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Castano R.,University of Antioquia | Alvarez O.,Gastroenterologo | Lopera J.,Texas A&M University | Ruiz M.H.,Cirujano General | Rojas A.,Institute Cancerologia Clinica Las Americas
Revista Colombiana de Gastroenterologia | Year: 2015

Background: Benign stenoses, digestive tract ruptures and fistulas are conditions that endanger life and are often treated surgically. Recently, the placement of partially or fully covered metal stents has emerged as a minimally invasive treatment option. This article looks at a new design for stents to determine its clinical effectiveness. The new stent is a completely covered nitinol stent for treatment of gastrointestinal perforations and anastomotic leaks. This article places special emphasis on evaluating reactive hyperplasia. Methods: Fifteen had the new completely covered self-expanding nitinol stent placed for treatment of benign esophageal perforations, anastomotic leaks, and stenoses following upper or lower gastrointestinal surgery during 2012 and 2013. The stents are 20 mm in diameter in the middle and 28 mm in diameter at the proximal end. Information about patient demographics, type of lesion, lesion locations, stent removal, clinical success and complications was collected. Results: A total of 15 stents were placed in 15 patients to treat anastomotic leaks (n = 8), esophageal stenoses (n = 2), colorectal stenoses (n = 2), a gastrojejunostomy stenosis (n = 1), an esophageal iatrogenic rupture (n = 1), and a pyloric stenosis (n = 1). Endoscopic removal of the stent was successful in all patients. Although it was particularly difficult in one case because of reactive hyperplasia. Clinical success was achieved in nine patients (73%). Average duration of time between stent placement and removal was 10 weeks with a range of 7 to 12 weeks. In total, seven complications occurred in 15 patients (47%): reactive hyperplasia (n = 1), migration (n = 3) severe pain (n = 2) esophageal ulceration (n = 1) only one patient required surgery after stent failure. No patients died as the result of stenting. Conclusions: A redesigned completely covered stent kept in place for 10 weeks may be an alternative to surgery for treating gastrointestinal perforations, anastomotic stenoses and fistulas. The efficacy of the new stent differs from that of conventional stents. The choice depends on the expected risks of stent migration and reactive hyperplasia. © 2015 Asociaciones Colombianas de Gastroenterología, Endoscopia digestiva, Coloproctología y Hepatología. Source


Castano R.,University of Antioquia | Alvarez O.,Gastroenterologo | Pineres A.,Cirujano General | Ruiz M.H.,Cirujano General | Rojas A.,Institute Cancerologia Clinica Las Americas
Revista Colombiana de Gastroenterologia | Year: 2014

Introduction: Various endoscopic techniques for ablation of metaplastic esophageal epithelia which maintain the integrity of the submucosa have been described. All maintain patients under aggressive acid suppressive therapy with proton pump inhibitors. To date, few studies have compared the different endoscopic techniques for eradicating Barrett’s esophagus (BE) with dysplasia. Similarly the factors that might infl uence patients’ prognoses after these therapies have not been very consistently evaluated. Objective: This is a pilot study which compares the effectiveness of complete eradication of BE with dysplasia through endoscopic mucosal resection (EMR) with bands and low voltage endoscopic argon plasma coagulation (APC). The three points evaluated are whether complete ablation of BE was achieved, the number of sessions required and whether and what complications occurred. Methods: APC was performed using a fl exible 10 French catheter. The voltage used was 50 W and flow timed varied between 1 minute and 2 l/min. In one group BE mucosa was treated with multi-band ligation. Up to six bands were placed per session. The mucosa with BE was removed with a polypectomy loop and a mixed stream of water. Patients were followed up endoscopically and biopsies were obtained from the four quadrants in both treated and untreated areas at three, six and twelve months after treatment ended. All patients received high doses of proton pump inhibitors. Results: This prospective study describes our results in a group of 62 patients with Barrett’s Esophagus and dysplasia. Thirty-three patients (22 men, 67%) were treated with APC and 29 were treated with EMR (19 men, 66%). Complete ablation of BE was achieved in 86.2% of patients treated with EMR and in 79% of those treated with APC. The number of sessions required to achieve complete ablation was 1 ± 1 for EMR and 2 ± 1 for APC. No major complications such as gastrointestinal bleeding requiring transfusion or perforations occurred. The only complications were two cases of esophageal stenosis, one in each group. These were successfully treated with single sessions of dilation. After a mean of 68.7 ± 18.9 months of follow-up in the APC group and 50.2 ± 19.3 months in the EMR group no cases of carcinoma of the esophagus and no deaths due to disease or therapy had occurred. Conclusions: In patients with BE with high or low grade dysplasia, APC and EMR achieve comparably high eradication rates of neoplasia and intestinal metaplasia (79% versus 86%). Both procedures have comparable levels of effectiveness and safety and have low rates of complications. Nevertheless, APC is associated with a greater number of sessions. © 2014 Asociaciones Colombianas de Gastroenterología, Endoscopia digestiva, Coloproctología y Hepatología. Source


