[Predictive pre-treatment value of the Prognostic Nutritional Index on survival in gastric carcinoma]

BACKGROUND

The Prognostic Nutritional Index (PNI) combines the values of circulating lymphocytes and serum albumin and, in the Asian literature; it has been related with the prognosis following R0 resection of gastric cancer. No results are available in Western countries. We study the possible independent prognostic value, at the moment of the tumour's diagnosis, of PNI on survival.

PATIENTS AND METHODS

We review 234 consecutive gastric carcinomas, calculating global survival and tumour-specific survival. We considered pre-treatment PNI values of < 40 to be pathological. We carried out a univariate and multivariate analysis of cases of survival according to PNI, including the following adjustment variables: age > 70 years, ASA anaesthetic at the time of diagnosis, size of the neoplasia > 5cm, macroscopic type, undifferentiated degree and TNM clinical stage through echoendoscopy and/or CAT.

RESULTS

The univariate analysis registered greater global and specific survival in cases with PNI ≥ 40 versus PNI < 40: [HR = 2.28; CI 95% = (1.60-3.26); p< 0.001] and [HR = 2.35; CI 95% = (1.63-3.39); p< 0.001], respectively. The multivariate analysis confirmed a better independent prognosis in cases with OI ≥ 40: global survival: [HR = 1.48; CI 95% = (1.02-2.16); p = 0.040], specific survival: [HR = 1.51; CI 95% = (1.03-2.23); p = 0.036].

CONCLUSIONS

At the moment of diagnosis of gastric cancer and including all registered cases, a PNI ≥ 40 is accompanied by a signifi-cantly greater global and tumour-specific survival. In our series, this better prognosis is independent of the patient's age group, his/her ASA classification, the size and degree of differentiation of the neoplasia and its TNM clinical stage.

[Relation between preoperative prognostic Onodera's Index and postsurgery complications in the R0 gastric carcinoma resection]

BACKGROUND

It has been postulated in the Asian literature that a low prognostic nutritional index (OI) could be associated with a higher rate of complications following radical gastric cancer surgery, but there is a lack of data concerning western countries. The aim is to analyze the relationship between a low preoperative OI and the frequency and severity of surgical complications in R0 gastric cancer resection.

PATIENTS AND METHODS

In the present article, 124 cases of gastric cancer with R0 resection were reviewed. An OI <45 was considered pathologically low. The complication rate was compared between both groups: OI <45 vs OI =45. A multivariate analysis was performed adjusting for: age > 68 years, ASA score, preoperative hemoglobin level <12 g/dL, pTNM stage, administration of neoadyuvant therapy and type of gastrectomy. The relationship between a PNI<45 and the severity of complications graded according to the Clavien-Dindo classification was determined.

RESULTS

We registered mild complications in 11.3% of cases, severe complications in 9.7% and a mortality rate of 2.4%. Patients with a OI <45 showed a higher complication rate: 37.7% versus 12.7% [odds ratio (OR) = 4.17; CI95% = (1.71 - 10.20 p = 0.001)], confirmed by multivariate analysis: [OR = 4.17; CI95% = (1.54 - 11.30); p = 0.005]. Patients with OI <45 had more severe complication-exitus: 20.8% versus 5.6% [OR = 4.39; CI95% = (1.31 - 14.68); p = 0.011].

CONCLUSIONS

We confirmed that patients with a low preoperative OI show a higher independent risk of complications after a R0 gastric cancer resection in a western country as well. Complications, in these cases with OI <45, registered a significantly higher severity grade.

Pretreatment predictive value of blood neutrophil/lymphocyte ratio in R0 gastric cancer resectability

INTRODUCTION

New parameters complementary to clinical TNM classification are needed, to orient preoperative on the possibility of a R0 gastric cancer resection. We analysed the possible predictive value of blood neutrophil/lymphocytic ratio (N/L) in relation to resectability.

METHODS

Two hundred and fifty-seven gastric cancers consecutively diagnosed and without neoadjuvant treatment were retrospectively studied. Univariate and multivariate analysis of the frequency of R0 cases was performed between groups with a normal N/L ratio (<5) and pathological N/L ratio (≥5). Furthermore, we studied the subgroup of operated patients (n=156) analysing the frequency of R0 resection according to N/L ratio<5 or≥5.

RESULTS

One hundred and fifty-six patients underwent surgical intervention, of which 139 had R0 resections. A high N/L ratio was registered in 46 cases (17.9%). Globally, resectability was higher in patients with a N/L ratio<5: 59.7% vs. N/L ratio≥5: 28.6% (P<.001; OR=3.76; 95% CI=1.78-8.04). The relation between N/L ratio<5 and R0 resection was confirmed in the multivariate (P=.006; OR=3.86; 95% CI=1.46-10.22). In the operated subgroup, the higher frequency of R0 resection achievement is maintained in cases with N/L ratio<5: 91.3% vs. 72.2% (P=.015; OR=4.04; 95% CI=1.23-13.26).

