Volume 81 - 2018 - Fasc.3 - Original articles
oesophageal stents for the treatment of radiation and anastomotic oesophageal strictures
Benign oesophageal strictures can arise in the treatment of oesophageal cancer as a result of radiation therapy, or at anastomotic sites, post-oesophagectomy. Data on the benefit of stenting of these types of stricture is limited. We analyzed the effects of oesophageal stents on such benign esophageal strictures. In this retrospective study, data was obtained from consecutive patients, 18 years and above from January 2000 to May 2016. Inclusion criteria comprised of oesophageal stenting in post-radiation strictures and anastomotic strictures, without any malignant residual disease.
17 patients had 22 stents inserted. 11 of these were female. 17 stents were self-expanding metallic stents (SEMS) and five were biodegradable (BDS). 12 strictures occurred post-radiation, while five were anastomotic strictures. Technical and clinical success rates were 100% and 86.4% respectively. Overall long- term clinical success was 45.5% (47% for BDS, 40% for SEMS). Minor, short-term complications, including pain and/or vomiting, were observed in 54.6% (n=12). The overall mean dysphagia score pre- and post-stenting was 2.95 and 1.36 (p=0.0001). Comparison of the dysphagia free survival for anastomotic and post-radiation strictures was statistically similar (p=0.22), as was the dysphagia free survival comparison between BDS and SEMS (p=0.055).
BDS and SEMS are a safe and effective treatment modality for oesophageal strictures arising post-radiation or at the site of anastomoses. Retrospective study design and a low number of patients remain limiting factors of the study. (Acta Gastroenterol. belg., 2018, 81, 361-365).
Adult intussusception : A 14-year retrospective study of clinical assessment and computed tomography diagnosis
Background and study aims : Intussusception in adults often remains unrecognized. Our aim was to report our experience with this entity to determine the usefulness of CT scan in its preoperative diagnosis.
Patients and Methods : The medical records and imaging studies of all patients =16 years of age with intussusception, who were managed at our hospitals, were retrospectively reviewed.
Results: 17 cases of adult intussusception (7 males, 10 females; mean age 35.9 years; age range of 16-78) were identified. The diagnosis was possible in all patients using CT scan. The underlying etiologies were colon cancer (n=2), lymphoma (n=2), small bowel polyps (n=2), jejunal lipoma (n=1), metastatic melanoma (n=1), Meckel's diverticulum (MD) (n=1) and idiopathic (n=1). In the remaining 7 patients, the intussusceptions were of the transitory form and were treated conservatively and no significant sequela occurred after a follow-up of 2-60 months. CT scan findings in transient cases characteristically showed that the intussusception was localized to the proximal intestine and all of them had a short segment (2-4 cm) of intussusception.
Conclusions : The important role of the CT in the preoperative diagnosis of intussusception and characterizing its causes cannot be overemphasized. All transient cases had a short segment of intussusception. (Acta gastroenterol. belg., 2018, 81, 367-372).
Increasing challenges of inflammatory bowel disease in a Turkish cohort (2006-2016)
Background : We aimed to describe the natural course of inflam-matory bowel disease (IBD) in adult Turkish patients during the past decade.
Methods : We performed a retrospective investigation in total 508 patients with IBD between 2006 and 2016. The severity of IBD was assessed by the need for hospitalization, biological therapy and surgery. The study consisted of 304 (59.8%) patients with UC, 180 (35.4%) with CD and 24 (4.7%) IBD unclassified patients.
The ratio of severe disease for both CD and UC was as follows: hospitalization in 71 (39.4%) and 37 (12.2%), biological therapy received in 20 (11.1%) and 3 (1.0%), and surgery in 23 (12.8%) and 2 (0.7%) respectively.
Patients were divided into two groups based on the date of disease onset. Earlier group includes the patients followed-up between 2006-2011 and later group, between 2011-2016. Our results revealed that the proportion of patients receiving biological therapies was significantly higher and the rate of surgery was significantly lower in the later group compared to the earlier group (14.5% to 0%, 9.4 to 23.8, respectively). The hospitalization rate was lower in the later group compared to earlier group but did not reach a significant difference (37.7% to 45.2% respectively).
Conclusions : The course of IBD in Turkish patients appears to be between that of Europe and Asia. In patients with CD, proportion of patients receiving biologic therapy has increased while rate of surgery has decreased. (Acta Gastroenterol. belg., 2018, 81, 373-380).
Patterns of renal involvement in a cohort of patients with inflammatory bowel disease in Egypt
Background and study aim : Renal complications are frequent extraintestinal manifestations in inflammatory bowel disease (IBD). We aimed in our study to describe the spectrum of renal affection in our IBD patients.
