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Background: Cholecystectomy use varies moderately across regions and countries. The purpose of this study was to evaluate the appropriateness of the use of cholecystectomy in patients with nonmalignant diseases in different hospitals using explicit criteria developed by an expert panel. Methods: Patients on waiting lists to undergo a cholecystectomy for nonmalignant diseases in six public hospitals in Spain were included in this prospective observational study over a 1-year period. Appropriateness criteria were first developed by a panel of experts using the RAND appropriateness method. The appropriateness of the indication was judged by applying explicit criteria developed previously. Complications were recorded 3 months after surgery. Results: After evaluation of 960 patients, 7 (0.7%) were considered to have undergone inappropriate procedures and 76 (7.9%) were judged to be uncertain. Differences were found in the rate of appropriateness among some centres (inappropriateness rate ranging from to 0 to 2.6%). No differences were found among the appropriateness categories for length of stay or complications, mortality, or readmission up to the third month after discharge. Conclusions: This study identified a low percentage of inappropriately performed cholecystectomies in our area. Even so, appropriateness differences among hospitals were found.

Postoperative biliary tract lesions are becoming increasingly common. The diagnosis is made by direct cholangiography via endoscopic retrograde cholangiopancreatography (ERCP) or percutaneous transhepatic cholangiography (PTC). The present comparative study evaluates the diagnostic efficacy of magnetic resonance cholangiopancreatography (MRCP) in application to iatrogenic bile duct injury. A prospective blind study was performed, contrasting MRCP and ERCP in 10 patients with suspected postoperative biliary tract lesions. MRCP was performed less than 72 h before ERCP. Final diagnosis was made on the basis of findings at surgery and ERCP. The presence of biliary dilatation, excision injury, stricture, fluid collection and free fluid was analyzed. The mean patient age was 66.5 years. There were three males and seven females. The type of postoperative lesion (Bergman classification) are five patients type C, three type D, one type B and one type A. Diagnostic failure was recorded in two cases with ERCP, while in five patients it was unable to define a therapeutic approach. In contrast, MRCP correctly diagnosed all patients. MRCP is effective in diagnosing postoperative biliary tract lesions, and can help decide the best therapeutic approach.

Background Few studies have assessed health-related quality of life (HRQoL) among patients undergoing cholecystectomy. This study aimed to determine clinical variables that predict changes in HRQoL following cholecystectomy. Methods This was a prospective study of consecutive patients undergoing elective cholecystectomy for gallstones in six hospitals. Patients were asked to complete two questionnaires—the Short Form 36 (SF-36) and the Gastrointestinal Quality of Life Index (GIQLI)—before and 3 months after cholecystectomy. Multivariate linear regression models were used to examine factors potentially contributing to changes in HRQoL. Results Patients with symptomatic cholelithiasis and low surgical risk experienced the highest HRQoL gains in several SF-36 and GIQLI domains, with significant improvements in physical function detected by both instruments, compared with asymptomatic individuals at high surgical risk. Patients with asymptomatic cholelithiasis or high surgical risk experienced least improvement. Conclusion These data indicate that cholecystectomy is appropriate for patients with symptomatic cholelithiasis and low surgical risk. In terms of HRQoL, the risk to benefit ratio seems poor for patients with asymptomatic gallstones.

Background: Few studies have assessed the health outcomes of patients who underwent cholecystectomy. The goal of this study was to evaluate the health-related quality-of-life (HRQoL) improvement of patients undergoing laparoscopic versus open cholecystectomy. Methods: A prospective observational study was performed of consecutive patients on waiting lists to undergo cholecystectomy for nonmalignant disease in six hospitals. Patients were asked to complete two questionnaires that measure (HRQoL)—the SF-36 and the Gastrointestinal Quality of Life Index (GIQLI)—before the intervention and 3 months later. Results: Improvement after surgery, measured by the SF-36 and GIQLI, was similar for both surgical techniques. The SF-health transition item showed a perception of worse health, compared to 1 year previously, for those who underwent open surgery and complications were also higher. Conclusions: HRQoL improvement at 3 months was relevant and similar for both surgical techniques, although the health transition perception was worse for those who underwent open surgery.