CONCLUSIONS

The presence of a N/L ratio<5 at the diagnosis of a gastric carcinoma is related in a significant and independent way with a higher frequency of R0 tumoral resection, globally. This higher proportion of R0 resection cases in patients with a N/L<5 ratio is confirmed in the subgroup of operated patients.

Prevalence of severe esophagitis in Spain. Results of the PRESS study (Prevalence and Risk factors for Esophagitis in Spain: A cross-sectional study)

BACKGROUND

*N.P. and M.P. contributed equally to this study.The current prevalence of esophagitis in southern Europe is unknown. In addition, the risk factors for reflux esophagitis are not fully understood.

OBJECTIVE

The objective of this article is to assess the prevalence and risk factors for esophagitis in Spain.

METHODS

A prospective, observational, cross-sectional, multicenter study (PRESS study) was conducted among 31 gastrointestinal endoscopy units throughout Spain. A total of 1361 patients undergoing upper gastrointestinal endoscopy were enrolled. Sociodemographic, clinical and treatment data were recorded.

RESULTS

A total of 95% of patients were Caucasian and 52% were male (mean age: 53 ± 17 years). The most frequent symptoms prompting endoscopy were heartburn (40%), regurgitation (26%) and dysphagia (15%). Fifty-four percent of patients undergoing endoscopy were receiving proton pump inhibitor (PPI) treatment. Esophagitis (mainly mild-moderate) was present in 154 (12.4%) patients. The severe form was recorded in only 11 (0.8%) patients. Multivariate analysis results indicated that the likelihood of esophagitis was higher in men (OR = 1.91, 95% CI = 1.31-2.78), in patients with high GERD-Q scores (OR = 1.256, 95% CI = 1.176-1.343), weight increase (OR = 1.014, 95% CI = 1.003-1.025) and high alcohol consumption (OR = 2.49, 95% CI = 1.16-5.36).

CONCLUSION

Severe esophagitis is a rare finding in the Spanish population. Male gender, high GERD-Q score, weight increase and high alcohol consumption are main risk factors for its appearance.

[Prognostic value of preoperative carcinoembryogenic antigen: Is it useful in all stages of colorectal cancer?]

INTRODUCTION

Recent reports have reopened discussion of the prognostic value of elevated pre-treatment carcinoembryonic antigen (CEA) levels in colorectal cancer. Due to the discrepancies in the published results, we aimed to analyze the possible predictive value of CEA, both overall and in different tumoral stages in our environment.

PATIENTS AND METHODS

We retrospectively studied 303 consecutive patients with colorectal cancer resected with curative intent by analysing tumor-related mortality. The frequency of patients with increased CEA levels (> 5mg/l) was registered. Univariate and multivariate analyses of survival curves were performed, comparing patients with increased CEA levels and those with CEA levels within normal limits, both in the overall series and in the different pTNM tumoral stages.

RESULTS

Frequency of patients with CEA>5mg/l was 31%. The median clinical follow-up was 83 months. A poor survival rate was registered in the multivariate analysis of the whole series in patients with high CEA levels: hazard ratio (HR)=1.81; 95% confidence interval (95% CI)=(1.15-3.10); P=.012. This predictive value was only maintained in stage II in the survival analysis of the distinct tumoral stages (n=104): HR=3.02; 95% CI=(1.22-7.45); P=.017.

CONCLUSIONS

Before treatment, 31% of our patients with colorectal cancer resected with curative intent had pathological CEA values. In the overall series, a high pretreatment CEA level showed an independent prognostic value for poor survival. When pTNM tumoral stages were analyzed separately, CEA level had predictive value only in pTNM II tumors.

[Prognostic value of Onodera's index in colorectal cancer survival]

BACKGROUND

Onodera's prognostic nutritional index (OPNI), which is calculated using total lymphocyte count and serum albumin level, has been used as a marker of nutritional status, with its potential prognostic value in colorectal cancer having recently been postulated in Japan and China. There is still no data on the predictive value of OPNI in a Western population.

PATIENTS AND METHODS

A consecutive case series of 207 patients scheduled for colorectal cancer resection with curative intent was reviewed. Pre-treatment OPNI was calculated using the formula: [10 x serum albumin (g/dl) + 0.005 x lymphocytes/mm²]. OPNI values under 40 were considered low. Univariate and multivariate analysis were performed on survival curves, comparing cases with OPNI values less than, equal to or greater than 40 (Cox model, stepwise), in the overall series and in pTNM stage II.

RESULTS

The median for clinical follow-up was 81 months (interquartile range 60-96). Twenty-six patients (12.6%) had a low OPNI (≤ 40). In the multivariate analysis, patients with low OPNI showed less favourable survival curves, both in the overall series: [p <0.001; HR = 3.16; 95% CI = 1.67-5.94] and in the 78 cases in pTNM stage II: [p <0.004; HR = 4.36; 95% CI = 1.61-11.76].

