Oriol Sendino

Severe Complications Limit Long-Term Clinical Success of Self-Expanding Metal Stents in Patients With Obstructive Colorectal Cancer

OBJECTIVES:Self-expanding metal stents (SEMS) are increasingly being used to treat malignant colorectal obstruction. However, complications have been reported in up to 50% of patients. There is limited information on long-term outcomes of these patients. The aim of this study was to retrospectively assess the long-term clinical success of SEMS in patients with malignant colorectal obstruction in a single tertiary center and to identify possible predictive factors of developing complications.METHODS:A total of 47 attempts to insert colorectal SEMS were made in 47 patients during a 5-year period. Stents of 9-cm length were placed under endoscopic and radiologic monitoring. After 24u2009h, all patients underwent abdominal X-ray to verify correct positioning of the stent. Patients were followed at the outpatient clinic.RESULTS:Insertion success was achieved in 44 (94%) patients. Acceptable initial colonic decompression was observed in 44 out of 47 (94%) attempts and in all (100%) successfully inserted stents. The stents were placed in the rectum (n=7, 15%), sigmoid (n=33, 70%), left colon (n=4, 9%), or anastomosis (n=3, 6%). The majority of patients had stage IV disease (n=40, 85%). SEMS served as a bridge to scheduled surgery in 9 (20%) patients and as a palliative definitive treatment in 38 (80%) cases. Three patients were lost to follow-up, so the outcome was evaluated in 41 patients. Long-term clinical failure occurred in 21 (51%) patients and was due to complications such as: migration (n=9, 22%), obstruction (n=7, 17%), perforation (n=3, 7%), and tenesmus (n=2, 5%). Perforations occurred 3, 4, and 34 days after insertion, and all patients died. In the bridge-to-surgery group, primary anastomosis was possible in only four of nine patients (44%). Clinical failure was not associated with any tumor-related factor. However, eight of nine patients with stent migration and two of three patients with perforation had been previously treated with chemotherapy.CONCLUSIONS:Placement of SEMS does not seem to be as effective as suggested because of late complications. For patients with potentially curable lesions, the use of colonic stents for malignant obstruction should only be considered when surgery is scheduled shortly after the stent insertion. Moreover, in patients with incurable obstructing colorectal cancer eligible for chemotherapy and a long life expectancy, palliative treatments other than SEMS should be considered.

Narrow-band imaging as an alternative to chromoendoscopy for the detection of dysplasia in long-standing inflammatory bowel disease: a prospective, randomized, crossover study

BACKGROUNDnNarrow-band imaging (NBI) is a novel technique that may represent an alternative method to chromoendoscopy (CE) for the detection of colitis-associated intraepithelial neoplasia (IN) in patients with long-standing inflammatory bowel disease (IBD).nnnOBJECTIVEnTo compare NBI with CE for the detection of IN.nnnDESIGNnProspective, randomized, crossover study.nnnSETTINGnAcademic hospital.nnnPATIENTSnPatients with clinically inactive colonic IBD (≥8 years).nnnINTERVENTIONnPatients underwent both CE and NBI in randomized order. Targeted biopsy specimens from abnormal areas were obtained. Pathological examination was regarded as the reference standard.nnnMAIN OUTCOME MEASUREMENTSnNumber of false-positive and true-positive lesions in patients undergoing CE and NBI were compared as well as the proportion of patients with missed IN lesions.nnnRESULTSnEighty patients were screened, of whom 20 were excluded. Mean ± standard deviation withdrawal time for CE was significantly longer than that for NBI (26.87 ± 9.89 minutes vs 15.74 ± 5.62 minutes, P < .01). Thirteen patients had at least 1 IN lesion on 1 of the examinations. In the per-lesion analysis, NBI resulted in a significantly inferior false-positive biopsy rate (P = .001) and a similar true-positive rate. The percentage of missed IN lesions and patients was superior with NBI, albeit without reaching statistical significance.nnnLIMITATIONSnLesions were sampled immediately after detection, which precluded the possibility of paired analysis.nnnCONCLUSIONSnNBI appears to be a less time-consuming and equally effective alternative to CE for the detection of IN. However, given the NBI lesion and patient miss rates, it cannot be recommended as the standard technique.

