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Volume 77 - 2014 - Fasc.3 - Original articles

Biliary stenting as alternative therapy to stone clearance in elderly patients with bile duct stones

Background and study aims : Endoscopic retrograde cholangio- pancreatography with stone retrieval following endoscopic sphinc- terotomy (ES) is the standard method for the management of cho- ledocholithiasis. However, biliary stenting is used to treat patients with endoscopically irretrievable bile duct stones, especially elderly and high-risk patients. The aim of this study was to evaluate the benefits and risks of biliary stenting versus stone clearance follow- ing ES in the management of choledocholithiasis. Patients and methods : Between January 2010 and December 2012, 165 patients with common bile duct stones who underwent biliary stenting or stone clearance following ES were enrolled. One 7 Fr. double-pigtail plastic stent was placed without ES or stone extraction. The procedure time, hospitalization period, adverse events, additional endoscopic interventions required and one-year mortality were evaluated retrospectively. Results : Ninety-nine and 66 patients were included in stenting group and in stone clearance group, respectively. Except for age, number of stones, and use of antithrombotic agents in the stent group, there were no statistically significant difference between groups. The average procedure time and hospitalization period in the stenting group were significantly shorter than those in stone clearance group (mean 21 min vs. 43.9 min, P < 0.0001 ; 3.8 days vs. 6.5 days, P < 0.0001). No significant differences were seen in ad- verse events and additional endoscopic interventions required be- tween both groups for at least a 1.5-year follow-up. No one-year mortality occurred. Conclusions : Biliary stenting using a double-pigtail stent proved to be a useful alternative therapy to stone clearance following ES in the management of choledocholithiasis in elderly patients. (Acta gastroenterol. belg., 2014, 77, 297-301).


The role of fecal calprotectin in assessment of hepatic encephalopathy in patients with liver cirrhosis

Introduction : Calprotectin is a cytoplasmatic protein of neutro- philic granulocytes and it is an established marker for the assess- ment of localized intestinal inflammation. Aim : To explore correlation between values of fecal calprotectin and degree of liver cirrhosis and hepatic encephalopathy. Methods : We included 60 patients with liver cirrhosis and 37 healthy patients as controls. Patients revealing other causes of ab- normal calprotectin results (gastrointestinal bleeding or inflamma- tory bowel disease) were excluded. The degree of liver insufficiency was assessed according to the Child-Pugh classification and Model of End Stage Liver Disease (MELD), and degree of hepatic enceph- alopathy by West-Haven criteria, serum concentration of ammo- nium ion and the number connection test. Results : The mean value of fecal calprotectin in patients with liver cirrhosis was 189.1 ± 168.0 µg/g, and 35.0 ± 26.0 µg/g in the control group, respectively. We have confirmed significantly higher fecal calprotectin in patients with cirrhosis (p < 0.001). There were no significant differences in values of fecal calprotectin between the patients with different stages of liver cirrhosis according to Child- Pugh classification and MELD score (p > 0.05). We observed statis- tically significant difference comparing fecal calprotectin by West- Haven criteria of hepatic encephalopathy (p < 0.001), while there were no correlation with the number connection test and serum concentration of ammonium ion (p > 0.05). Conclusion : We confirmed significantly higher values of fecal calprotectin in patients with liver cirrhosis, especially in hepatic encephalopathy according to West-Haven criteria. (Acta gastro- enterol. belg., 2014, 77, 302-305).


Laparoscopic cholecystectomy in acute cholecystitis : support for an early inter- val surgery

Background and study aims : Although laparoscopic cholecystec- tomy is advocated for acute cholecystitis, debate still exists about its optimal timing. This retrospective study compares the outcome of laparoscopic cholecystectomy within versus later than 5 days of onset of symptoms in patients with acute cholecystitis. Patients and methods : One hundred thirty six patients with acute cholecystitis grade I or II were included in the study and divided in two groups. Group 1 received surgery within 5 days of symptoms and group 2 received conservative therapy and delayed surgery after 6 weeks. Results : Group 1 and 2 consisted of 100 and 36 patients respec- tively. Because of failure of conservative therapy 5 patients of group 2 had surgery before 6 weeks. The remaining 31 patients underwent surgery after 6 weeks. Preoperative ERCP was indi- cated in 2 and 11 patients in groups 1 and 2 respectively (p < 0.001). The median total hospital stay was 3.0 days for group 1 and 11.0 days for group 2 (p < 0.001). In terms of operation time, con- version rates, intraoperative cholangiography, postoperative ERCP, morbidity or mortality both groups were comparable (p > 0.05). Conclusion : Laparoscopic cholecystectomy can be performed safely within 5 days after the onset of symptoms in patients with acute cholecystitis. Because of shortened total hospital stay and risk of failure of conservative therapy, early laparoscopic cholecystec- tomy should be favored. (Acta gastroenterol. belg., 2014, 77, 306- 311).


