopic ultrasound or magnetic resonance should be considered for the estimation of submucosal invasion of these neoplasms. Lesions suitable for endoscopic resection are those confined to the mucosa or selected cases with submucosal invasion ≤1000 μm. Polypectomy or endoscopic mucosal resection remain a first-line therapy for large colorectal neoplasms, whereas endoscopic submucosal dissection in high-volume centers or surgery should be considered for large LSTs for which en bloc resection is mandatory.

MALIGNANCY IN LARGE COLORECTAL LESIONS

CONTEXTnThe size of colorectal lesions, besides a risk factor for malignancy, is a predictor for deeper invasion objectives: To evaluate the malignancy of colorectal lesions ≥20 mm.nnnMETHODSnBetween 2007 and 2011, 76 neoplasms ≥20 mm in 70 patients were analyzed.nnnRESULTSnThe mean age of the patients was 67.4 years, and 41 were women. Mean lesion size was 24.7 mm ± 6.2 mm (range: 20 to 50 mm). Half of the neoplasms were polypoid and the other half were non-polypoid. Forty-two (55.3%) lesions were located in the left colon, and 34 in the right colon. There was a high prevalence of III L (39.5%) and IV (53.9%) pit patterns. There were 72 adenomas and 4 adenocarcinomas. Malignancy was observed in 5.3% of the lesions. Thirty-three lesions presented advanced histology (adenomas with high-grade dysplasia or early adenocarcinoma), with no difference in morphology and site. Only one lesion (1.3%) invaded the submucosa. Lesions larger than 30 mm had advanced histology (P = 0.001). The primary treatment was endoscopic resection, and invasive carcinoma was referred to surgery. Recurrence rate was 10.6%.nnnCONCLUSIONSnLarge colorectal neoplasms showed a low rate of malignancy. Endoscopic treatment is an effective therapy for these lesions.

4676 Therapeutic ercp in outpatients: a series of 530 consecutive cases.

The aim of the study was to determine the safety of discharge following therapeutic ERCP. We assessed 530 patients undergoing outpatient therapeutic ERCP from a cohort of 1,227 consecutive ERCP procedures from 1994 to 1999. Patient selection was based on relative good health (ASA I or II). Patients were observed for a minimum of 4 hours before discharge and were told to contact the service if any symptoms developed. Plastic stents were inserted in 43 patients (giant stones n=8; malignancy n = 20; cystic duct leak n =8; chronic pancreatitis n = 4; stricture without confirmed etiology n = 3); biliary sphincterotomy was performed in 515 cases. The majority of this group was treated for coledocholithiasis and stone extraction (n=491). Ten patients were treated for ampulary tumor and 5 for sphincter of Oddi dysfunction. Admission was required in 32 cases (6,03%), 25 during the four-hour post- ERCP observation period, and 7 after a median time of 24 hours following discharge (range 5-72 hours). Reasons for admission were pancreatitis in 25 patients, post-sphincterotomy bleeding in 2, cholangitis in 3, and abdominal pain in 2. The overall median hospital stay was 3 days (range 1-17 days). One patient (HIV-positive) developed cholangitis, sepsis and died 14 days after the procedure. Another patient with cirrhosis presented severe bleeding and died 72 hours after successful stone extraction. In this selected series of 530 consecutive cases, endoscopic sphincterotomy and stent placement were safely performed in an ambulatory setting.A randomized comparative trial between outpatient and inpatient ERCP is necessary prior to recommending a generalized change in the current practice.