Complications and survival in patients undergoing colonic stenting for malignant obstruction

AIM:To investigate whether predicting patients that might be at a higher risk for complications might serve to improve the selection of patients undergoing colonic stenting.METHODS:A retrospective review of consecutive patients who underwent an attempted self-expandable metal stent(SEMS)insertion for malignant colonic obstruction between November 2006 and March 2013.All patients were either referred for preoperative colonic decompression with the intent of a single surgical procedure,or for palliation of the malignant colorectal obstruction for unresectable cancer.Fisher’s test orχ2test was performed on categorical variables,and the t test for continuous variables.Univariable and multivariable logistic regression were used to examine the association between independent variables and the presence of complications from SEMS insertion.RESULTS:SEMS insertion was attempted in 73 patients.Males comprised 55.71%and the mean age was 67.41±12.41 years.Of these,65.15%underwent subsequent surgery,while 34.85%received SEMS as palliation for advanced disease.Extracolonic tumors were only4.76%.The majority of patients had stageⅣdisease(63.83%),while the remainder had stageⅢ(36.17%).SEMS were successfully inserted in 93.85%(95%CI:87.85%-99.85%).Perforations occurred in 4.10%,SEMS migration in 8.21%,and stent re-occlusion from ingrowth occurred in 2.74%of patients.The mean duration of follow up for the patients was 13.52±17.48 mo(range 0-73 mo).None of the variables:age,sex,time between the onset of symptoms to SEMS insertion,time between SEMS insertion and surgery,length of the stenosis,location of the stenosis,albumin level,or receiving neoadjuvant chemotherapy,could predict the development of complications from either SEMS insertion nor prolonged survival.CONCLUSION:None of the variables could predict the development of complications or survival.Further studies are required to identify patients who would benefit the most from SEMS.

Probe based confocal laser endomicroscopy of the pancreatobiliary system

AIM:To review applications of confocal laser endomicroscopy(CLE) in pancreatobiliary lesions and studies that assessed training and interpretation of images. METHODS: A computerized literature search was performed using OVID MEDLINE, EMBASE, Cochrane library, and the ISI Web of Knowledge from 1980 to October 2014. We also searched abstracts from major meetings that included the Digestive Disease Week, Canadian Digestive Disease Week and the United European Gastroenterology Week using a combination of controlled vocabulary and text words related to p CLE, confocal, endomicroscopy, probe-based confocal laser endomicroscopy, and bile duct to identify reports of trials. In addition, recursive searches and crossreferencing was performed, and manual searches of articles identified after the initial search was also completed. We included fully published articles and those in abstract form. Given the relatively recent introduction of CLE we included randomized trials and cohort studies.R E S U LT S : In the evaluation of indeterminate pancreatobiliary strictures CLE with ERCP compared to ERCP alone can increase the detection of cancerous strictures with a sensitivity of(98% vs 45%) andhas a negative predictive value(97% vs 69%), but decreased the specificity(67% vs 100%) and the positive predictive value(71% vs 100%) when compared to index pathology. Modifications in the classification systems in indeterminate biliary strictures have increased the specificity of p CLE from 67% to 73%. In pancreatic cystic lesions there is a need to develop similar systems to interpret and characterize lesions based on CLE images obtained. The presence of superficial vascular network predicts serous cystadenomas accurately. Also training in acquiring and interpretation of images is feasible in those without any prior knowledge in CLE in a relatively simple manner and computer-aided diagnosis software is a promising innovation. CONCLUSION: The role of p CLE in the evaluation of pancreatobiliary disorders might be better suited for those with an intermediate and low probability.

Sedated vs unsedated colonoscopy:A prospective study

AIM:To compare sedated to unsedated colonoscopy in terms of duration,pain and the patient’s willingness to repeat the procedure.METHODS:Consecutive patients who underwent colonoscopies over a 2-year period were invited to participate.All patients who were to undergo our endoscopy unit were offered sedation with standard intravenous sedatives and analgesics,or an unsedated colonoscopy was attempted.Demographic details were recorded.The patient anxiety level prior to the procedure,time to reach the cecum,total discharge time,patient and endoscopist pain assessments,satisfaction after the examination and the patient’s willingness to return for the same procedure in the future were recorded.RESULTS:Among the 403 observed patients,more males were observed in the unsedated group(66.2%vs 55.2%,P=0.04).Additionally,the unsedated group patients were less anxious prior to the procedure(5.1vs 6.0,P<0.01).The colonoscopy completion rates were comparable between the 2 groups(85.9%vs84.2%,P=0.66).The time to reach the cecum was also comparable(12.2 min vs 11.8 min);however,the total discharge times were shorter in the unsedated group(20.7 min vs 83.0 min,P<0.01).Moreover,the average patient pain score(3.4 vs 5.7,P<0.01)was lower in the sedated group,while the satisfaction score(8.8 vs 7.8,P<0.01)was significantly higher.There was no significant difference,however,between the groups in terms of willingness to repeat the procedure if another was required in the future(83.3%vs 77.3%,P=0.17).CONCLUSION:Unsedated colonoscopy is feasible in willing patients.The option saves the endoscopy units up to one hour per patient and does not affect the patient willingness to return to the same physician again for additional colonoscopies if a repeated procedure is needed.