OBJECTIVE: To date, ERCP has been the reference technique in the diagnosis of pancreatic duct pathology. The aim of the present study was to evaluate the accuracy of magnetic resonance cholangiopancreatography (MRCP), a relatively new, noninvasive diagnostic method, in studying the pancreatic duct. METHODS: A prospective 15-month study was done of 78 patients with suspected biliopancreatic pathology and indications for ERCP. In all cases, MRCP was performed

Background: The rendezvous technique combines endoscopy with percutaneous transhepatic cholangiography to facilitate cannulation of the bile duct when previous attempts have failed. Methods: Over a 7-year period, a total of 1753 ERCPs were performed. Twelve of these patients with a diagnosis of choledocholithiasis were poor candidates for surgery. Percutaneous transhepatic cholangiography as well as ERCP with precut papillotomy failed to resolve biliary obstruction. In a further 2 cases the percutaneous approach was used by means of a T-tube positioned at a prior cholecystectomy. Observations: The combined procedure was successful in 13 patients (93%). It was unsuccessful in 1 patient because of a stone lodged distally near the papilla. There was only 1 complication (7%), a retroperitoneal perforation that occurred during papillotomy; no mortality was directly attributable to the technique. Conclusions: The rendezvous technique is recommended for patients who are not eligible for surgery when ERCP is unsuccessful and when it is impossible to resolve biliary obstruction by percutaneous transhepatic cholangiography.

Introduccion Se dispone de pocos datos sobre la duracion de la respuesta de la leucocitoaferesis en CU, con vistas a establecer la necesidad o no de mantenimiento Objetivo Evaluar la eficacia al ano de la leucocitoaferesis en CU corticodependiente y la importancia de la respuesta clinica y endoscopica inicial. Material y metodos Estudio prospectivo, abierto en 18 pacientes (12V/6M) con CU corticodependiente tratados con leucocitoaferesis. En 17, tras fracaso o intolerancia a inmunomoduladores tiopurinicos; en 2 tras fracaso a metotrexate y en 3 a infliximab.Se realizaron sesiones semanales de aferesis por via periferica en 16 casos y central en 2. Cuatro pacientes se trataron con 10 sesiones, dos con 6 y doce con 5 sesiones. Se realizo una evaluacion clinica, analitica y endoscopica (indice de la Clinica Mayo) al mes de la ultima aferesis, a los 6 y 12 meses.Se considero remision clinica un indice ⩽2 asociado a retirada completa de corticoides; respuesta el descenso ⩾3 puntos sobre el basal y remision endoscopica un subindice de 0 o 1 sin corticoides. Se analizo la eficacia en todos los pacientes al ano Resultados Remision inicial: clinica 10 casos (55%) y endoscopica 9 (50%); objetivandose una significativa correlacion entre remision clinica y endoscopica (r s =0,894; p Conclusiones 1) La leucocitoaferesis es una alternativa terapeutica en CU corticodependiente. En la mitad de los casos su eficacia se mantiene al ano sin necesidad de reintroducir corticoides u otros tratamientos. 2) La respuesta parcial inicial se sigue de pobres resultados a largo plazo. 3) La remision clinica completa y la curacion endoscopica parecen importantes para lograr un respuesta duradera. 4) Son necesarios estudios que evaluen factores de respuesta duradera con vistas a seleccionar candidatos a tratamiento de mantenimiento.

surgery was 40.4% at one year and 59.3% at two years with a median time to surgery of 22 months (range 0.5 84 months). Patients who were steroid refractory, or dependent, prior to starting tacrolimus were more likely to have surgery (P= 0.006), while patients who were able to achieve or maintain a clinical response with tacrolimus by 90-days were less likely (P= 0.004). Conclusions: Tacrolimus is able to induce a clinical response in a third and remission in a fifth of medically refractory IBD patients at one year. A 90 day therapeutic trial is worthwhile in difficult to treat patients.