Impact of Wide-Angle, High-Definition Endoscopy in the Diagnosis of Colorectal Neoplasia: A Randomized Controlled Trial

BACKGROUND & AIMSnIt is essential to optimize standard colonoscopy technique to be able to increase polyp detection. We sought to compare the performance of colonoscopy using a high-definition, wide-angle endoscope (HDE) versus a standard colonoscope (SC) for the detection of colorectal neoplasia.nnnPATIENTS AND METHODSnAll consecutive consenting adult patients referred from primary care centers were included and randomly assigned at a 1:1 ratio to undergo HDE or SC. Times to reach and withdraw from the cecum were measured. Morphology, size, location, and pathologic diagnosis of each polyp were recorded. Sample size calculation resulted in a total of 682 patients needed.nnnRESULTSnA total of 693 consecutive patients fulfilled all inclusion criteria (73 excluded owing to insufficient bowel preparation). Each arm included 310 patients with no baseline characteristic differences. Time to reach the cecum was slightly superior for SC (8.9 +/- 4.8 minutes vs 8.2 +/- 4.5 minutes; P = .055). Pathology examination was feasible in 418 lesions (272 adenomas, 109 hyperplastic polyps, and 37 inflammatory lesions). Both techniques detected a similar number and type of lesions, and there were no differences in the distribution along the colon, in the degree of dysplasia, or morphology of adenomas. The per-patient basis analyses demonstrated that there were no differences between the 2 arms of the study in the detection rates of polyps (SC, 0.84 +/- 1.59; HDE, 0.83 +/- 1.30), adenomas (0.45 +/- 1.07 vs 0.43 +/- 0.87), small adenomas (0.22 +/- 0.71 vs 0.28 +/- 0.78), flat adenomas (0.30 +/- 0.91 vs 0.21 +/- 0.63), or hyperplastic polyps (0.16 +/- 0.50 vs 0.18 +/- 0.54).nnnCONCLUSIONnHDE did not detect significantly more colorectal neoplasia than SC.

EUS and magnetic resonance imaging in the staging of rectal cancer: a prospective and comparative study

BACKGROUNDnAccurate locoregional staging is crucial in rectal cancer for deciding patient management because the administration of neoadjuvant therapy depends on it. EUS and magnetic resonance imaging (MRI) are used indistinctly in the pretherapeutic workup of rectal cancer.nnnOBJECTIVEnTo prospectively compare the performance of EUS and MRI in the locoregional staging of rectal cancer in a large series of patients.nnnDESIGNnProspective and comparative study.nnnSETTINGnTertiary center.nnnPATIENTSnPatients with histologically proven rectal cancer.nnnINTERVENTIONSnEUS and MRI were performed in all patients by a different operator unaware of the results of the other procedure.nnnMAIN OUTCOME MEASUREMENTSnEpidemiological, clinical, radiological, and echographic variables were evaluated. Pathological examination of the surgical specimen was used as the criterion standard.nnnRESULTSnNinety patients (54 men and 36 women with a mean age of 68 ± 12 years; range 33-87 years) constitute the final sample of this study. Most of the tumors were stages T2-T3 (85%; 95% CI, 77%-92%). Twenty of them (22%; 95% CI, 14%-32%) were stenotic and 24 (27%; 95% CI, 18%-37%) had polypoid morphology. The accuracy of T staging was very similar for EUS and MRI for stage T2 (76%; 95% CI, 65%-84% and 77%; 95% CI, 67%-85%, respectively; P = not significant) and stage T3 (76%; 95% CI, 65%-84% and 83%, 95% CI, 73%-90%, respectively; P = not significant). MRI was not able to visualize any T1 tumor, whereas EUS understaged all T4 tumors. The univariate analysis showed that the polypoid morphology of the tumor inversely correlated with T staging on MRI. The accuracy of MRI for N staging was higher than that of EUS, although the difference did not reach statistical significance (79%; 95% CI, 65%-88% and 65%; 95% CI, 51%-78%, respectively). When performing the univariate analysis to assess the reasons for this difference, the presence of a stenotic tumor was the only parameter significantly related to a poorer performance of EUS in N staging.nnnLIMITATIONSnThe small number of early and locally advanced lesions.nnnCONCLUSIONSnEUS and MRI have similar accuracy in the T and N staging in rectal cancer. The presence of stenosis and polypoid morphology is inversely associated with accuracy for either EUS or MRI.

Aberrant gene promoter methylation associated with sporadic multiple colorectal cancer.