Performance of American Society for Gastrointestinal Endoscopy guidelines for dyspepsia in Saudi population: Prospective observational study

AIM: To evaluate adherence of primary care physicians(PCPs) to international guidelines when referring patients for upper-gastrointestinal endoscopy(UGE), evaluate the importance of alarm symptoms and the performance of the American Society for Gastrointestinal Endoscopy(ASGE) guidelines in a Saudi population.METHODS: A prospective, observational cross-sectional study on dyspeptic patients undergoing UGE who were referred by PCPs over a 4 mo period. Refer-rals were classified as appropriate or inappropriate according to adherence to ASGE guidelines.RESULTS: Total of 221 dyspeptic patients was enrolled; 161 patients met our inclusion criteria. Mean age was 40.3 years(SD ± 18.1). Females comprised 70.1%. Alarm symptoms included low hemoglobin level(39%), weight loss(18%), vomiting(16%), loss of appetite(16%), difficulty swallowing(3%), and gastrointestinal bleeding(3%). Abnormal endoscopy findings included gastritis(52%), duodenitis(10%), hiatus hernia(7.8%), features suggestive of celiac disease(6.5%), ulcers(3.9%), malignancy(2.6%) and gastroesophageal reflux disease(GERD: 17%). Among patients who underwent UGE, 63% met ASGE guidelines, and 50% had abnormal endoscopic findings. Endoscopy was not indicated in remaining 37% of patients. Among the latter group, endoscopy was normal in 54% of patients. There was no difference in proportion of abnormal endoscopic findings between two groups(P = 0.639).CONCLUSION: Dyspeptic patients had a low prevalence of important endoscopic lesions, and none of the alarm symptoms could significantly predict abnormalendoscopic findings.

Fatal aortoesophageal fistula bleeding after stenting for a leak post sleeve gastrectomy

Bariatric surgeries have been used in an effort to curtail the obesity epidemic. The type of surgery used has changed over time, with sleeve gastrectomies being one of the preferred options. This has been associated with some complications, including staple line leaks. We report a 43-year old female who had undergone a laparoscopic sleeve gastrectomy that was complicated by a proximal gastric pouch leak at the gastroesophageal junction. We used self-expandable stents(SEMS) in the management of the leak. Seven weeks after the insertion of the initial SEMS, the patient presented with a massive gastrointestinal bleed that could not be localized due to profuse bleeding. The patient underwenta computerized tomography angiogram and then an angiogram that could not localize the site of the bleed. An emergency laparotomy was performed and identified the source of bleeding to be an aortoesophageal fistula. A graft of the diseased area was attempted but the patient unfortunately did not survive the procedure. An aortoesophageal fistula after an esophageal SEMS insertion for a benign disease has rarely been reported and only in cases where there was a thoracic neoplasm, thoracic aortic aneurism, endovascular stent repair, foreign body or esophageal surgery. To our knowledge, this is the first case that reports an aortoesophageal fistula as a result of a SEMS for the management of a gastric pouch leak after a laparoscopic sleeve gastrectomy.

Prevalence and clinical features of colonic diverticulosis in a Middle Eastern population

AIM: To determine the prevalence, location, associations and clinical features of colonic-diverticulosis and its role as a cause of lower-gastroenterology-bleeding. METHODS: We retrospectively reviewed the medical records of 3649 consecutive patients who under-went a colonoscopy for all indications between 2007 and 2011 at King Khalid University Hospital, Riyadh, Saudi Arabia. The demographic data were collected retrospectively through the hospital's information system, electronic file system, endoscopic e-reports, and manual review of the files by two research assistants. The demographic information included the age, sex, comorbidities and indication for the colonoscopy. The association among colonic polyps, comorbidities and diverticular disease was also measured.RESULTS: A total of 270 patients out of 3649 were diagnosed with colonic diverticulosis, with a prevalence of 7.4%. The mean age was 60.82 years ± 0.833, (range 12-110). Females comprised 38.89% (95%CI: 33-44.7) of the study population. The major symp-toms were rectal bleeding in 33.6%, abdominal pain in 19.3%, constipation in 12.8% and anemia in 6%. Diverticula were predominantly left-sided (sigmoid and descending colon) in 62%, right-sided in 13% and in multiple locations in 25%. There was an association between the presence of diverticulosis and adenomatous polyps (Pvalue < 0.001), hypertension (P-value < 0.0001) and diabetes mellitus (P-value < 0.0016). Diverticular disease was the second most common cause of lower gastrointestinal bleeding, in 33.6% (95%CI: 27.7-39.4), after internal hemor-rhoids, in 44.6% (95%CI: 40.3-48.9). On multivariable logistic regression, hypertension (OR = 2.30; 95%CI: 1.29-4.10), rectal bleeding (OR = 2.57; 95%CI: 1.50-4.38), and per year increment in age (OR = 1.05; 95%CI: 1.03-1.07) were associated with diverticulosis but not with bleeding diverticular disease. Limitations: A small proportion of the patients included had colo-noscopies performed as a screening test.CONCLUSION: Colonic-diverticulosis was found to have a low prevalence, be predominantly left-sided and associated with adenomatous-polyps. Age, hypertension and rectal bleeding predict the presence of diverticular disease.