To study the prognosis (recurrence and mortality) of patients with ischemic colitis (IC).This study was conducted in four Spanish hospitals, participants in the Ischemic Colitis in Spain study We analyzed prospectively 135 consecutive patients who met criteria for definitive or probable IC according to Brandt criteria, and follow up these patients during the next five years, retrospectively. Long-term results (recurrence and mortality) were evaluated retrospectively after a median interval of 62 mo (range 54-75 mo).Estimated IC recurrence rates were 2.9%, 5.1%, 8.1% and 9.7% at years 1, 2, 3 and 5 years, respectively. Five-year survival was 69% (93 of 135) and 24% (10 of 42 patients) died for causes related to the IC. Among these 10 patients, 8 died in their first episode at hospital (4 had gangrenous colitis and 4 fulminant colitis) and 2 due to recurrence.The five-year recurrence rate of IC was low. On the other hand, mortality during follow-up was high and was not associated with ischemic colitis.

Shortand Long-Term Outcomes of Infliximab Dose Intensification in Patients With Ulcerative Colitis Carlos Taxonera, Manuel Barreiro-de Acosta, Marta Calvo, Cristina Saro, Guillermo Bastida, Maria Dolores Martin Arranz, Javier P. Gisbert, Valle Garcia-Sanchez, Ignacio Marin-Jimenez, Fernando Bermejo, Maria Chaparro, Angel Ponferrada Diaz, Ignacio Fernandez-Blanco, Pilar Martinez-Montiel, R. Pajares, Celia de Gracia, David Olivares, Fermin Estremera Arevalo, Juan L. Mendoza

M.J. Casanova1, M. Chaparro1 *, E. Domenech2, M. Barreiro-de Acosta3, F. Bermejo4, E. Iglesias5, F. Gomollon6, L. Rodrigo7, X. Calvet8, M. Esteve9, E. Garcia-Planella10, S. Garcia11, C. Taxonera12, M. Calvo13, M. Lopez14, D. Ginard15, M. Gomez16, E. Garrido17, J. Perez-Calle18, B. Beltran19, M. Piqueras20, C. Saro21, B. Botella22, C. Duenas23, A. Ponferrada24, M. Manosa2, M. Iglesias3, A. Algaba4, V. Garcia-Sanchez5, J. Mate1, J.P. Gisbert1. 1Hospital Universitario de La Princesa, IP, Gastroenterology and CIBEREHD, Madrid, Spain, 2Hospital Germans Trias i Pujol, Badalona, Spain, 3Hospital Clinico Santiago, Santiago de Compostela, Spain, 4Hospital de Fuenlabrada, Madrid, Spain, 5Hospital Reina Sofia, Cordoba, Spain, 6Hospital Clinico Lozano Blesa, Zaragoza, Spain, 7Hospital Central de Asturias, Asturias, Spain, 8Hospital Parc Tauli, Barcelona, Spain, 9Hospital Mutua de Terrassa, Terrassa, Spain, 10Hospital Santa Creu i Sant Pau, Barcelona, Spain, 11Hospital Miguel Servet, Zaragoza, Spain, 12Hospital Clinico San Carlos, Madrid, Spain, 13Hospital Puerta de Hierro, Madrid, Spain, 14Hospital de Galdakao, Galdakao, Spain, 15Hospital Son Espases, Mallorca, Spain, 16Hospital Virgen de Las Nieves, Granada, Spain, 17Hospital Ramon y Cajal, Madrid, Spain, 18Hospital Fundacion Alcorcon, Madrid, Spain, 19Hospital La Fe, Valencia, Spain, 20Consorcio Sanitario Terrassa, Terrassa, Spain, 21Hospital de Cabuenes, Gijon, Spain, 22Hospital Infanta Cristina, Madrid, Spain, 23Hospital San Pedro Alcantara, Caceres, Spain, 24Hospital Infanta Leonor, Madrid, Spain

