Long-Term Self-Expandable Metal Stent (SEMS) for Esophageal Variceal Bleeding: A Picture of the Natural History

INTRODUCTION

We aim to discuss the utility of self-expandable esophageal metal stent (SEMS) in variceal bleeding in challenging cases.

METHODS

Case description, discussion on patient management and decision-making process in an uncommon situation, from a multidisciplinary point of view.

RESULTS

We report a case of a cirrhotic patient with refractory variceal bleeding who underwent a SEMS placement, which remained in situ for 9 months. This decision was based on the initial poor status and short life expectancy, limiting the consideration of other options for lowering portal hypertension, along with an underlying prothrombotic predisposition. However, the patient's general and hepatic improvement and the development of dysphagia led to the SEMS removal, exposing a large esophageal-tracheal fistula.

DISCUSSION

Early patient evaluation, risks of long-term SEMS, and life expectancy should be taken in consideration before SEMS placement.

Endoscopic Treatment of Early Gastric Obstruction After Sleeve Gastrectomy: Report of Two Cases

Morbid obesity is an epidemic and complex disease which imposes a multidisciplinary approach. Laparoscopic sleeve gastrectomy has become a frequent procedure given its efficacy and safety compared to other surgical options. However, it isn’t free from complications. Lax gastric fixation or incorrect positioning of the stomach during surgery can result in early gastric outlet obstruction caused by a volvulus-like mechanism by rotation of the stomach around its anatomic axes. This report refers to two cases of post sleeve gastric torsion resulting in persisting vomiting after initiating oral intake. The diagnosis was confirmed by upper gastrointestinal-contrast study and gastroscopy. In both cases, a fully covered self-expandable metallic stent was inserted which prompted the gastric lumen to become permeable resulting in symptomatic resolution. The stents were removed endoscopically after two and three months. Beyond more than three years of follow-up, the patients remain asymptomatic and no recurring “stenosis” was noticed. In these cases the use of fully covered self-expandable metallic stents demonstrated to be effective and safe in the treatment of post sleeve gastric torsion.

[Prognostic value of the finding of blood/clots in the stomach at the emergency upper endoscopy]

INTRODUCTION

In the setting of upper endoscopy after upper gastrointestinal bleeding (UGIB), the presence of blood or clots in the gastric lumen precluding the complete mucosal examination is a frequent finding.

AIMS

To define the prognostic value of this endoscopic finding and the need of a follow-up endoscopy.

METHODS

Retrospective study of 100 consecutive patients with UGIB and the endoscopic finding of blood in the stomach (Group A) and 100 at the same conditions but without this endoscopic finding (Group B). In both groups we compared the bleeding lesions and the presence of clinic, laboratorial and endoscopic signs of severity.

RESULTS

Gastric and duodenal ulcers were the bleeding lesions more frequently identified in both groups. Lesions related to portal hypertension were more frequent in the first than in the second one. There was also a significant association with other endoscopic signs of severe haemorrhage and with the clinical signs of bad prognosis. In the follow-up endoscopy we found new lesions in 46% of the patients in the first group and only in 15% of the second one.

CONCLUSIONS

The endoscopic finding of blood or clots in the stomach should be considered as a bad prognostic sign and lead to a second endoscopy.

[Malignant peritoneal mesothelioma -- diagnostic and therapeutic difficulties]

Malignant Peritoneal Mesothelioma (MPM) is an uncommon tumour. Clinical presentation is indefinite and differential diagnosis with peritoneal carcinomatosis is difficult. It has a bad prognosis (survival of 6-12 months) due to the delay of the diagnosis and inefficacy of the conventional therapeutic. The authors present a case of MPM which was diagnosed over the investigation of ascitis. The laparoscopic peritoneal biopsy permitted the diagnosis. After systemic quimiotherapy, the patient is in partial remission at 42 months of follow-up.