Clinical epidemiology of ulcerative colitis in Arabs based on the Montréal classification

AIM:To determine the clinical,epidemiological and phenotypic characteristics of ulcerative colitis(UC)in Saudi Arabia by studying the largest cohort of Arab UC patients.METHODS:Data from UC patients attending gastroenterology clinics in four tertiary care centers in three cities between September 2009 and September 2013were entered into a validated web-based registry,inflammatory bowel disease information system(IBDIS).The IBDIS database covers numerous aspects of inflammatory bowel disease.Patient characteristics,disease phenotype and behavior,age at diagnosis,course of the disease,and extraintestinal manifestations were recorded.RESULTS:Among 394 UC patients,males comprised51.0%and females 49.0%.According to the Montréal classification of age,the major chunk of our patients belonged to the A2 category for age of diagnosis at17-40 years(68.4%),while 24.2%belonged to the A3category for age of diagnosis at>40 years.According to the same classification,a majority of patients had extensive UC(42.7%),35.3%had left-sided colitis and29.2%had only proctitis.Moreover,51.3%were in remission,16.6%had mild UC,23.4%had moderate UC and 8.6%had severe UC.Frequent relapse occurred in17.4%patients,infrequent relapse in 77%and 4.8%had chronic disease.A majority(85.2%)of patients was steroid responsive.With regard to extraintestinal manifestations,arthritis was present in 16.4%,osteopenia in 31.4%,osteoporosis in 17.1%and cutaneous involvement in 7.0%.CONCLUSION:The majority of UC cases were young people(17-40 years),with a male preponderance.While the disease course was found to be similar to that reported in Western countries,more similarities were found with Asian countries with regards to the extent of the disease and response to steroid therapy.

Resolution of an esophageal leak and posterior gastric wall necrosis with esophageal self-expandable metal stents

The use of weight reduction surgeries has increased over the years with a higher proportion of these surgeries being sleeve gastrectomies,this has been associated with some complications including staple line leaks.We report a 32-year-old male who had undergone a laparoscopic gastric band surgery and subsequently a laparoscopic sleeve gastrectomy,this was complicated by both an staple line leak at the gastroesophageal junction as well as a large(> 4 cm) posterior gastric wall defect due to gastric wall necrosis. We used two co-axially inserted self-expandable stents(SEMS) in the management of this patient,5 stents were used over repeated endoscopy sessions and 20 wk. Both defects had resolved without the need for surgical intervention.This is the first reported case were SEMS are used for both a staple line leak as well as a gastric wall defect.We also review the literature on the use of SEMS in the management of leaks post weight reduction surgeries.

Seroprevalence of celiac disease among healthy adolescents in Saudi Arabia

AIM: To identify the seroprevalence of celiac disease among healthy Saudi adolescents. METHODS: Between December 2007 and January 2008, healthy students from the 10th to 12th grades were randomly selected from three regions in Saudi Arabia. These regions included the following: (1) Aseer region, with a student population of 25512; (2) Madinah, with a student population of 23852; and (3) Al-Qaseem, with a student population of 16067. Demographic data were recorded, and a venous blood sample (5-10 mL) was taken from each student. The blood samples were tested for immunoglobulin A and immunoglobulin G endomysial antibodies (EMA) by indirect immunofluorescence.RESULTS: In total, 1167 students (614 males and 553 females) from these three regions were randomly selected. The majority of the study population was classified as lower middle class (82.7%). There were 26 (2.2%) students who had a positive anti-EMA test, including 17 females (3.1%) and 9 males (1.5%). Al-Qaseem region had the highest celiac disease prevalence among the three studied regions in Saudi Arabia (3.1%). The prevalence by region was as follows: Aseer 2.1% (10/479), Madinah 1.8% (8/436), and Al-Qaseem 3.2% (8/252). The prevalence in Madinah was significantly lower than the prevalence in Aseer and Al-Qaseem (P=0.02). CONCLUSION: Our data suggest celiac disease prevalence might be one of the highest in the world. Further studies are needed to determine the real prevalence.