Long-Term Durability of Response to Adalimumab Treatment in Crohn's Disease Maria Chaparro, Julian Panes, V. Garcia, Olga Merino, Pilar Nos, Eugeni Domenech, Mireia Penalva, Esther Garcia-Planella, Maria Esteve, Joaquin Hinojosa, Montserrat Andreu, Fernando Munoz, Ana Gutierrez, Juan L. Mendoza, Jesus Barrio, Manuel Barreiro, Isabel Vera, Pere Vilar, Jose Luis Cabriada, Miguel A. Montoro, Xavier Aldeguer Mante, Cristina Saro, Javier P. Gisbert

Introduccion La historia natural de la C.I no es bien conocida y hasta el momento no se han realizado estudios que hayan investigado de un modo prospectivo el pronostico de estos pacientes. Objetivo Evaluar de un modo prospectivo los factores que pueden predecir un curso desfavorable en los pacientes con C.I. Metodo Entre septiembre de 2005 y marzo de 2007 se reclutaron todos los pacientes con un diagnostico definitivo o probable de C.I., en 24 hospitales con un area de influencia global de 3,5×105 habitantes. Se excluyeron los casos con sospecha clinica no confirmada por colonoscopia, USD-Doppler, TC-abdominal, laparotomia o necropsia (casos posibles). En todos los casos se recogio informacion relativa a sintomas y signos en el momento de presentacion, datos de laboratorio, localizacion del segmento afectado y patrones evolutivos. Una website ( www.colitisisquemica.org ) proporciono un soporte electronico para la recogida de datos. El analisis uni y multivariable permitio definir las variables con valor predictivo independiente para el desarrollo de un curso desfavorable, definido por la necesidad de cirugia o mortalidad. Resultados 364 pacientes reunieron criterios de inclusion para el estudio [x: 73,7±10 anos, 57 mujeres]. Un total de 317 pacientes (87,1%) tuvieron un curso favorable, mientras que 47 (12, 9%) mostraron un curso desfavorable. 28 pacientes (7,7%) fallecieron como consecuencia de la enfermedad. El curso desfavorable fue mas frecuente en las formas gangrenosas (77,8% vs 2,5%; p Conclusiones 1. La mayoria de los pacientes con C.I. presentan un curso favorable. 2. Ademas de la presencia de signos peritoneales, los pacientes que presentan dolor abdominal sin rectorragia o diarrea no sanguinolenta presentan mayor probabilidad de un curso desfavorable. 3. En la C.I. la afectacion aislada del colon derecho comporta un mayor riesgo de cirugia y/o mortalidad.