CONCLUSIONS

A low pre-treatment OPNI (<40) has an independent, unfavourable predictive value on survival in European patients with resected colorectal cancer, both in the overall series and in pTNM stage II.

[Does endoscopist fatigue play a role in incomplete colonoscopies and detection of polypoid lesions?]

INTRODUCTION

Nowadays, the possible effect of endoscopist fatigue on the results of colonoscopies is under discussion. We aimed to analyze possible differences in cecal intubation and the polyp and adenoma detection rate, depending on whether colonoscopies were performed at the beginning or at the end of the daily endoscopy session and to analyze the influence of the queue position on the detection rate.

PATIENTS AND METHODS

A retrospective study was performed with 1,000 ambulatory and consecutive colonoscopies, divided into 2 groups: «early» and «late» procedures. A total of 95 colonoscopies were excluded due to poor colon cleansing. After confirming that patient characteristics were homogenous in the two groups, we compared the frequency of complete colonoscopies and the polyp and adenoma detection rate. Possible differences between the 2 groups in the polyp detection rate according to the colonoscopy schedule were analyzed.

RESULTS

The overall polyp and adenoma detection rates were 44.2 and 30.5%, respectively, with no significant differences among 13 different endoscopists; polyps: p = 0.21; adenomas: p=0.63. No significant differences were found between the «early group» (n= 532) and the «late group» (n = 373) in the rates of complete colonoscopies [97.2 vs 99.4% (p=0.92)], the polyp detection rate [45.9 vs 41.8% (p=0.23)], the adenoma detection rate [30.8 vs 30% (p=0.80)] or the serrated adenoma rate [2.1% vs 1.6% (p=0.62)]. The lesion detection rate did not vary in relation to the «queue position»: polyps [p = 0.60, and adenomas: p = 0.83.

CONCLUSIONS

In our series, endoscopist fatigue at the end of the day had no influence on the complete colonoscopy rate or on the polyp and adenoma detection rate. There were no differences in the number of polypoid lesions detected according to the timing of the colonoscopy schedule.

Endoscopic localization of colorectal cancer: study of its accuracy and possible error factors

INTRODUCTION

accurate preoperative localization of colorectal cancer (CRC) is very important, with a wide range of published error rates.

AIMS

to determine accuracy of endoscopic localization of CRC in comparison with preoperative computed tomography (CT). To analyse variables that could be associated with a wrong endoscopic localization.

PATIENTS AND METHODS

endoscopic and CT localization of a series of CRC without previous surgery were reviewed. We studied the concordance between endoscopic and radiologic localization against operative findings comparing accuracy of endoscopy and CT. We analysed the frequency of wrong endoscopic diagnoses with regard to a series of patient, endoscopy and tumor variables.

RESULTS

two hundred thirty seven CRC in 223 patients were studied. Concordance with surgical localization was: colonoscopy = 0.87 and CT = 0.69. Endoscopic localization accuracy was:91.1%; CT: 76.2%: p = 0.00001; OR = 3.22 (1.82-5.72). Obstructive cancer presented a higher rate of wrong localization: 18 vs. 5.7% in non-obstructive tumors (p = 0.0034; OR = 3.65 (1.35-9.96). Endoscopic localization mistakes varied depending on tumor location, being more frequent in descending colon: 36.3%, p = 0.014; OR = 6.23 (1.38-26.87) and cecum: 23.1%, p = 0.007; OR = 3.92 (1.20-12.43).

CONCLUSIONS

endoscopic accuracy for CRC localization was very high and significantly better than CT accuracy. Obstructive tumor and those located in the descending colon or cecum wereassociated with a significant increase of the error risk of CRC endoscopic localization.

[Tissue expression of mismatch repair proteins and tumor lymphocytic infiltration: prognostic significance in resected colorectal carcinoma]

BACKGROUND

In colorectal cancer there is discussion about the possible relation between the mismatch repair protein expression (MMRPE) and tumour lymphocytic infiltration (TLI), as well as the possible prognostic effect of both factors.

METHODS

A review was made of 243 colorectal cancers, consecutively resected. We made an immunohystochemical study of the MMRPE of MLH1, MSH2 and MSH6. The TLI was evaluated through CD3 staining in the tumoural epithelium. We compared mortality and post-operative tumoural progression amongst the cases with and without MMRPE and with and without TLI. Additionally, we studied mortality and tumoural progression amongst MMRPE (+) cases, according to whether or not they presented TLI.

RESULTS

Thirteen point six percent of the tumours expressed MMRPE (+) and 25.5% TLI (+). The follow-up was: 73.8±34.6 months. The frequency of TLI (+) turned out to be similar between MMRPE (+) tumours: 27.3% and MMRPE (-): 25.2% (p = 0.80). The MMRPE (+) cases showed less mortality: 12.1% versus 23.3% (p = 0.15) and less tumoural progression: 21.2% versus 29% (p = 0.35). The ITL neoplasias (+) had a lower mortality: 9.7% versus 26% [p = 0.007; OR = 3.27(1.25-9.05)] and tumoural progression: 12.9% versus 33.1% [p = 0.002; OR = 3.35 (1.42-8.15)]. The 9 MMRPE (+) and ILT (+) tumours did not present mortality or tumoural progression, against a mortality: 16.7% and progression: 29.2% of the 24 MMRPE (+) and TLI (-) cases p = 0.19 and p = 0.07 respectively.

