Browsing by Author "Lopes, L"
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- Acute Treatment of Malignant Colorectal Occlusion: Real Life PracticePublication . Fernandes, D; Domingues, S; Gonçalves, BM; Bastos, P; Ferreira, A; Rodrigues, A; Gonçalves, R; Lopes, L; Rolanda, CINTRODUCTION: Colorectal cancer presents itself as acute bowel occlusion in 10-40% of patients. There are two main therapeutic approaches: urgent surgery and endoluminal placement self-expandable metallic stents (SEMS). AIMS AND METHODS: This study intended to better clarify the risk/benefit ratio of the above-mentioned approaches. We conducted a retrospective longitudinal multicenter study, including 189 patients with acute malignant colorectal occlusion, diagnosed between January 2005 and March 2013. RESULTS: Globally (85 patients - 35 bridge-to-surgery and 50 palliative), SEMS's technical success was of 94%. Palliative SEMS had limited clinical success (60%) and were associated with 40% of complications. SEMS occlusion (19%) was the most frequent complication, followed by migration (9%) and bowel perforation (7%). Elective surgery after stenting was associated with a higher frequency of primary anastomosis (94% vs. 76%; p = 0.038), and a lower rate of colostomy (26% vs. 55%; p = 0.004) and overall mortality (31% vs. 57%; p = 0.02). However, no significant differences were identified concerning postoperative complications. Regarding palliative treatment, no difference was found in the complications rate and overall mortality between SEMS and decompressive colostomy/ileostomy. In this SEMS subgroup, we found a higher rate of reinterventions (40% vs. 5%; p = 0.004) and a longer hospital stay (14, nine vs. seven, three days; p = 0.004). CONCLUSION: SEMS placement as a bridge-to-surgery should be considered in the acute treatment of colorectal malignant occlusion, since it displays advantages regarding primary anastomosis, colostomy rate and overall mortality. In contrast, in this study, palliative SEMS did not appear to present significant advantages when compared to decompressive colostomy.
- Early precut fistulotomy for biliary access: time to change the paradigm of "the later, the better?Publication . Lopes, L; Dinis-Ribeiro, M; Rolanda, CBACKGROUND: The precut timing during the biliary cannulation algorithm is a subject of controversy. Some studies suggest that early institution of precut is a safe and effective strategy even though the extent to which this approach may affect the duration of the ERCP is seldom addressed. OBJECTIVE: To assess the success, safety, and procedure duration of an early precut fistulotomy (group A) versus a classic precut strategy after a difficult biliary cannulation (group B). DESIGN: Single-center, prospective cohort study. SETTING: University-affiliated hospital. PATIENTS: A total of 350 patients with a naïve papilla. INTERVENTIONS: Standard biliary cannulation followed by needle-knife fistulotomy (NKF). MAIN OUTCOME MEASUREMENTS: Biliary cannulation rate, NKF success, adverse events, and ERCP duration. RESULTS: The overall cannulation rate was similar, at 96% and 94% for groups A and B, respectively. The adverse event rate was 6.2% and 6.4%, respectively, with pancreatitis as the most frequent adverse event (group A, 3.9%; group B, 5.2%). The mean ERCP duration was, however, significantly shorter in group A, both when biliary cannulation was achieved without precutting (14 minutes vs 25 minutes, P < .001) as well as when biliary cannulation was attempted after NKF (18 minutes vs 31 minutes, P < .0001). LIMITATIONS: Single-center study design, referral center. CONCLUSIONS: If the endoscopist is experienced in ERCP and precut techniques, an early precut strategy should be the preferred cannulation strategy because this approach is as safe and effective as the late fistulotomy approach and substantially reduces ERCP duration.
- Gaining competence in needle-knife fistulotomy - can I begin on my own?Publication . Lopes, L; Dinis-Ribeiro, M; Rolanda, CBACKGROUND: While there are guidelines for appropriate training in ERCP, these are non-existent for needle-knife precut. The aim of this study was: (1) evaluate the experience curve of three endoscopists in needle-knife fistulotomy (NKF); (2) propose a minimum number of NKF procedures to attest proficiency. METHODS: Between November 1997 and March 2011, the first 120 consecutive NKF performed by three endoscopists (A, B, and C) were selected (360 patients) from three centers. Each group of 120 patients was chronologically ordered into three subgroups of 40. The main outcomes were: NKF use, NKF success, and post-ERCP adverse events. RESULTS: The need for NKF did not decrease over time. The NKF success rate in the first attempt for endoscopist A and C in each of the three subgroups was 85 %/85 %, 87.5 %/87.5 %, and 87.5 %/90 %, respectively. Furthermore, both demonstrated a high NKF success in their initial 20 NKFs (85 % and 80 %, respectively). Endoscopist B however presented a different pattern as the success rate initiated at 60 %, then rose to 82.5 % and 85 % for the last group (P = 0.03). Adverse events were mild (28 of the 32 occurrences) with no clear reduction with increased experience. CONCLUSIONS: A skillful endoscopist may expect to master NKF easily with few adverse events. While some endoscopists could begin on their own because of their innate skills, a minimal training is needed for all, as we cannot predict skills in advance. We propose a minimum of 20 NKF precuts to attest a trainee's competence in this procedure.
