A comparative study of postendoscopic sphincterotomy complications with various types of electrosurgical current in patients with choledocholithiasis

BACKGROUND: Whether the type of electrosurgical current used for endoscopic sphincterotomy influences the frequency of postsphincterotomy complications is unknown. METHODS: One hundred eighty-six patients with choledocholithiasis were prospectively randomized to undergo endoscopic sphincterotomy with pure cutting current (n = 62, Group A), blended current (n = 62, Group B), or pure cutting initially followed by blended current (n = 62, Group C). Serum concentrations of amylase and lipase were evaluated in all patients 12 and 24 hours after sphincterotomy. Clinical pancreatitis was classified as mild, moderate, or severe. Postsphincterotomy bleeding was defined as a decrease in hematocrit of greater than 5%. RESULTS: Serum concentrations of amylase and lipase were greater in Groups B and C at 12 and 24 hours after the procedure, as compared with Group A. Clinical mild pancreatitis occurred in 2 patients in Group A (3.2%), 8 in Group B (12.9%), and in 8 in Group C (12.9%). The differences were statistically significant for Group A compared with either Group B or Group C (p = 0.048). Postsphincterotomy bleeding occurred in 3 patients (1.6%), one in each group. CONCLUSION: The use of pure cutting electrosurgical current during endoscopic sphincterotomy in patients with choledocholithiasis is associated with a lesser degree of pancreatic enzyme elevation and lower frequency of pancreatitis, whereas bleeding is not increased compared with blended current. Changing from pure cutting to blended current after the first 3 to 5 mm of the incision is associated with an increased rate of complications compared to the use of pure cutting current for the entire sphincterotomy.     

Gastrocolic fistula secondary to nonsteroidal anti-inflammatory drugs abuse in a cirrhotic patient

Gastrocolic fistula is rarely described in the literature. It has been associated with a variety of diseases and recently with benign gastric ulcers related to the use of nonsteroidal anti-inflammatory drugs (NSAIDs'). The present case represents the first report of gastrocolic fistula due to NSAIDs in a cirrhotic patient. This is in keeping with the established knowledge that cirrhotic patients constitute a high-risk group of patients when treated with NSAIDs'. Review of the literature shows that this condition warrants a complete diagnostic work-up to exclude more ominous underlined diseases.     

Antecolic gastrointestinal reconstruction with pylorus dilatation. Does it improve delayed gastric emptying after pylorus-preserving pancreaticoduodenectomy?

Objective. The aim of our study focuses upon prevention of delayed gastric emptying (DGE) after pancreaticoduodenectomy using a alternative reconstruction procedure. Method. Forty consecutive patients underwent a typical pylorus-preserving pancreaticoduodenectomy (PPPD) with antecolic reconstruction in a two-year period (January 2002 until January 2004), while a similar group of 40 consecutive patients underwent PPPD with application of pyloric dilatation between January 2004 and January 2006. Early and late complications were compared between the two groups. Results. DGE occurred significantly more often in the group of patients treated by the classical PPPD technique (nine patients −22%) compared with those operated on with the addition of pyloric dilatation technique (two patients −5%) (p<0.05). The incidence of other complications did not differ significantly between the two groups. Conclusions. The application of dilatation may decrease the incidence of DGE after PPPD and facilitates earlier hospital discharge.     

Improving endograft stability by accommodation onto the aortic bifurcation.

PURPOSE: To report the technique for deploying a 3-part endovascular graft onto the native aortic bifurcation for greater stent-graft stability. TECHNIQUE: The Zenith Composite Endovascular Graft is a 3-part system consisting of a proximal tubular body with an uncovered Gianturco Z stent, a distal bifurcated body, and a contralateral leg. Proximally, 8-mm flexible interstent gaps facilitate precise infrarenal aortic placement, even in angulated necks. Technically, the bifurcated part is deployed first and pulled down to the aortic bifurcation, while the tubular main body and contralateral leg deployment follow. Using this technique to accommodate the graft onto the natural aortic bifurcation, distal stability can be enhanced and graft migration minimized. CONCLUSION: The Composite configuration can be an alternative to ensure a higher security index in difficult anatomies. It may be beneficial in patients with short (10-15 mm), angulated (>60 degrees ), or conical necks and deserves investigation in these patient populations.     

Balantidium coli pneumonia in an immunocompromised patient

A fatal case is reported of Balantidium coli pneumonia in a 71-y-old woman suffering from anal cancer. The diagnosis was made by the discovery of motile trophozoites in a wet mount from bronchial secretions. The usual habitat of the parasite is the colon; lung balantidiasis is very rare.     

Tuberculosis-related deaths in Queensland, Australia, 1989-1998: characteristics and risk factors.