CONCLUSIONS

No relation was found between MMRPE and TLI, with very similar rates of TLI (+) between cases with and without MMRPE. The LTI (+) showed a favourable prognostic effect higher than that of the MMRPE (+). The combination of LTI (+) and MMRPE (+) seems to have an accumulative protective effect, although its limited frequency reduces the significance of the finding.

Long-term follow-up of 1,000 patients cured of Helicobacter pylori infection following an episode of peptic ulcer bleeding

OBJECTIVES

To evaluate the effect of Helicobacter pylori (H. pylori) eradication on ulcer bleeding recurrence in a prospective, long-term study including 1,000 patients.

METHODS

Patients with peptic ulcer bleeding were prospectively included. Prior non-steroidal anti-inflammatory drug (NSAID) use was not considered exclusion criteria. H. pylori infection was confirmed by rapid urease test, histology, or (13)C-urea breath test. Several eradication therapies were used. Subsequently, ranitidine 150 mg o.d. was administered until eradication was confirmed by (13)C-urea breath test 8 weeks after completing therapy. Patients with therapy failure received a second, third, or fourth course of eradication therapy. Patients with eradication success did not receive maintenance anti-ulcer therapy and were controlled yearly with a repeat breath test. NSAID use was not permitted during follow-up.

RESULTS

Thousand patients were followed up for at least 12 months, with a total of 3,253 patient-years of follow-up. Mean age 56 years, 75% males, 41% previous NSAID users. In all, 69% had duodenal ulcer, 27% gastric ulcer, and 4% pyloric ulcer. Recurrence of bleeding was demonstrated in three patients at 1 year (which occurred after NSAID use in two cases, and after H. pylori reinfection in another one), and in two more patients at 2 years (one after NSAID use and another after H. pylori reinfection). The cumulative incidence of rebleeding was 0.5% (95% confidence interval, 0.16-1.16%), and the incidence rate of rebleeding was 0.15% (0.05-0.36%) per patient-year of follow up.

CONCLUSION

Peptic ulcer rebleeding virtually does not occur in patients with complicated ulcers after H. pylori eradication. Maintenance anti-ulcer (antisecretory) therapy is not necessary if eradication is achieved. However, NSAID intake or H. pylori reinfection may exceptionally cause rebleeding in H. pylori-eradicated patients.

Clinical patterns and outcomes of ischaemic colitis: results of the Working Group for the Study of Ischaemic Colitis in Spain (CIE study)

BACKGROUND

There is a lack of prospective studies evaluating the natural history of colonic ischaemia (CI). We performed such a study to evaluate the clinical presentation, outcome, and mortality as well as clinical variables associated with poor prognosis.

METHODS

An open, prospective, and multicentre study was conducted in 24 Spanish hospitals serving a population of 3.5 million people. The study included only patients who met criteria for definitive or probable CI. A website (www.colitisisquemica.org) provided logistical support.

RESULTS

A total of 364 patients met criteria for inclusion. CI was suspected clinically in only 24.2% of cases. The distribution of clinical patterns was as follows: reversible colopathy (26.1%), transient colitis (43.7%), gangrenous colitis (9.9%), fulminant pancolitis (2.5%), and chronic segmental colitis (17.9%). A total of 47 patients (12.9%) had an unfavorable outcome as defined by mortality and/or the need for surgery. Multivariate analysis identified the following signs as independent risk factors for an unfavorable outcome: abdominal pain without rectal bleeding [odds ratio (OR) 3.9; 95% confidence interval (CI) = 1.6-9.3], non-bloody diarrhoea (OR 10; 95% CI = 3.7-27.4), and peritoneal signs (OR 7.3; 95% CI = 2.7-19.6). Unfavorable outcomes also were more frequent in isolated right colon ischaemia (IRCI) compared with non-IRCI (40.9 vs. 10.3%, respectively; p < 0.0001). The overall mortality rate was 7.7%.

CONCLUSIONS

The clinical presentation of CI is very heterogeneous, perhaps explaining why clinical suspicion of this disease is so low. The presence of IRCI, and occurrence of peritoneal signs or onset of CI as severe abdominal pain without bleeding, should alert the physician to a potentially unfavorable course.