Antecedentes Existe poca informacion sobre la duracion de la respuesta a IFX en los pacientes con enfermedad de Crohn que reciben este tratamiento durante un periodo de tiempo superior a 12 meses. En los pacientes en los que se pierde la respuesta inicial, se puede “intensificar” el tratamiento con IFX (aumentar la dosis o acortar los intervalos entre las dosis) para mantener el beneficio terapeutico. Objetivos El objetivo primario de nuestro estudio fue evaluar la respuesta a largo plazo del tratamiento de mantenimiento con IFX. El objetivo secundario fue valorar la eficacia de la intensificacion del tratamiento con IFX en aquellos pacientes que habian perdido la respuesta inicial. Metodos Evaluamos de forma retrospectiva una cohorte de pacientes con EC que habian recibido tratamiento con IFX (induccion y mantenimiento) y en los que se habia observado respuesta inicial. Los datos fueron obtenidos a partir de una base de datos espanola de enfermedad inflamatoria intestinal (ENEIDA). El estudio de la respuesta a largo plazo se analizo mediante el metodo de Kaplan-Meier. Se analizo la eficacia de la intensificacion del tratamiento en aquellos pacientes que habian perdido respuesta al IFX. Resultados Se incluyeron 309 pacientes con EC (media de edad 39 anos, 55% mujeres, 33% fumadores) que inicialmente habian respondido al tratamiento con IFX. El 61% de los pacientes presentaba afectacion ileocolica, el 57% patron inflamatorio y el 45% enfermedad perianal. La media de tiempo en seguimiento de los pacientes fue de 41 meses (rango de 4 a 108 meses), y la mayoria (95%) recibia tratamiento concomitante con inmunosupresores. La perdida de respuesta a IFX se produjo una mediana de 13 meses despues de haber iniciado el tratamiento con IFX. El riesgo de perdida de respuesta al tratamiento con IFX por paciente y ano de seguimiento fue del 12%. Ante la perdida de respuesta, un 53% de los pacientes iniciaron tratamiento con adalimumab y un 41% recibieron IFX a dosis intensificada (un 51% aumentando la dosis a 10 mg/kg de peso y un 49% disminuyendo el intervalo de tiempo entre dosis). El 96% de los pacientes que iniciaron tratamiento con IFX a dosis intensificada tuvieron respuesta inicial (con la primera dosis intensificada): el 56% respuesta completa y el 40% respuesta parcial. Conclusiones Un porcentaje relevante de pacientes con EC presenta perdida de respuesta al tratamiento con IFX a largo plazo (aproximadamente un 10% por paciente y ano de seguimiento). Tras la perdida de respuesta, una elevada proporcion de estos pacientes responden inicialmente a la intensificacion de la dosis de IFX.

Objetivo En ocasiones, la infeccion por H. pylori persiste a pesar de haber administrado 3 tratamientos erradicadores consecutivos. Se desconoce hasta que punto merece la pena (en cuanto a eficacia y seguridad) intentar un 4° tratamiento erradicador en estos casos refractarios. Nuestro objetivo fue evaluar la eficacia de un 4° tratamiento de rescate empirico (con rifabutina o con levofloxacino) en pacientes en los que habian fracasado previamente 3 intentos erradicadores. Metodos 45 pacientes con tres fracasos consecutivos en la erradicacion de H. pylori fueron incluidos prospectivamente. En todos ellos se habia administrado un 1 er tratamiento con IBP-claritromicina-amoxicilina y un 2° tratamiento con cuadruple terapia (IBP-bismuto-tetraciclina-metronidazol). En 13 de ellos se habia pautado un 3 er tratamiento con IBP-amoxicilina-rifabutina, por lo que se administro un 4o tratamiento con IBP, amoxicilina (1 g/12 h) y levofloxacino (500 mg/12 h) durante 10 dias. En los 32 restantes se habia pautado un 3 er tratamiento con IBP-amoxicilina-levofloxacino, por lo que se administro un 4° tratamiento con IBP, amoxicilina (1 g/12 h) y rifabutina (150 mg/12 h) durante 10 dias. La susceptibilidad antibiotica se desconocia y, por lo tanto, los tratamientos de rescate fueron prescritos empiricamente. La erradicacion se comprobo mediante prueba del aliento con 13 C-urea. Resultados 13 pacientes recibieron un 4° tratamiento con levofloxacino y 32 con rifabutina. Todos los pacientes menos tres (todos del grupo de rifabutina) completaron el seguimiento. El cumplimiento terapeutico del grupo tratado con levofloxacino fue del 100%, mientras que 3 pacientes del grupo que recibio rifabutina no tomaron correctamente la medicacion (por efectos adversos: fiebre, mialgia, dolor abdominal y diarrea en un caso, y vomitos en otros dos). La incidencia de efectos adversos con el 4° tratamiento de rescate con rifabutina fue del 33% (ninguno de ellos grave; a destacar leucopenia y trombopenia autolimitada en sendos pacientes) y del 46% en aquellos que recibieron levofloxacino (fundamentalmente mialgias). La tasa global de erradicacion con el cuarto tratamiento “por protocolo” y “por intencion de tratar” fue, respectivamente, del 52% (IC 95%, 36–67%) y del 51% (IC 95%, 35–66%). Las tasas de erradicacion “por intencion de tratar” con levofloxacino y con rifabutina como 4o tratamiento fueron, respectivamente, del 69% y del 44%. Conclusion Incluso tras el fracaso de 3 tratamientos previos, una cuarta terapia de rescate empirica (con levofloxacino o con rifabutina) puede ser efectiva para erradicar la infeccion por H. pylori en aproximadamente la mitad de los casos.