OBJECTIVE: To review factors associated with TB-related deaths in Queensland, Australia. DESIGN: Review of data for TB patients dying before treatment completion; demographic and clinico-pathological comparison of TB-related deaths with other notified patients after exclusion of losses to follow-up; matched case-control study of co-morbid conditions in patients under 75 years. RESULTS: Of 1003 tuberculosis cases notified between 1989 and 1998, 127 died before completing anti-tuberculosis treatment. Tuberculosis was the main cause of death in 53 cases, a significant contributor in 34 and unrelated in 40, giving a TB-related case fatality rate of 8.7%. Decedents were older on average, except among indigenous Australians (IA); age-adjusted case fatality rates did not vary significantly among ethnic groups. Pulmonary and disseminated TB, coexistent malnutrition, renal disease and liver disease increased the risk of death. HIV infection increased the risk of dying, but was uncommon among Queensland cases. Neither sputum smear positivity nor drug resistance was associated with risk of death. Twenty-five TB-related deaths occurred before diagnosis, with significant overrepresentation of IA. Most had serious co-morbidities and symptomatic pulmonary disease. Seven socially or geographically isolated decedents did not access documented health care for tuberculosis. CONCLUSIONS: Fatality was related to older age, disseminated disease and co-morbidity. Dying undiagnosed from tuberculosis was associated with respiratory co-morbidity and social and geographical isolation, mainly in the aged in low TB risk populations and in IA in remote regions.     

Serum lipid profile and hepatic steatosis of adult beta-thalassaemia patients with chronic HCV infection

OBJECTIVES: The aim of this study was to evaluate the serum lipid profile and to assess the prevalence of hepatic steatosis in adult beta-thalassaemic patients with chronic hepatitis C virus (HCV) infection. METHODS: Thirty-five adult HCV infected, multi-transfused, beta-thalassaemia patients (beta-HCV patients), 63 otherwise normal patients with chronic HCV infection (HCV patients) and 54 beta-thalassaemia patients without chronic viral hepatitis (beta patients) were studied. Total cholesterol, high-density lipoprotein cholesterol (HDL-C), low-density lipoprotein cholesterol (LDL-C), triglycerides, viral markers and liver histology were evaluated. RESULTS: Serum total cholesterol, HDL-C and LDL-C were found at significantly lower levels in beta-HCV and beta patients than in HCV patients. Triglyceride levels were significantly lower in the HCV group compared with the beta group. Nine (25.7%) of the 35 beta-HCV patients had mild hepatic steatosis. Thirteen (23.6%) of 55 HCV patients presented mild and 4/55 (7.3%) moderate hepatic steatosis. None of the beta group presented steatosis. When we compared beta-HCV and HCV patients with steatosis, we found that beta-HCV patients had a lower degree of steatosis (11.1+/-7% vs 22.9+/-17.2%, P=0.021). Multivariate logistic regression analysis showed that the only independent predictor associated with hepatic steatosis in beta-HCV and HCV patients was genotype 3a (OR, 3.61; 95% CI, 1.22-10.71, P=0.021). CONCLUSIONS: Adult beta-thalassaemia patients, compared to other patients with chronic HCV infection, present lower cholesterol levels (total cholesterol, HDL, LDL) and similar frequency but a lower degree of hepatic steatosis. This difference in the degree of steatosis is most likely due to the higher prevalence of genotype 3a in the non-beta-thalassaemia group.     

Liver steatosis is an independent risk factor for treatment failure in patients with chronic hepatitis C

OBJECTIVES: Hepatic steatosis is a common feature of chronic hepatitis C. The purpose of this study was to determine factors related to the presence of steatosis and to define the role of steatosis in the response to antiviral treatment in chronic hepatitis C patients. METHODS: We retrospectively analysed all patients with chronic hepatitis C treated in a 5 year period in our department. Patients were included in the study only if a pretreatment liver biopsy specimen was available for evaluation. All patients treated either with interferon in combination with ribavirin, or with pegylated interferon in combination with ribavirin were included irrespectively of their response (early, end of treatment and/or sustained) to antiviral therapy. RESULTS: A total of 116 patients with chronic hepatitis C were included in the study with a mean age of 45.5 +/- 14.1 years. Steatosis was present in 52 patients (44.8%). On univariate analysis age, P = 0.04 and body mass index > or = 25, P = 0.004 were correlated with the presence of steatosis and on multivariate analysis only body mass index > or = 25, P = 0.032. Advanced fibrosis was not found associated with steatosis. Sixty patients out of 116 (51.7%) had sustained virological response (SVR). In particular 42 out of 64 patients with no steatosis (65.6%) had SVR compared to 20 out of 52 patients (38.4%) with any degree of steatosis (P = 0.009). Patients with genotype 2 or 3 had a more favourable outcome compared to patients with 1 or 4 genotypes, 63.2% vs 49.2%, P = 0.032. Also increased age (P = 0.0001), gamma glutamyltransferase (GGT) (P = 0.029), no history of intravenous drugs use (P = 0.001) and advanced fibrosis on pretreatment biopsy (P = 0.046) were correlated with treatment failure. On multivariate analysis significant independent association with SVR was found with the presence of steatosis on pretreatment biopsy (P = 0.004), increased GGT (P = 0.005) and genotype (P = 0.017). CONCLUSION: Steatosis in the liver biopsy performed before the beginning of antiviral treatment was found to be associated only to the body mass index of the patients and to be a strong independent factor for treatment failure.