[Incidence and characteristics of eosinophilic esophagitis in adults]

Eosinophilic esophagitis (EE) is a disease characterised by the infiltration of esophageal mucous by eosinophils, whose incidence in adults seems to have been increasing in recent years, in a way that is similar to what is occurring with other diseases of a probable immunoallergic aetiology. It predominates in young adults and is mainly expressed by dysphagia and esophageal food impactation. Treatment is based on eliminating the allergen that is potentially involved and the administration of corticoids. This article offers a retrospective review of EE cases diagnosed in the Hospital de Navarra between January 2002 and August 2008, with 25 patients found, which represents an incidence of 2.13 cases/105 inhabitants/year. Seventy-two percent of our patients showed dysphagia and 52% a history of food bolus impaction, with endoscopic alterations found in 23 of the 25 cases. Out of 24 patients studied, 76% showed an alimentary allergy or neumoallergens, which supports the immunoallergic basis of the disease and the need for an allergy exam in all patients with EE. The majority of our patients (22 out of 24 evaluated) presented a good clinical response to treatment, which was based on avoiding exposure to the potentially involved allergen and/or the administration of corticoids (topical or systemic) and/or the administration of proton pump inhibitors.

Prospective observational study of the incidental findings on endoscopic ultrasonography: should a complete exploration always be performed?

OBJECTIVES

To quantify the additional non-suspected new diagnoses made on upper endosonography (EUS) which were unknown before the procedure, and to analyse their influence on the management of patients. A further objective was to evaluate the influence that previous radiological or endoscopic explorations have on the capacity of EUS to diagnose these unsuspected lesions.

MATERIAL AND METHODS

During a 2-year period every patient sent to our unit for upper EUS underwent a complete investigation, after signing an informed consent document. An upper EUS was considered as complete whenever the gut wall, pancreas, biliary tract, ampulla, large abdominal vessels, liver, spleen, left adrenal gland, posterior mediastinum and thyroid lobes had been explored. An additional diagnosis (AD) was defined as a diagnosis made on EUS that was previously unknown and not suspected. A significant additional diagnosis (SAD) was defined as an AD that required further study. The results of complementary explorations carried out before EUS were registered.

RESULTS

A total of 239 patients were included in the study. ADs were found in 92 patients (38.5%), which were considered to be SADs in 27 patients (11.3%). Those patients had previously undergone computed tomography (CT) and those who underwent more than one exploration had fewer incidences of ADs on EUS (p=0.03 and p=0.02, respectively). No exploration alone or in combination with others showed any influence on the capacity of EUS to find a SAD (p >0.05).

CONCLUSIONS

In our series, an AD was found on upper endosonography in 38.5% of the patients studied, and a SAD in 11.3%. The probability of finding a SAD on EUS is not influenced by previous endoscopic or radiologic explorations.

[Study of colorectal metachronous neoplastic lesions]

BACKGROUND

To analyse the frequency and characteristics of metachronous neoplastic lesions, carcinomas and adenomas, following resection of colorectal cancer.

PATIENTS AND METHODS

We reviewed 382 patients subjected to RCC operations and followed up through complete colonoscopies in two hospitals in our province. We analysed the metachronous lesions registered, evaluating their localisation, time of diagnosis, histology, number and size. We studied the frequency of early adenomas (12 months), comparing their size with the rest of the lesions.

RESULTS

The average follow-up was 48 months (12-112), with 2.74+/-1.47 colonoscopies/case. We diagnosed 7 metachronous cancers (1.8%), 4 of them in stage I. The average time until their diagnosis was 24 months (13-54). We registered metachronous adenomas in 162 cases (42.4%), without differences between the two hospitals: 42.1% vs. 43.8% (p=0.88). Six point three percent of the patients presented advanced adenomas. In 164 cases where the control was carried out after 12 months, the incidence of adenomas was 24%. In the majority of cases, the adenomas were sole (60.8%) and smaller than 5 mm (68.5%). In 55.5% of the cases with polyps, some had a proximal localisation. Diagnosis was made on the 1st exploration (56.2%), the 2nd (27.8%) or the 3rd (9%). Average time until diagnosis was 21 months (12-112) for simple adenoma and 35 (12-112) for advanced adenoma.

CONCLUSIONS

Our follow up made it possible to apply a theoretically curative treatment in the majority of the metachronous carcinomas diagnosed. The high incidence of adenomas and the frequent proximal localisation make a follow up with complete colonoscopies necessary, which must be started one year after the operation and can become less strict following three consecutive explorations without polyps.

[Synchronous neoplastic lesions in colorectal cancer. An analysis of possible risk factors favouring presentation]

AIM

few data have been published regarding the causes of synchronous lesions in patients with colorectal cancer. The aim of our study was to identify potential factors that might be implicated in the development of multicentric lesions, since this knowledge could be useful for tailored follow-up once initial synchronous lesions have been removed.

METHODS

we retrospectively reviewed 382 colorectal cancer cases diagnosed by total colonoscopy and histological study of surgical specimens. We divided our population into 2 groups, based on whether they had synchronous lesions or otherwise. Several data related to personal and family history, habits, symptoms, and tumor characteristics were assessed. Univariate and multivariate statistical analyses were performed.