Efficacy of endoscopic ultrasound fine needle aspiration in diagnosing the rare (non-adenocarcinoma) tumors of pancreas

Background : Five percent of pancreatic neoplasms are non- adenocarcinoma tumors. Clinical presentation and imaging char- acteristics of these tumors are similar to adenocarcinoma. This study aims at evaluating the results and efficacy of Endoscopic ultrasound guided fine needle aspiration (EUS-FNA) in diagnosing the pancreatic non-adenocarcinoma tumor in patients with solid pancreatic mass. Methodology : The present study which is of a descriptive, pro- spective and case series nature, has been studying the diagnostic value of EUS-FNA in pancreatic non-adenocarcinoma tumor in 60 patients with pancreatic solid neoplasm. Cytopathologic diagnosis founded on EUS-FNA accepted as final diagnosis in unresectable ones. But the reference standard for the final diagnosis in patients with resectable tumor was surgical pathology. In patients with non diagnostic EUS-FNA specimen, final diagnosis achieved by re- FNA, Computerized Tomography (CT) guided biopsy, or surgery. Results : Ten patients (17%) found to have non-adenocarcinoma tumor. Half of them were male. EUS-FNA was diagnostic in 8 cases (80%) including the 4 neuroendocrine tumors, one gastrointestinal stromal tumor, one mucinous neoplasm, one pseudopapillary tumor, and one geant cell tumor. Surgical pathology confirmed the EUS-FNA diagnosis in five patients that had resectable tumor. However EUS-FNA recognition accepted as final diagnosis in three patients that had unresectable tumor. EUS-FNA was non-diagnos- tic in one patient with pancreatic lymphoma and another patient with colon cancer metastasis. Conclusion : EUS FNA is a safe and effective for diagnosing the solid non- adenocarcinoma tumors as well as adenocarcinomas of pancreas. (Acta gastroenterol. belg., 2014, 77, 312-317).


99mTc-Pertechnetate imaging for detection of ectopic gastric mucosa : A systema- tic review and meta-analysis of the pertinent literature

Background and aims : 99mTc-pertechnetate scintigraphy has long been used for detection of ectopic gastric mucosa (EGM) in the medical practice and evaluation of children with lower gastrointes- tinal bleeding. In the current study, we reviewed the available med- ical literature in this regard. Methods : Medline and SCOPUS were searched for relevant studies. Studies with sample size of at least 5 patients which pro- vided enough numerical data to calculate the sensitivity and/or specificity of 99mTc-pertechnetate for detection of EGM were includ- ed in the systematic review. Results : Overall 40 studies were included in our systematic re- view. Overall diagnostic indices of the 99mTc-pertechnetate scintig- raphy for EGM diagnosis were : sensitivity 92.1%[95%CI : 90.2- 93.8], specificity 95.4%[94.3-96.3], positive likelihood ratio 16.5[9.9-27.5], negative likelihood ratio 0.15[0.1-0.2], diagnostic odds ratio 120.7[73-199]. The pooled sensitivity was higher for studies using H2 blockers as a premedication (92.4% vs. 86.4%), studies using delayed imaging (94.3% vs. 88.4%), children (92.3% vs. 81.8%), and patients with gastrointestinal bleeding (95.3% vs. 75.3%). Conclusions : 99mTc-pertechnetate imaging is a highly accurate diagnostic modality for detection of EGM. This imaging is more accurate in children and patients presenting with gastrointestinal bleeding. Premedication with H2 blockers and delayed imaging can increase the diagnostic accuracy and should be routinely included in the imaging protocol. (Acta gastroenterol. belg., 2014, 77, 318- 327).


The drinking test : a current noninvasive technique to evaluate gastric accom- modation and perception

Impaired gastric accommodation has been proposed as an im- portant mechanism in the generation of functional dyspepsia. There is an interest in methods that allow recording and quantifica- tion of the gastric accommodation reflex. Drinking tests, with water or nutrients, have been developed as a noninvasive, inexpensive method to assess gastric perception and accommodation. These tests are easily performed, do not need any special equipment and are well tolerated by patients. Drink test results are reported as the maximum tolerated volume, individual and cumulative symptom scores. Patients with functional dyspepsia have showed lower max- imum tolerated volumes than healthy volunteers. In these patients the maximum tolerated volume reflects the severity of early satiety and predicts impaired gastric accommodation, but it remains un- clear what physiologic processes are assessed by the drinking tests. Results of drinking tests may be influenced by physiologic factors, thus these results do not guide therapy. Given these facts, drinking tests are best reserved for clinical research purposes evaluating functional dyspeptic patients or patients with gastroparesis. (Acta gastroenterol. belg., 2014, 77, 328-332).