- Gaining competence in needle-knife fistulotomy - can I begin on my own?Publication . Lopes, L; Dinis-Ribeiro, M; Rolanda, CBACKGROUND: While there are guidelines for appropriate training in ERCP, these are non-existent for needle-knife precut. The aim of this study was: (1) evaluate the experience curve of three endoscopists in needle-knife fistulotomy (NKF); (2) propose a minimum number of NKF procedures to attest proficiency. METHODS: Between November 1997 and March 2011, the first 120 consecutive NKF performed by three endoscopists (A, B, and C) were selected (360 patients) from three centers. Each group of 120 patients was chronologically ordered into three subgroups of 40. The main outcomes were: NKF use, NKF success, and post-ERCP adverse events. RESULTS: The need for NKF did not decrease over time. The NKF success rate in the first attempt for endoscopist A and C in each of the three subgroups was 85 %/85 %, 87.5 %/87.5 %, and 87.5 %/90 %, respectively. Furthermore, both demonstrated a high NKF success in their initial 20 NKFs (85 % and 80 %, respectively). Endoscopist B however presented a different pattern as the success rate initiated at 60 %, then rose to 82.5 % and 85 % for the last group (P = 0.03). Adverse events were mild (28 of the 32 occurrences) with no clear reduction with increased experience. CONCLUSIONS: A skillful endoscopist may expect to master NKF easily with few adverse events. While some endoscopists could begin on their own because of their innate skills, a minimal training is needed for all, as we cannot predict skills in advance. We propose a minimum of 20 NKF precuts to attest a trainee's competence in this procedure.
- Importância da prova de Synacthen no diagnóstico diferencial de pubarca precocePublication . Santos, MJ; Amaral, D; Limbert, C; Pina, R; Lopes, LIntrodução Nos doentes com pubarca precoce, o gold‐standard para o diagnóstico diferencial entre pubarca precoce idiopática (PPI) e a forma não clássica da hiperplasia congénita da suprarrenal (HCSR‐NC) é a prova de Synacthen. Esta permite também estimar a reserva adrenal de cortisol nos doentes com HCSR‐NC. Objetivos Comparar as características clínicas e perfil hormonal basal dos doentes com pubarca precoce; avaliar a importância da prova de Synacthen no diagnóstico diferencial entre PPI e HCSR‐NC e na determinação da reserva adrenal de cortisol. Material e métodos Estudo transversal de doentes com pubarca precoce que realizaram prova de Synacthen. ResultadosForam incluídos 43 doentes, com idade mediana de 7,5 anos (3,5‐9,4), sendo 37 (86,0%) do sexo feminino. Na prova de Synacthen, 37 (86,0%) foram classificados como PPI e 6 (14,0%) como HCSR‐NC. Não houve diferenças significativas entre os 2 grupos quanto às características clínicas e doseamentos basais de ACTH, cortisol e androgénios da suprarrenal. A 17‐OHP basal e estimulada foi mais elevada nos doentes com HCSR‐NC (p = 0,001 e p < 0,001, respetivamente) (basal: 4,62 ± 3,70 ng/ml [0,80‐10,50]; estimulada: 35,41 ± 24,87 ng/ml [12,0‐80,2]) do que nos doentes com PPI (basal: 1,04 ± 0,77 ng/ml [0,22‐3,80]; estimulada: 4,18 ± 1,71 ng/ml [1,0‐8,96]). O cut‐off basal habitualmente proposto (< 2,0 ng/ml) para a distinção entre estes grupos não o permitiu em 2 doentes, que apenas foram diagnosticados após realização da prova de Synacthen. Dois doentes com HCSR‐NC (33,3%) tiveram cortisol após estimulação < 18 μg/dl, revelando necessidade de tratamento com glucocorticoide em stress. Os doentes com HCSR‐NC com valores mais elevados de 17‐OHP basal tiveram valores de cortisol mais baixos após estimulação (p = 0,004; r = ‐0,43). Conclusão A realização desta prova foi útil para distinguir os doentes com HCSR‐NC e PPI, pois nenhum valor de 17‐OHP basal permitia fazer o diagnóstico diferencial definitivo. Em alguns doentes com HCSR‐NC a prova revelou secreção inapropriada de cortisol em stress, contribuindo para a decisão terapêutica.
- Response.Publication . Lopes, L; Dinis-Ribeiro, M; Rolanda, CResponse: Luís Lopes, MD, PhD Mário Dinis-Ribeiro, MD, PhD Carla Rolanda, MD, PhD Show more doi:10.1016/j.gie.2015.01.001 Refers To: Panagiotis Katsinelos, Georgia Lazaraki, Grigoris Chatzimavroudis, Christos Zavos, Jannis Kountouras The endoscopic morphology of major papillae influences the selected precut technique for biliary access Gastrointestinal Endoscopy, Volume 81, Issue 4, April 2015, Page 1056