Volume 83 - 2020 - Fasc.3 - Case series
Intralesional steroid injections in addition to endoscopic dilation in benign refractory esophageal strictures : a systematic review
Background and study aims : Benign esophageal strictures are primarily treated with dilation therapy, but strictures can recur or can be unresponsive, requiring additional or repeated treatment. This study investigates the efficacy and safety of intralesional steroid injections in addition to dilation in comparison to dilation alone in patients with benign refractory or recurrent esophageal strictures.
Methods : A systematic search was carried out in PubMed, using the search terms “Esophageal Stenosis”[Mesh] AND “Injections, Intralesional”[Mesh]. In addition, the reference list of all selected articles was searched manually for other relevant articles. All clinical trials and case series were considered.
Results : This systematic review included four randomized controlled trials, six case series and two cohort studies, comprising 341 patients with benign esophageal strictures of different etiologies. A benefit of adding intralesional steroid injections to dilation in reducing the need for repeat dilation was seen in the subgroups of peptic, radiation-induced and corrosive strictures. Results were inconsistent for anastomotic strictures and too limited for strictures due to eosinophilic esophagitis, sclerotherapy or pill esophagitis. Complications were rare and of limited severity.
Conclusion : Endoscopic dilation remains the first-line treatment, since its efficacy and safety are mostly satisfactory. In recurrent or refractory strictures, intralesional steroid injections are advised in peptic strictures and can be considered in radiation- induced, corrosive strictures and anastomotic strictures. It is recommended to restrict the steroid use to a maximum of three sessions and to consider alternative treatment if treatment effects remain insufficient. (Acta gastroenterol. belg., 2020, 83, 432-440).
Appendiceal cancer : a review of the literature
Primary appendiceal cancer is rare and most commonly found incidentally on a surgical specimen after appendectomy for acute appendicitis.
This small organ gives rise to different subtypes which are histological and biological distinct. Historically the classification of these tumors has been confusing because of the different nomenclature that is used. This review has broadly classified them into four subgroups : colonic-type adenocarcinoma, mucinous neoplasm, goblet cell carcinoma and neuroendocrine neoplasm. Signet ring cells is not considered as a distinct subgroup but as a histologic feature that can be present in colonic-type adenocarcinoma and mucinous neoplams.
As staging and management of appendiceal tumors depends on these subtypes, an adequate classification of them is important. This review aimed to give an overview of the epidemiology, grading and staging, management and prognosis of these neoplasms. Despite its rarety specific staging systems and treatment guidelines exist for some subtypes. For other subtypes staging systems and management is extrapolised from colorectal cancer because of the lack of randomised, prospective trials. (Acta gastroenterol. belg., 2020, 83, 441-448).
Pre-surgical risk assessment in patients with cirrhosis
Over the last decades, significant improvements in the clini- cal management of patients with cirrhosis have increased their life expectancy. Thus, indications for surgical procedures other than liver transplantation are becoming more frequent. However, patients with advanced liver disease are at high risk of perioperative morbidity and mortality. This is the consequence of multiple factors that include the presence of portal hypertension, alterations on hemostasis and coagulation, the immune dysfunction that entails an increased risk of infections, and the impaired synthesis of proteins that impacts on the nutritional status and the wound healing. Surgical outcomes are not only determined by the severity of the liver disease, but also by the type of surgery and the presence of other comorbidities. Different models to predict mortality have been proposed, including the MELD score, the Child-Pugh classification, the hepatic venous pressure gradient, and the Mayo postoperative mortality risk calculator, among others. Multidisciplinary committees including surgeons, anesthesiologists, hepatologists, critical care physicians and other specialties involved in each case, should assess individually the risk-benefit of the surgical procedure, also considering patient`s expectations and will. (Acta gastroenterol. belg., 2020, 83, 449-453).
Prevalence of liver injury in patients with coronavirus disease 2019 (COVID-19) : a systematic review and meta-analysis
Background and study aims : The coronavirus disease 2019 (COVID-19) represents a public health emergency of international concern, causing thousands of deaths worldwide. We performed a systematic review with meta-analysis in order to investigate the prevalence of COVID-19-induced liver injury.
Patients and methods : We searched MEDLINE, Scopus, Web of Science and the Cochrane Library, for studies reporting laboratory data about COVID-19 patients, with last update on 25th March 2020. The primary outcome was the pooled prevalence of COVID- 19-induced liver damage, mainly represented by increase in serum transaminases and bilirubin. The secondary outcome was the description of abnormalities in serum albumin and prothrombin time (PT). We focused on laboratory data only on hospital admission, and adopted random-effects model for meta-analysis.
Results : Eleven studies were eligible for meta-analysis. Out of 793 included patients, the pooled prevalence of COVID-19-related liver damage was 22.17% (95% CI 17.64 to 27.07), mostly indicated by hypertransaminasemia. Serum bilirubin was increased in 5.53% (95% CI 3.60 to 7.85) of cases. Abnormal serum albumin was observed in 78.92% (95% CI 39.82 to 99.56), and increased PT value in 19.98% (95% CI 2.49 to 78.23), but these results derived from significantly heterogeneous studies.
Conclusions : COVID-19-induced liver injury must not be ignored, as it is observed in one fifth of infected patients. Prospective studies evaluating liver function during the course of COVID-19 are needed to provide a complete overview of hepatic involvement during this viral infection. (Acta gastroenterol. belg., 2020, 83, 454-460).