Patients and methods : This study is a retrospective analysis of renal biopsies done for IBD patients who developed renal diseases, at Cairo University Hospital, from June 2005 to Jan. 2016.
Results : Among 896 IBD patients, 218 patients (24.3%) developed renal affection. The onset of renal disease mandated renal biopsy at 5.6 ± 7.4 years after IBD diagnosis. Nephrotic range proteinuria was the most common indication for a renal biopsy [81 (37.15%) patients]. Amyloidosis was the most common renal pathological diagnosis [56 patients (25.7%)] followed by immunoglobulin A (IgA) nephropathy [35 patients (16.1%)], focal segmental glome- rulosclerosis (FSGS) [32patients (14.7%)], crescentic glomerulo- nephritis (CGN) [32 patients (14.7%)], membranous nephropathy (MN) [18 patients (8.25%)], minimal change disease [17 patients (7.7%)], chronic interstitial nephritis (CIN) [10 patients (4.6%)], acute tubular necrosis (ATN) [8 patients (3.7%)], thrombotic microangiopathy (TMA) [6 patients (2.75%)], and acute interstitial nephritis (AIN)[4 patients (1.8%)]. Variable renal histopathology diagnoses did not correlate with age, duration of IBD diagnosis, or drugs used for IBD treatment. Crescentic GN was significantly correlating with ASCA, ANCA-p, and ANCA-c in serum. Conclusion : Amyloidosis is a common renal pathological diagnosis in our patients, and is followed by IgA nephropathy, and FSGS. (Acta gastroenterol. belg., 2018, 81, 381-386).
Surgical outcomes among inflammatory bowel disease patients undergoing col- ectomy : results from a national database
Introduction : Colectomy is relatively common in inflammatory bowel diseases (IBD), occurring more in Ulcerative Colitis (UC) as compared to Crohn's disease (CD). The surgical outcomes among this mixed population of patients are not well understood. This study aims to determine the predictors of post colectomy surgical outcomes in this patient population.
Methods : Using the National Surgical Quality Improvement Project (NSQIP) demographics, preoperative and post-operative data were analyzed for all patients undergoing colectomy for either CD or UC. Multiple variables were linked to several outcomes including mortality, anastomotic leak, and reoperation post colectomy.
Results : A total of 5049 IBD patients that underwent colectomy were identified. Rate of reoperation and anastomotic leak were significantly increased with steroid intake with an Odds Ratio (OR) of 1.66 (95% Confidence Interval (CI) (1.26-2.19)) and 1.81 (95%CI (1.34-2.45)) respectively. As for 30-day mortality, it was significantly lower among patients on steroid (OR=0.41; 95%CI (0.19-0.86)).
Comparing UC to CD, anastomotic leaks were less common among UC patients (OR=0.53; 95%CI (0.37-0.76)), but 30-day mortality was significantly more prevalent among UC patients (OR=8.11; 95%CI (4.22-15.6)).
Conclusion : Among IBD patients undergoing colectomy, major surgical complications except 30-day mortality appear to increase with the use of preoperative steroids (Acta gastroenterol. belg., 2018, 81, 387-392).
Long-term results of percutaneous cholecystostomy for definitive treatment of acute acalculous cholecystitis : a 10-year single-center experience
Background and study aims : Conventional use of percutaneous cholecystostomy [PC] is bridging therapy to delayed cholecystectomy for acute cholecystitis in high-surgical risk patients. Primary aim of this report is to evaluate the long-term outcome of PC as a definitive treatment for acute acalculous cholecystitis [AAC]. Patients and methods : Seventy-one AAC patients who underwent PC procedure were identified. Fifty-one interventions in 47 patients who were treated only with PC and followed-up after catheter withdrawal were reviewed to evaluate the long-term efficacy of PC as a definitive treatment for AAC.
Results : Technical and short-term clinical success rates were 100% and 92%, respectively. In-hospital mortality rate was 9.3%, minor complication rate was 5.3%, major complication rate was 2.7% and procedure related mortality was 0%. Median follow-up after catheter withdrawal was 8 months. Long-term primary clinical success after removal of the catheter was 87.2%. With the repeated PC in 4 of 6 recurrences, clinical success was 95.7%. Presence of bile sludge, perforation or a co-existing disease did not result in a significant difference in recurrence free survival.
Conclusions : PC was a safe and easy to perform procedure with high positive clinical response and low long-term recurrence rate. PC without subsequent cholecystectomy may be a favorable treatment for AAC with respect to high surgical risk present in most of the AAC patients. (Acta gastroenterol. belg., 2018, 81, 393- 397).