RESULTS

208 (54.5%) patients had synchronous adenomas and 28 (7.3%) had synchronous cancer. A multivariate analysis showed that the following parameters were consistently related to the presence of multicentric lesions--male gender: OR = 1.97; CI = 1.13-3.45; p = 0.017; age = 59 years: OR = 2.57; CI = 1.54-4.29; p < 0.001; personal history of colonic adenomas: OR = 3.04; CI = 1.04-8.85; p = 0.042; and obstructive tumors: OR = 0.48; CI = 0.27-0.85; p = 0.012.

CONCLUSION

our results show that several parameters that are easy to measure could be considered risk factors for the development of multicentric lesions. These factors need to be confirmed with follow-up studies analyzing their role in patients with and without metachronic lesions once all synchronous lesions have been removed.

[Study of frequency, distribution and diagnostic performance in synchronic neoplastic lesions of colorectal carcinoma]

AIM

To analyse the frequency, characteristics and diagnosis of synchronic neoplastic lesions in colorectal cancer.

METHODS

A review was carried out of 384 colorectal cancers, diagnosed through complete colonoscopy and resected. The synchronic cancers and the characteristics of the adenomas were determined: number, size, histological type, dysplasia, as well as their localisation in the colon and with respect to the carcinoma.

RESULTS

Twenty-eight synchronic cancers were found (7.3% of the total); 8 developed tumours and 20 malignant polyps. In 54.4% of the cases there was a synchronic adenoma. In patients with synchronic lesions, 43% showed an advanced adenoma. Twenty percent of the synchronic polyps found were proximal to the splenic flexure; 41% were distal and 38% had both localisations. Fifty-nine point one percent of the patients had some adenoma proximal to the cancer, with criteria of advanced adenoma in 13.9%. The distribution of the adenomas was more uniformly spread in the cancers with a proximal localisation (p = 0.038). Seventeen percent of the distal cancers presented synchronic lesions with a proximal colon localisation exclusively. Partial endoscopies would diagnose the distal cancers, but would omit a synchronic adenoma in 42.3% of the sigmoidoscopies and 40% of the short colonoscopies.

CONCLUSIONS

High rates of carcinoma and synchronic adenomas were registered. We underline the high index of advanced adenomas and the frequency of synchronic lesions proximal to the cancer, which is why incomplete colonoscopies, although allowing the diagnosis of the distal cancer, omit a high percentage of synchronic adenomas, including advanced lesions. All of this confirms the need to perform a complete pre-, intra- and post operational colonoscopy in resectable colorectal cancer.

[The role of endoscopic ultrasonography in the etiological evaluation of idiopathic acute pancreatitis]

Up to 30% of patients with acute pancreatitis are diagnosed of idiopathic acute pancreatitis after an initial evaluation including a complete clinical history, physical examination, analysis with calcium and triglycerides determination, and at least one transabdominal ultrasonography. Unexplained pancreatitis represents a diagnostic challenge, although after different explorations a cause is found in the majority of these patients. During the last years endosonography has proved to be a low morbidity exploration very useful in the evaluation of patients with this entity. In this article we review the role of endosonography in the etiologic study of patients with idiopathic acute pancreatitis.

[Rectal cancer staging with endoscopic ultrasonography: correlation with pathological staging]

OBJECTIVE

our aim was to evaluate the accuracy of endosonography (EUS) in our experience, to stage rectal cancer.

MATERIAL AND METHODS

we prospectively included all patients with rectal cancer staged in our unit from September 2002 until February 2006 in a database. We selected those patients who had a complete EUS examination and were surgically treated without neoadjuvant therapy. Once we had the results of the histopathological staging (pTN), which was considered the gold standard, we compared the results of the previous EUS staging (uTN) with those of the pTN. We calculated the sensitivity, specificity, positive predictive value, negative predictive value and accuracy for each T stage, and for N staging considered as N positive or negative. We also calculated the global accuracy for T stage. We also calculated the agreement of uTN with pTN staging using the kappa index for N stage, and quadratic weighted kappa index for T stage.

RESULTS

we staged 120 patients with rectal cancer during the mentioned period. Of these, 36 patients met inclusion criteria and were evaluated, 21 women and 15 men. Mean age was 68,53+/-10,15 yo (range: 48-90). Global T stage accuracy was 83%. N stage accuracy was 72%. We obtained a S, E, PPV, NPV and A of 91, 100, 100, 96 and 97% for T1; 82, 88, 75, 91 and 86% for T2; 86, 91, 86, 91 and 89% for T3; and 14, 86, 20, 80 and 72% for N stage respectively. Kappa value for T stage was 0,87 indicating a "very good" agreement between uT and pT according to the kappa index criteria. Kappa value for N stage agreement was 0,005; "poor" according to the same criteria.

CONCLUSIONS

in our experience, the diagnostic accuracy of EUS for T and N staging of rectal cancer is 83% and 72% respectively, similar results as previously published. uT staging for rectal cancer shows a "very good" agreement with pT staging.

Eradication of Helicobacter pylori for the prevention of peptic ulcer rebleeding

AIM

To evaluate the effect of Helicobacter pylori eradication on ulcer bleeding recurrence in a prospective, long-term study including more than 400 patients.