Background Colorectal cancer (CRC) multiplicity has been mainly related to polyposis and non-polyposis hereditary syndromes. In sporadic CRC, aberrant gene promoter methylation has been shown to play a key role in carcinogenesis, although little is known about its involvement in multiplicity. To assess the effect of methylation in tumor multiplicity in sporadic CRC, hypermethylation of key tumor suppressor genes was evaluated in patients with both multiple and solitary tumors, as a proof-of-concept of an underlying epigenetic defect. Methodology/Principal Findings We examined a total of 47 synchronous/metachronous primary CRC from 41 patients, and 41 gender, age (5-year intervals) and tumor location-paired patients with solitary tumors. Exclusion criteria were polyposis syndromes, Lynch syndrome and inflammatory bowel disease. DNA methylation at the promoter region of the MGMT, CDKN2A, SFRP1, TMEFF2, HS3ST2 (3OST2), RASSF1A and GATA4 genes was evaluated by quantitative methylation specific PCR in both tumor and corresponding normal appearing colorectal mucosa samples. Overall, patients with multiple lesions exhibited a higher degree of methylation in tumor samples than those with solitary tumors regarding all evaluated genes. After adjusting for age and gender, binomial logistic regression analysis identified methylation of MGMT2 (OR, 1.48; 95% CI, 1.10 to 1.97; pu200a=u200a0.008) and RASSF1A (OR, 2.04; 95% CI, 1.01 to 4.13; pu200a=u200a0.047) as variables independently associated with tumor multiplicity, being the risk related to methylation of any of these two genes 4.57 (95% CI, 1.53 to 13.61; pu200a=u200a0.006). Moreover, in six patients in whom both tumors were available, we found a correlation in the methylation levels of MGMT2 (ru200a=u200a0.64, pu200a=u200a0.17), SFRP1 (ru200a=u200a0.83, 0.06), HPP1 (ru200a=u200a0.64, pu200a=u200a0.17), 3OST2 (ru200a=u200a0.83, pu200a=u200a0.06) and GATA4 (ru200a=u200a0.6, pu200a=u200a0.24). Methylation in normal appearing colorectal mucosa from patients with multiple and solitary CRC showed no relevant difference in any evaluated gene. Conclusions These results provide a proof-of-concept that gene promoter methylation is associated with tumor multiplicity. This underlying epigenetic defect may have noteworthy implications in the prevention of patients with sporadic CRC.

Endoscopic ultrasonography-guided brushing increases cellular diagnosis of pancreatic cysts: A prospective study

BACKGROUNDnThe diagnosis of pancreatic cystic lesions is still a challenge.nnnAIMnTo prospectively investigate the usefulness and safety of EUS-guided cytology brushing (EUS BR) in the cellular diagnosis of pancreatic cysts.nnnMETHODSnCysts >15mm were sampled with a 19G needle. The fluid was aspirated and processed for cytology. The brush was introduced to scrub the cystic wall and processed as standard brushings. Antibiotic prophylaxis was administered. Complications were assessed in the first 24h and 7 days after the procedure.nnnRESULTSn30 patients were included. In 8 patients the technique failed for technical reasons. EUS BR provided with a cellular diagnosis in 20/22 cases (91%). The EUS BR was superior to the aspirated fluid for detecting diagnostic cells (73% vs. 36%, p=0.08) and mucinous cells (50% vs. 18%, p=0.016). In the 8 patients operated on, the specimen was consistent with EUS BR diagnosis. Three patients (10%) had complications, one of them a subacute retroperitoneal haemorrhage in a patient on anticoagulation therapy who died for complications 1 month later.nnnCONCLUSIONSnEUS BR increases cellular diagnosis of pancreatic cystic lesions as compared with fluid analysis, mainly in mucinous lesions. Its use is not recommended in patients under anticoagulation therapy.

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 AIMSnInitial 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.nnnMETHODSnThis 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.nnnRESULTSnThe 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.nnnCONCLUSIONSnAn 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.