Castano R.,University of Antioquia | Alvarez O.,University of Texas at San Antonio | Pineres A.,Clinica Bolivariana | Ruiz M.H.,Hospital Pablo Tobon Uribe | Rojas A.,Institute Cancerologia Clinica Las Americas
Revista Colombiana de Gastroenterologia | Year: 2014

Introduction: Barrett’s esophagus (BE) with dysplasia has a recognized potential for malignancy. Neither acid suppression nor anti-reflux surgery produce consistent or complete regression of metaplasia or dysplasia in the epithelium. Endoscopic argon plasma ablation (APC) offers the possibility of eradication, but factors that may influence the outcome of therapy have not been consistently evaluated. Objective: The objective of this study was to evaluate the efficacy of APC for eradication of BE with dysplasia and to evaluate the factors that infl uence the immediate outcome and results after one year of follow up. Methods: The study population included thirty-three patients suffering from BE with dysplasia: 19 men (58%), mean age of 56.9 ± 6.35 years (range 45-69 years) and an average length of EB 4.1 cm (range 2 to 8 cm.). All patients had undergone APC at intervals of 4 to 6 weeks to eradicate Barrett’s esophagus. Patients also received double doses of proton pump inhibitors (PPIs). Patients were endoscopically monitored at 3, 6 and 12 months and thereafter every year with four-quadrant biopsies of treated areas. Results: Ablation of BE and dysplasia was achieved in all patients after a median of 2 sessions of APC (1-4 sessions). Recurrence of BE and dysplasia is associated with longer initial lengths affected by BE and larger circumferences of its circular or proximal margin, despite treatment with additional APC sessions (no significant differences). Documented recurrences of Barrett’s esophagus occurred in seven patients (21.2%), documented recurrences of dysplasia occurred in three patients (9.1%). Two of these were low grade and one was high grade. The most frequent complication was chest pain which was experienced by six patients (18.2%), four had stenoses that required endoscopic dilatation (12.1%), and one patient’s (3%) bleeding required sclerotherapy during the procedure. The average follow-up time was 43.7 ± 19 months. Noesophageal carcinoma developed nor were there any deaths related to the disease or therapy. Conclusions: Treatment with APC is safe and effective ablative therapy for short segments of BE with dysplasia. Post treatment recurrences of BE and dysplasia are common especially among patients with long segments of BE. © 2014 Asociaciones Colombianas de Gastroenterología, Endoscopia digestiva, Coloproctología y Hepatología. Source


Castano R.,University of Antioquia | Alvarez O.,Texas Valley Coastal Bend Veterans Administration | Pineres A.,Clinica Bolivariana | Ruiz M.H.,Hospital Pablo Tobon Uribe | And 3 more authors.
Revista Colombiana de Gastroenterologia | Year: 2014