Prognostic Utility of Hypokalemia in Cirrhotic Patients
Background and Aim : We researched the relationships between serum potassium level and prognostic scores and complications of cirrhosis, and mortality.
Methods : This study was performed retrospectively in Turkish High Specialty Training and Research Hospital between 2009 and 2015. Patients who had missing patient files and electrolyte disorder for another reason, showed complications at the time of application and were using diuretics were excluded from the study.
Results : 218 patients were included in the study. During the follow-up period, 23.4% (n: 51) of the entire population passed away. Compared to the patients who survived, the patients who passed away had higher HCC and HES development rate, mean Child-Pugh and MELD score and lower mean blood potassium level. The stepwise multivariable Cox regression model which included significant independent predictors showed that Child- Pugh score (HR: 1.29; p< 0.001), MELD score (HR:1.13; p= 0.006), and potassium level (HR: 0.18; p< 0.001) were independent predictors of mortality. The cut off value for potassium level in predicting mortality was found to be = 3.4 mmol/L with 80.4% sensitivity and 100% specificity. Compared to the patients with a potassium level > 3.4 mmol/L, the patients with a potassium level = 3.4 mmol/L had higher mortality rate, HCC and HES development rate, mean Child-Pugh and mean MELD scores.
Conclusion : Hypokalemia is an important prognostic factor in cirrhotic patients. (Acta gastroenterol. belg., 2018, 81, 398-403).
Clinical significance of fibrotic, haemostatic and endotoxic changes in patients with liver cirrhosis
Background and study aims : To investigate the relationship among fibrotic, haemostatic and endotoxic changes in patients with different degrees of liver cirrhosis.
Patients and methods : Liver fibrotic markers, including hyaluronic acid (HA), Ccollagen IV (Col-IV), laminin (LN), and N-terminal pro-peptide of collagen type III (PIIINP), were determined by radioimmunoassay. A series of haemostatic tests, including prothrombin time (PT), international normalized ratiO. activated partial thromboplastin time, antithrombin-III, thrombin time, fibrinogen, fibrin(ogen) degradation product and D-dimer were determined using an automatic coagulation analyszer. Plasma levels of endotoxin were detected quantitatively using an endotoxin detection kit. Correlation analysis of the data was performed.
Results : Based on Child-Pugh classification, statistically signi- ficant differences in fibrotic markers and haemostatic parameters were found in 249 patients with liver cirrhosis, while no significant differences in endotoxin levels were observed. Based on ascites classification, statistically significant differences in fibrotic markers (such as HA, Col-IV and PIIINP, except for LN) and haemostatic parameters were found. As for endotoxin levels, there were significant differences between the ascites, spontaneous bacterial peritonitis (SBP) and no-ascites groups, while no significant differences were observed between the ascites and SBP groups. Correlation analysis demonstrated some correlation among fibrotic markers, haemostatic parameters and endotoxin.
Conclusions : A close relationship exists between the severity of cirrhosis and fibrotic changes, as well as haemostatic changes. Endotoxin may be an important contributing factor to the development of ascites in cirrhosis. Some correlation may exist between fibrosis, haemostatic and endotoxin. (Acta gastroenterol. belg., 2018, 81, 404-409).
Urinary 24-hour copper excretion at the time of diagnosis in children with Wilson's disease
The optimal cut-off value of 24-hour (h) urinary copper (Cu) levels to identify Wilson's disease (WD) has not been widely studied in children. In sixty-six children with confirmed WD and 88 children without WD, 24-h urinary excretion of Cu at the time of diagnosis was studied. The receiver operating characteristic (ROC) curves revealed that the optimal cut-off value of urinary Cu to identify WD was 70 mcg [area under the curve (AUC) = 0.894] with a sensitivity and specificity of 81.8% and 89.8%, respectively. When the serum ceruloplasmin level was <20 mg/dl and the 24-h urinary excretion of Cu was >70 mcg, the sensitivity was 75.8%, and the specificity was 97.7%. After the exclusion of cholestatic patients, the ROC curves revealed that the optimal cut-off value for 24-h urinary Cu excretion was 55 mcg (AUC = 0.910) with a sensitivity and specificity of 83.3% and 90.3%, respectively. When the ceruloplasmin level was <20 mg/dl and the 24-h urinary Cu excretion was >55 mcg, the sensitivity and specificity were 77.3% and 98.4%, respectively.
A 24-h urinary Cu level of >70 mcg plus a ceruloplasmin level of <20 mg/dl in the patients, and a 24-h urinary Cu level of >55 mcg plus a ceruloplasmin level of <20 mg/dl in non-cholestatic patients exhibited the highest specificity and the highest positive and negative predictive values to identify WD in children. (Acta gastroenterol. belg., 2018, 81, 410-414).