Ramón Añón

Recurrence of acute gallstone pancreatitis and relationship with cholecystectomy or endoscopic sphincterotomy.

OBJECTIVES:To determine the prevalence of recurrence of gallstone pancreatitis, its clinical features, and the presence of prognostic factors of recurrence.METHODS:From January 1, 2000 to August 31, 2003, 233 patients admitted with acute gallstone pancreatitis (AGP) were prospectively studied. Patients were divided into two groups: recurrent and nonrecurrent group. Clinical, analytical, radiological, prognostic parameters, and severity (Atlanta criteria) were assessed, along with the performance of cholecystectomy or endoscopic sphincterotomy (ES). Clinical features of recurrence were analyzed. Univariate (χ2, Students t-test) and multivariate tests were performed. Statistical significance was assumed if p < 0.05.RESULTS:Two hundred and eighty-six attacks were identified. Forty-two patients (18.2%) recurred, suffering 53 recurrent attacks, which took place within 30 days in 23.3%. Patients who did not undergo surgery after the first attack had 31-fold risk of recurrence (OR = 31.5%, CI = 95%[7.22–137.84], p < 0.001). In patients not operated, recurrence was more frequent if ES was not performed (37.04%vs 0%, p= 0.019). Among patients with surgical risk, none who recurred underwent ES, compared with 27.9% of those who did not recur. Patients in the nonrecurrent group underwent cholecystectomy within the first 30 days or ES more frequently (31.2%vs 7.3%, p= 0.001).CONCLUSIONS:Recurrence of gallstone pancreatitis is a frequent event. Delay of cholecystectomy implies an increased risk of recurrence. ES could be an acceptable option to prevent recurrence in patients who are not candidates for surgery or who do not desire to undergo cholecystectomy.

A risk score system for identification of patients with upper-GI bleeding suitable for outpatient management

BACKGROUND The aim of this study was to develop a risk score system for identification of patients with upper-GI hemorrhage who are suitable for outpatient management. METHODS From a prospective cohort of 983 consecutive patients with upper-GI hemorrhage not associated with portal hypertension, 581 cases that did not meet pre-established criteria for admission were selected, and a logistic regression analysis was performed to identify factors associated with two adverse outcomes: recurrent bleeding and/or the need for emergency surgery. The risk score system was developed by using the beta coefficients of the logistic model, and its performance was evaluated. The results of this model were combined with pre-established criteria for admission to build a simplified scoring system for identification of patients who can be managed safely on an outpatient basis. RESULTS Chronic alcoholism, active malignancy, prior upper digestive tract surgery, wasting syndrome, hemodynamic compromise, duodenal ulcer as the cause of upper-GI hemorrhage, and hemorrhage of unknown cause were independently associated with a greater risk of unfavorable outcomes in the group that did not meet pre-established criteria for admission. The logistic model showed a high capacity for discrimination (C statistic: 0.87) and good calibration (p value for Hosmer-Lemeshow goodness-of-fit test, 0.62), with a sensitivity of 100% and specificity of 64%. The simplified score had a sensitivity of 100% and specificity of 29% for adverse outcomes, and sensitivity of 78% and specificity of 38% for mortality. CONCLUSIONS The score system developed in this study may be helpful in deciding between hospitalization and outpatient management for patients with upper-GI hemorrhage, but it remains to be validated in patient groups other than those used for its development.

Neoplasias de páncreas y periampulares: morbimortalidad, resultados funcionales y supervivencia a largo plazo