Introduction: Barrett’s esophagus (BE) is the result of chronic damage to the esophageal epithelium caused by the acid of gastrointestinal reflux diseases (GERD). It is defined as replacement of the by stratified squamous epithelium that normally lines the esophagus with metaplastic columnar epithelium. BE represents a risk factor for esophageal adenocarcinoma. The aim of radiofrequency ablation (RFA) is to destroy the metaplastic epithelium with the electric current of a radiofrequency to stimulate the reappearance of stratified squamous epithelium in the distal esophagus. Objective: The objective of this study was to evaluate the efficiency and safety of RFA which has recently been introduced in the city of Medellin, Colombia for management of BE with in situ dysplasia or carcinoma. Materials and Methods: Ten patients were treated with RFA. BE patients with in situ dysplasia or carcinoma and histological diagnoses were chosen for treatment. RFA procedures were done with BARRX equipment, the circular HALO360 system or the HALO90 system. Macroscopic and microscopic effects of RFA, patient tolerance to treatment and complications were evaluated. Results: A group of 10 patients received treatment with RFA. All ten finished treatment and follow-up. Seven patients had low-grade dysplasia, two had high-grade dysplasia, and one patient had in situ carcinoma. Two patients had undergone endoscopic resections of nodules and treatments of mucosa with bands prior to therapy with RFA. A total of 13 procedures were performed: 10 RFAs with the HALO360, 2 RFAs with the HALO90 and one argon plasma treatment for residual BE in one patient. Eradication of metaplastic and dysplastic esophageal epithelium was achieved in all patients and confirmed by endoscopic and histologic evaluation. No significant complications related to RFA were found, but in two patients esophageal stenoses were found. One required endoscopic dilatation three weeks after therapy. Conclusions: Based on these preliminary results we believe that this is a promising method that is welltolerated by patients and which has no major complications. Metaplastic and dysplastic epithelium of the distal esophagus were successfully eradicated in most patients. © 2014 Asociaciones Colombianas de Gastroenterología, Endoscopia digestiva, Coloproctología y Hepatología Source


Pareja R.,Institute Cancerologia Clinica Las Americas | Nick A.M.,University of Houston | Schmeler K.M.,University of Houston | Frumovitz M.,University of Houston | And 6 more authors.
Gynecologic Oncology | Year: 2012

Objective: To help determine whether global collaborations for prospective gynecologic surgery trials should include hospitals in developing countries, we compared surgical and oncologic outcomes of patients undergoing laparoscopic radical hysterectomy at a large comprehensive cancer center in the United States and a cancer center in Colombia. Methods: Records of the first 50 consecutive patients who underwent laparoscopic radical hysterectomy at The University of Texas MD Anderson Cancer Center in Houston (between April 2004 and July 2007) and the first 50 consecutive patients who underwent the same procedure at the Instituto de Cancerología-Clínica las Américas in Medellín (between December 2008 and October 2010) were retrospectively reviewed. Surgical and oncologic outcomes were compared between the 2 groups. Results: There was no significant difference in median patient age (US 41.9 years [range 23-73] vs. Colombia 44.5 years [range 24-75], P = 0.09). Patients in Colombia had a lower median body mass index than patients in the US (24.4 kg/m 2 vs. 28.7 kg/m 2, P = 0.002). Compared to patients treated in Colombia, patients who underwent surgery in the US had a greater median estimated blood loss (200 mL vs. 79 mL, P < 0.001), longer median operative time (328.5 min vs. 235 min, P < 0.001), and longer postoperative hospital stay (2 days vs. 1 day, P < 0.001). Conclusions: Surgical and oncologic outcomes of laparoscopic radical hysterectomy were not worse at a cancer center in a developing country than at a large comprehensive cancer center in the United States. These results support consideration of developing countries for inclusion in collaborations for prospective surgical studies. © 2011 Elsevier B.V. All rights reserved. Source

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