METHODS

Patients with peptic ulcer bleeding were prospectively included. H. pylori infection was confirmed by rapid urease test, histology or (13)C-urea breath test. Several eradication regimens were used. Ranitidine 150 mg was administered daily until eradication was confirmed by breath test 8 weeks after completing eradication therapy. Patients with therapy failure received a second or third course of therapy. Patients with eradication success did not receive maintenance anti-ulcer therapy, and were controlled yearly with a repeated breath test.

RESULTS

Four hundred and twenty-two patients were followed up for at least 12 months, with a total of 906 patient-years of follow up. Mean age was 59 years, and 35% were previous nonsteroidal anti-inflammatory drug (NSAID) users. Sixty-nine percent had duodenal, 24% gastric, and 7% pyloric ulcer. Recurrence of bleeding was demonstrated in two patients at 1 year (incidence: 0.22% per patient-year of follow up), which occurred after NSAID use in both cases.

CONCLUSION

Peptic ulcer rebleeding does not occur in patients with complicated ulcers after H. pylori eradication. Maintenance anti-ulcer (antisecretory) therapy is not necessary if eradication is achieved.

Risk of upper gastrointestinal ulcer bleeding associated with selective cyclo-oxygenase-2 inhibitors, traditional non-aspirin non-steroidal anti-inflammatory drugs, aspirin and combinations

BACKGROUND

The risks and benefits of coxibs, non-steroidal anti-inflammatory drugs (NSAIDs), and aspirin treatment are under intense debate.

OBJECTIVE

To determine the risk of peptic ulcer upper gastrointestinal bleeding (UGIB) associated with the use of coxibs, traditional NSAIDs, aspirin or combinations of these drugs in clinical practice.

METHODS

A hospital-based, case-control study in the general community of patients from the National Health System in Spain. The study included 2777 consecutive patients with endoscopy-proved major UGIB because of the peptic lesions and 5532 controls matched by age, hospital and month of admission. Adjusted relative risk (adj RR) of UGIB determined by conditional logistic regression analysis is provided.

RESULTS

Use of non-aspirin-NSAIDs increased the risk of UGIB (adj RR 5.3; 95% confidence interval (CI) 4.5 to 6.2). Among non-aspirin-NSAIDs, aceclofenac (adj RR 3.1; 95% CI 2.3 to 4.2) had the lowest RR, whereas ketorolac (adj RR 14.4; 95% CI 5.2 to 39.9) had the highest. Rofecoxib treatment increased the risk of UGIB (adj RR 2.1; 95% CI 1.1 to 4.0), whereas celecoxib, paracetamol or concomitant use of a proton pump inhibitor with an NSAID presented no increased risk. Non-aspirin antiplatelet treatment (clopidogrel/ticlopidine) had a similar risk of UGIB (adj RR 2.8; 95% CI 1.9 to 4.2) to cardioprotective aspirin at a dose of 100 mg/day (adj RR 2.7; 95% CI 2.0 to 3.6) or anticoagulants (adj RR 2.8; 95% CI 2.1 to 3.7). An apparent interaction was found between low-dose aspirin and use of non-aspirin-NSAIDs, coxibs or thienopyridines, which increased further the risk of UGIB in a similar way.

CONCLUSIONS

Coxib use presents a lower RR of UGIB than non-selective NSAIDs. However, when combined with low-dose aspirin, the differences between non-selective NSAIDs and coxibs tend to disappear. Treatment with either non-aspirin antiplatelet or cardioprotective aspirin has a similar risk of UGIB.

[Utility of bolus somatostatin administration in preventing pancreatitis after endoscopic retrograde cholangiopancreatography: a controlled, non-randomized study]

INTRODUCTION

Somatostatin is one of the most extensively evaluated drugs in the prophylaxis of pancreatitis after endoscopic retrograde cholangiopancreatography (ERCP), but its utility remains controversial.

PATIENTS AND METHODS

The aim of this study was to evaluate the role of somatostatin as prophylaxis of ERCP-induced acute pancreatitis. A group of consecutive patients that underwent ERCP in our endoscopy unit was prospectively studied for 8 months. Patients in this group were administered an endovenous bolus of 250 micrograms of somatostatin immediately before introducing the catheter in the papilla of Vater (somatostatin group). This group was compared with another group composed of consecutive patients who had undergone ERCP in the 8 previous months, without somatostatin administration (placebo group). Both groups contained the same number of patients. The following variables were recorded; sex, age, contrast injection in the duct of Wirsung, endoscopist, therapeutic maneuvers, and the development of post-ERCP pancreatitis.

RESULTS

During the 16 months of patient inclusion, we performed 320 ERCP in our unit, of which 248 were included in the study: 142 in the somatostatin group and 142 in the placebo group. Of these patients, 152 (53.5%) were men and 132 (46.5%) were women. The mean age was 70.05 +/- 13.83 years (range: 27-93 years). Acute pancreatitis occurred in 10 patients in the somatostatin group and in 5 in the placebo group; this difference was not statistically significant (p > 0.05). No significant differences were found between the two groups in the remaining variables studied.

