With the increasing use of antiplatelet agents (APA), their management during the periendoscopic period has become a more common and more difficult problem. The increase in use is due to the ...availability of new drugs and the widespread use of drug-eluting coronary stents. Acute coronary syndromes can occur when APA therapy is withheld for noncardiovascular interventions. Guidelines about APA management during the periendoscopic period are traditionally based on assessments of the procedure-related risk of bleeding and the risk of thrombosis if APA are stopped. New data allow better assessment of these risks, of the necessary duration of APA discontinuation before endoscopy, of the use of alternative procedures (mostly for endoscopic retrograde cholangiopancreatography ERCP), and of endoscopic methods that can be used to prevent bleeding (following colonic polypectomy). This guideline makes graded, evidence-based, recommendations for the management of APA for all currently performed endoscopic procedures. A short summary and two tables are included for quick reference.
Aliment Pharmacol Ther 2010; 32: 225–232
Summary
Background Life‐threatening bleeding caused by early spontaneous slippage of rubber bands has been described after variceal ligation in cirrhotic ...patients.
Aim To determine the predictive factors of this complication in cirrhotic patients.
Methods Among 605 patients, 21 patients (mean age 56.6 ± 13.5 years) developed 23 spontaneous band slippages with bleeding on post banding ulcer, as confirmed by endoscopy. Cirrhosis was alcoholic in 13 patients (62%), post viral hepatitis in three (14%) and from other causes in five (24%). A case‐control study was performed comparing 17 from these patients who presented the complication after a first ligation with 84 of the 584 controls who underwent first endoscopic variceal ligation without bleeding complication.
Results Bleeding occurred 13.5 days ± 7.3 (2–29) following ligation. Eleven patients died following the bleeding complication (52%). Using a multivariate analysis, previous upper variceal digestive bleeding OR 12.07, 95%CI (2.3–63.43), peptic oesophagitis OR 8.9, 95%CI (1.65–47.8), high platelet ratio index (APRI) score OR 1.54, 95%CI (1.11–2.16) and low prothrombin index OR 0.54, 95% CI (0.31–0.94) were independent predictive factors of bleeding.
Conclusions Bleeding related to post‐banding ulcer is a rare, but severe complication. The proposed predictive factors should be looked for and minimized before variceal ligation.
Résumé: La question peut paraître un peu provocatrice. Cependant, il existe beaucoup de raisons « coliques » pour faire venir l’endoscopiste le week-end au chevet du malade. L’endoscopie peut être ...requise pour orienter un diagnostic, réaliser des prélèvements ou surtout, et le plus souvent, traiter. Pour essayer de répondre à cette question, il faut tout d’abord énumérer les urgences coliques, déterminer l’utilité de l’endoscopie dans chacune de ces situations aiguës et enfin relever les critères concrets cliniques, biologiques, iconographiques devant amener à réaliser cette endoscopie colique en dehors des heures ouvertes. Tous ces éléments doivent trouver réponse à la lumière de la littérature qui dans le domaine peut paraître mince. Cette présentation va essayer de relever ce challenge.
Abstract: The question may seem a little provocative. However, there are many colic reasons to bring the endoscopist during week-end at the bedside of the patient. To try to answer this question, we must first list the emergency in colic pathology, determine the usefulness of endoscopy in these acute situations and finally meet the specific clinical, biological, radiological criteria to get them to perform this endoscopy during open hours. All of these are answered in the light of the literature which is sometimes thin in the field. This presentation will attempt to meet this challenge.
Introduction
The management of post-operative anastomotic leakage and fistulas of the upper GI tract remains challenging. Fully covered stents are used despite a high risk of migration because of a ...better removability. The goal of our study was to evaluate the effectiveness of this new type of endoscopic stent in this indication. The secondary objective was to determine the ability of withdrawing this stent.
Methods
Thirty-six patients treated for upper GI fistula using a double-type metallic stent (DTMS) (Taewoong, Korea) for a benign indication were included in this retrospective study. This stent associates an outer uncovered metallic stent, decreasing the risk of migration, to an inner fully covered stent that ensured its tightness. The DTMS was removed after 4 weeks of treatment.