AIMS To evaluate postoperative morbidity and mortality, pancreatic function and long-term survival in patients with surgically treated pancreatic or periampullar tumours. PATIENTS AND METHODS Cohort study including 160 patients consecutively operated on: 80 pancreaticoduodenectomies (PD), 30 distal pancreatectomies (DP), 7 total pancreatectomies, 4 central pancreatic resections and 3 ampullectomies. The tumour was not resected in 36 patients. Pancreatic function was evaluated by oral glucose tolerance test, faecal fat excretion and elastase. RESULTS Resectability rate was 77.5%. In resected patients (n = 124), 38.7% had complications with a pancreatic fistula rate of 6.4% and a mortality rate of 4%. In PD, endocrine function worsened in 41% and 58.6% had steatorrhoea; these figures in DP were 53.6% and 21.7% respectively. In the 36 non-resected patients, postoperative morbidity was 27.7% and mortality 8.3%. Two and five-year survival rates in resected patients with pancreatic cancer were 42% and 9% respectively; in malignant ampulloma 71% and 53%; in mucinous adenocarcinomas 83% and 33%; in duodenal adenocarcinoma 100% and 75%; and in distal cholangiocarcinoma 50% and 50%. CONCLUSIONS Morbidity associated with resective pancreatic surgery is still high, but perioperative mortality is low. Endocrine and exocrine disturbances are very common depending on the type of resection. Despite the associated morbidity and functional disorders, surgery provides long-term survival in selected cases.

Congenital Splenic Cyst Treated with Percutaneous Sclerosis Using Alcohol

We report a case of successful percutaneous treatment of a congenital splenic cyst using alcohol as the sclerosing agent. A 14-year-old female adolescent presented with a nonsymptomatic cystic mass located in the spleen that was believed to be congenital. After ultrasonography, a drainage catheter was placed in the cavity. About 250 ml of serous liquid was extracted and sent for microbiologic and pathologic studies to rule out an infectious or malignant origin. Immediately afterwards, complete drainage and local sclerotherapy with alcohol was performed. This therapy was repeated 8 days later, after having observed 60 ml of fluid in the drainage bag. One year after treatment the cyst has practically disappeared. We believe that treatment of splenic cyst with percutaneous puncture, ethanolization, and drainage is a valid option and it does not rule out surgery if the conservative treatment fails.

Cost analysis of outpatient management versus hospitalization in patients diagnosed of upper gastrointestinal hemorrhage not associated with portal hypertension

Antecedents: In accord with objective criteria, outpatient management of upper gastrointestinal hemorrhage (UG1H) is a safe alternative to hospitalization, so it may save in terms of hospital costs. Aim: To compare the costs between outpatient management vs. hospitalization in patients with UGIH with similar clinical and endoscopic features. Patients and Methods: Two groups of patients with UG1H not associated with portal hypertension, who were prospectively evaluated at Emergency, were included: 150 admitted at hospital (HG) and 150 that were early discharge (OG). At Emergency, all patients were examined by a gastroenterologist: hemodynamic status, clinical history, laboratory tests and shortly endoscopy (before 8 hours in OG). In accord with specific guidelines, patients with any criterion for hospitalization were not included (severe heart failure; recent myocardial or cerebrovascular accident; severe coagulopathy; unsuitable family conditions; severe hemodynamic repercussion; endoscopy stigmata of recent bleeding; impossibility of performing endoscopy), as well as recurrent hemorrhage, surgery or death. Features of both groups were compared: clinical (comorbidy, alcohol/NSAlDs/anticoagulants use, symptoms, hemodypamic status); biological ; endoscopic findings (cause and severity of UGIH), need of blood transfusion and eradication therapy. Cost analysis were obtained by comparison between groups of cost data of Emergency stay, hospital stay, diagnostic procedures, hospital and outpatient therapy and clinic visit on four weeks after discharge. Results: No statistical differences between groups when clinical, hemodynamic, biological variables and transfusion were compared (p>0.05, ChiSquare test). Endoscopy was not performed in 9 patients of HG because negative and no endoscopic findings were detected in 16 of OG. The remaining (141 HG and 134 OG) presented blackish rests or lesion without stigmata. Mean of hospital stay was of 3.05 + 2.13 days in HG, whereas all patients of the OG were discharge at Emergency in <24 hours. Mean costs were of

Predictive value of the balloon expulsion test for excluding the diagnosis of pelvic floor dyssynergia in constipation

970 + 428 for HG and

Factors predicting poor prognosis in ischemic colitis

370 + 71 for OG (p<0.O01, Sntdent-t test). Room costs accounted for difference in total costs. Conclusion: In accord with specific guidelines that depends on clinical and endoscopic criteria, outpatient management of upper gastrointestinal hemorrhage not associated with portal hypertension is safe and produce significant savings in hospital costs