Complications after ERCP in liver transplant recipients

BACKGROUNDnComplications of the biliary tract after liver transplantation are successfully managed with ERCP; however, the incidence and risk factors for post-ERCP complications remain unknown.nnnOBJECTIVEnTo examine the incidence, risk factors, and short-term outcome of post-ERCP complications in liver transplant (LT) recipients.nnnDESIGNnRetrospective evaluation of all ERCPs performed in LT recipients at our institution during a 7-year, 4-month period.nnnSETTINGnTertiary referral center.nnnPATIENTSnA total of 243 ERCPs performed in 121 LT recipients with duct-to-duct anastomosis.nnnMAIN OUTCOME MEASUREMENTSnIncidence of post-ERCP complications. Predictive factors were determined by univariate and multivariate analyses.nnnRESULTSnOverall complications occurred in 22 procedures (9%) (13 mild, 9 moderate): pancreatitis in 9 patients (3.7%), cholangitis in 8 patients (3.3%), postsphincterotomy bleeding in 4 patients (1.6%), and subcapsular hematoma in 1 patient (0.4%). The mean hospitalization for post-ERCP complications was 4.8 days (range 2-11 days). Logistic regression identified mammalian target of rapamycin inhibitors (odds ratio [OR], 4.65; 95% CI, 1.01-21.81; P = .049), serum creatinine level greater than 2 mg/dL (OR, 4.17; 95% CI, 1.07-16.26; P = .04), biliary sphincterotomy (OR, 3.03; 95% CI, 1.07-8.53; P = .037), and more than 2 pancreatic duct contrast injections (OR, 2.95; 95% CI, 1.10-7.91; P = .032) as independent risk factors for post-ERCP complications, whereas steroid therapy (OR, 0.23; 95% CI, 0.08-0.63; P = .004) was an independent protective factor.nnnLIMITATIONSnSingle-center retrospective study.nnnCONCLUSIONSnThe rate of complications after ERCP in LT recipients seems to be similar to that of non-LT recipients. Complications in this analysis were more common in LT recipients receiving mammalian target of rapamycin inhibitors and those with renal failure, biliary sphincterotomy, and more than 2 pancreatic duct injections, whereas they were less common in those patients on steroid therapy.

Endoscopic dilation with Savary-Gilliard bougies of stomal strictures after laparosocopic gastric bypass in morbidly obese patients.

BackgroundAnastomotic strictures after bariatric surgery are a frequent complication that requires endoscopic management, but the optimal technique for dilation remains to be determined. The aim of this study was to evaluate the safety and efficacy of dilation with Savary–Gilliard bougies (SGB) in morbidly obese patients treated with laparoscopic Roux-en-Y gastric bypass (RYGBP).Patients and MethodsRetrospective review of prospectively collected data from a series of 474 consecutive patients with laparoscopic bariatric surgery. Four-hundred twenty four of these patients (90%) underwent a laparoscopic RYGBP. A total of 24 patients were referred for anastomotic stricture dilation with SGB from January 1998 to December 2006.ResultsA total of 24/424 patients (6%) developed a stricture that was successfully dilated with SGB. Patients were 17 females (71%) and seven males (29%) with a mean age of 41u2009±u200911xa0years (range 24–63) and a mean BMI of 48u2009±u20096 (range 40–69). The time between RYGBP and the appearance of stricture-related symptoms ranged from 29 to 154xa0days (mean, 69xa0days). The mean number of dilations was 1.6u2009±u20090.6. The majority of patients required one (nu2009=u200911; 46%) or two (nu2009=u200912; 50%) dilations and only one patient required three dilations. During the initial dilation, a final diameter of 11u2009±u20091.7xa0mm (range 7–12.8xa0mm) was achieved. In all cases, there was complete resolution of symptoms. There were no complications.ConclusionsDilation with SGB is an effective, safe, and durable method for managing anastomotic strictures after laparoscopic RYGBP.

Endoscopic management of early GI hemorrhage after laparoscopic gastric bypass

BACKGROUNDnEarly upper GI hemorrhage (UGH) is a potential complication after laparoscopic Roux-en-Y gastric bypass (RYGBP), and early reoperative intervention is the most accepted treatment. Experience with endoscopic treatment is limited.nnnOBJECTIVEnOur purpose was to describe the role of endoscopy and injection therapy in the management of early UGH after laparoscopic RYGBP.nnnDESIGNnCase series study.nnnSETTINGnEndoscopy Unit, Hospital Clínic, University of Barcelona, Barcelona, Spain.nnnPATIENTSnWe describe the endoscopic treatment of 6 patients with early UGH within 24 hours after a RYGBP.nnnINSTRUMENTATIONnUpper endoscopy was performed in all 6 cases. The origin of the bleeding was identified at the staple line in all cases, and epinephrine alone or combined with polidocanol was successfully injected in 5 of 6 patients.nnnRESULTSnEndoscopic therapy arrested active bleeding without any complications in all cases without the need for further surgery or endoscopic treatments.nnnLIMITATIONnOur experience is limited to 6 cases.nnnCONCLUSIONnEarly postoperative UGH after RYGBP may be adequately controlled with endoscopic treatment and may obviate the need for surgery. Further data are necessary to evaluate the safety and the efficacy of this approach.