In the “Materials and methods” section, under the subheading “Statistical analysis,” it was stated that just patients with ASA IV were in the high surgical risk group, whereas the high surgical risk group included patients with ASA III and ASA IV.

Background and aims: Inflammatory bowel disease is a chronic disorder of the gastrointestinal tract. Tacrolimus is a calcineurin inhibitor used in the prophylaxis of rejection after a solid organ transplant. There is some evidence for its use in inflammatory bowel disease, although there is a lack of information about the patients who will benefit the most with this drug and the prognostic factors for a favorable response. Material and methods: We performed a multicentric retrospective study evaluating all the patients who have received tacrolimus in the last 10 years as a treatment for IBD in our area. Results: A total of 20 patients, 12 with Crohn’s disease and 8 with ulcerative colitis, were included in four hospitals. The two most common indications were steroid-dependency and fistulizing Crohn’s disease. The median time receiving tacrolimus was 11 months. In 12 patients the treatment was stopped. The main reasons for drug withdrawal were absence or loss of response. The median clinical follow-up was 35.5 months. Overall, a 25% achieved clinical remission and 40% were in partial response. Biologic-naive patients demonstrated a significantly better remission rate as compared with those that were not (80 vs. 7%). Patients who achieved remission were more likely to have a significant reduction in C-reactive protein values 1 month after starting the drug. Seven patients required surgery during the follow- up period. Conclusions: Patients naive to biologics showed a significantly better response to tacrolimus. A reduction in C-reactive protein one month after starting this drug was associated with clinical remission.

Most intussusception cases in adults have an organic cause and their treatment is surgical. In some cases, there is no injury associated with intussusception and we can opt for conservative management. In our clinical practice we have shown the presence of intussusceptions in the absence of structural damage associated with chronic cannabis with a good course after conservative management. We describe three cases of recurrent intussusception in cannabis users, suggesting a relationship between cannabis use and the incidence of intussusception.

Objectives To investigate the diagnostic efficacy of magnetic resonance cholangiopancreatography (MRCP) in choledocholithiasis and to determine whether use of MRCP may eliminate the need for purely diagnostic endoscopic retrograde cholangiopancreatography (ERCP). Patients and Methods A total of 116 patients with suspected biliopancreatic pathology were studied prospectively between November 1996 and February 1998. Choledocholithiasis was initially suspected in 61 patients and rated before ERCP and MRCP as being of low, intermediate, or high probability based on clinical, laboratory, and/or imaging findings (Cotton criteria). Results The sensitivity of choledocholithiasis diagnosis was 91%, with a global efficacy of 90%. The level of duct stone obstruction was visualized in all patients. Suprastenotic dilatation also showed a good correlation to ERCP. Choledocholithiasis was found in 32 patients (65%) and 3 patients (33%) in the high- and intermediate- probability groups, respectively. None of the low-probability patients had choledocholithiasis. Endoscopic retrograde cholangiopancreatography was performed for only a diagnostic (not therapeutic) purpose in 3 patients (6%) and 2 patients (22%) of the high- and intermediate- probability cases, respectively. Conclusions Magnetic resonance cholangiopancreatography seems to be effective in diagnosing choledocholithiasis. It plays a fundamental role in patients with a low or intermediate risk of choledocholithiasis, contributing to the avoidance of purely diagnostic ERCP.