Results
Twenty-four patients had a post-operative fistula (15 sleeve gastrectomies), eight had an anastomotic leakage, and four had an esophageal perforation. Seventeen patients underwent a previous failed stenting, and fourteen had an associated treatment with OTSC clips. A final complete healing was achieved in twenty-six patients (72 %). For patients with fistulas, the overall success rate was 66.6 % (16/24) mostly in case of post sleeve fistula (80 %), and it was 75 % (6/8) for patients with anastomotic leakages (3/4). We reached a primary success (one session) in twenty-one cases (58.3 %), and a second session was required in five cases. All the stents were removed without complications after a median stenting time of 32 20–71 days. The spontaneous migration rate was 16.6 %.
Conclusion
This new double-type stent is a new and efficient way to treat post-operative fistulas and leakages in the upper GI tract. The stents were always removable despite the external uncovered part with a low migration rate.
Recent developments in therapeutic endoscopic ultrasound (EUS) have enabled new approaches to the management of refractory gastrointestinal bleeding, including EUS-guided sclerotherapy and vessel ...embolization. Few cases have been reported in the literature. Eight patients were admitted for severe, refractory gastrointestinal bleeding, seven of whom were actively bleeding. Causes of bleeding were gastric varices secondary to portal hypertension (n = 3); gastroduodenal artery aneurysm or fundal aneurysmal arterial malformation (n = 3); and Dieulafoy's ulcer (n = 2); the latter five patients having arterial bleeding. During the procedures, the bleeding vessel was punctured with a 19-gauge needle then injected with a sclerosing agent (cyanoacrylate glue n = 6 or polidocanol 2 % n = 2) under Doppler control. The median follow-up time was 9 months (3 - 18 months). In all 10 endoscopic procedures were performed. The procedure was successful at the first attempt in seven out of eight patients (87.5 %). No clinical complications were observed, although in one case there was diffusion of cyanoacrylate in the hepatic artery. The seven successful cases all showed immediate and complete disappearance of the Doppler flow signal at the end of the procedure. This retrospective study highlights the utility of EUS-guided vascular therapy. However, more large randomized studies should be conducted to confirm these results.
Summary Fistula as a complication of pancreatic intraductal papillary mucinous neoplasms (IPMN) is rare and may involve different adjacent organs, sometimes, several organs at the same time. Our ...patient had a pancreatico-gastric fistula, discovered at work-up for IPMN, which required extensive surgery.
Uncovered self-expanding metal stents offer effective relief for colonic obstruction. The aim of this study was to determine the effectiveness of fully covered self-expanding metal stents (FCSEMSs) ...in the treatment of benign colonic strictures.
All patients presenting with a symptomatic benign colonic stricture (occlusion or subocclusion) during a 6-year study period were treated with FCSEMSs. The stents were placed and removed 4 - 6 weeks later at one of 10 endoscopy centers. The efficacy of the stent (clinical and radiological signs of colonic decompression within 48 hours), technical success, stent retrieval, safety, and recurrence of symptoms were evaluated during follow-up. Univariate and multivariate analyses were performed to identify variables associated with clinical success, stent migration, and symptom recurrence.
The study included 43 patients (24 men, 19 women; mean age 67.6 ± 10.4) with occlusive (n = 18) or subocclusive symptoms (n = 25) due to anastomotic (n = 40), post-ischemic (n = 2), or post-radiation (n = 1) strictures. Insertion was successful in all patients. Clinical success was obtained in 35 patients (81 %). Migration was observed in 27 patients (63 %). The median duration of stenting was 21 days (95 %CI 17.8 - 35.4 days). Multivariate analysis showed that stents more than 20 mm wide migrated significantly less often. Recurrence of obstructive symptoms was observed in 23 patients (53 %), irrespective of migration. No predictive factors for recurrence or clinical efficacy were found.
FCSEMSs for treatment of symptomatic benign colonic strictures are safe and effective, despite a high rate of spontaneous migration.
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