CONCLUSION

Somatostatin does not seem to be useful in preventing post-ERCP acute pancreatitis.

Informed consent document in gastrointestinal endoscopy: understanding and acceptance by patients

OBJECTIVE

We wanted to know if patients read and understand the informed consent (IC) document used for endoscopic procedures, and to evaluate the readability of IC.

METHOD

During two months we gave patients studied in our endoscopy unit an anonymous questionnaire with different items concerning reading degree, knowledge of the technique, complications, sedation used, and information received. We evaluated IC readability using the Flesch index.

RESULTS

309 patients were included (mean age: 53 years, 55% males, 86% outpatients, 50% with basic education); 85% of patients read the IC, 96% considered they understood the exploration technique, 22% were not aware of severe complications, and 82% knew which kind of sedation would be used; 88% of patients received additional information from their doctors. Outpatients read the IC in a greater percentage versus inpatients (p < 0.05); patients with only basic education tended to ignore the possibility of complications (p < 0.05). Doctors gave more information to rural patients (p = 0.08), offered better information about complications to urban patients (p = 0.09), and offered more information on other diagnostic procedures to patients older than 50 years (p < 0.05). With the Flesch index we found that gastroscopy and colonoscopy ICs had a "standard" level of readability, while ERCP ICs were more complex.

CONCLUSIONS

The majority of our patients read and understands the IC. Doctors adapt information to patient characteristics. Our IC documents have an acceptable level of readability, but given that 50% of our patients have only a basic educational status, we should attempt to provide an easier IC document.

Indications, diagnostic tests and Helicobacter pylori eradication therapy. Recommendations by the 2nd Spanish Consensus Conference

The results of the 2nd Spanish Consensus Conference for appropriate practice regarding indications for eradication, diagnostic tests, and therapy regimens for Helicobacter pylori infection are summarized. The Conference was based on literature searches in Medline, abstracts from three international meetings, and abstracts from national meetings. Results were agreed upon and approved by the whole group. Results are supplemented by evidence grades and recommendation levels according to the classification used in the Clinical Practice Guidelines issued by Cochrane Collaboration. Convincing indications (peptic ulcer, duodenal erosions with no history of ASA or NSAIDs, MALT lymphoma), and not so convincing indications (functional dyspepsia, patients receiving low-dose ASA for platelet aggregation, gastrectomy stump in patients operated on for gastric cancer, first-degree relatives of patients with gastric cancer, lymphocytic gastritis, and Ménétrier s disease) for H. pylori eradication are discussed. Diagnostic recommendations for various clinical conditions (peptic ulcer, digestive hemorrhage secondary to ulcer, eradication control, patients currently or recently receiving antibiotic or antisecretory therapy), as well as diagnostic tests requiring biopsy collection (histology, urease fast test, and culture) when endoscopy is needed for clinical diagnosis, and non-invasive tests requiring no biopsy collection (13C-urea breath test, serologic tests, and fecal antigen tests) when endoscopy is not needed are also discussed. As regards treatment, first-choice therapies (triple therapy using a PPI and two antibiotics), therapy length, quadruple therapy, and a number of novel antibiotic options as "rescue" therapy are prioritized, the fact that prolonging PPI therapy following effective eradication is unnecessary for patients with duodenal ulcer but not for all gastric ulcers is documented, the fact that cultures and antibiograms are not needed for all eradicating therapies is indicated, and finally the test and treat strategy is considered adequate, however only under certain circumstances.

[Is pre-operative treatment with ursodeoxycholic acid useful in reducing relapses in acute biliary pancreatitis?]

In the present paper, we evaluate the possible reduction in the rate of relapses in acute biliary pancreatitis through treatment with ursodeoxycholic acid (UCA), between the episode of pancreatitis and the moment of cholecystectomy. We studied 72 consecutive first episodes of acute biliary pancreatitis, in patients who had not yet undergone colecistectomy, followed up until surgery. The cases were divided into group A (n=30), treated with ursodeoxycholic acid 10 mg/kg/day, until surgery, and group B or control (n=42). We evaluated the differences between both groups, regarding patient characteristics, pancreatitis severity, characteristics of the lithiasis and delay until surgery. We analysed pancreatitis relapses in both groups, with and without UCA. In the UCA group we compared the duration of treatment between patients with and without pancreatitis relapse. The two groups did not show significant differences regarding any of the studied parameters. We registered 7/30 (23.3%) relapses in UCA group, versus 9/42 (21.4%) relapses in the control group (p = 0.85). In UCA group, treatment duration was similar between relapsed cases: 4.9+/-4.5 months and those without relapse: 4.4+/-1.9 months (p = 0.78). In our experience, the use of UCA until the moment of cholecystectomy does not reduce relapse incidence in patients following the first episode of acute biliary pancreatitis. UCA treatment duration did not seem to be related with the occurrence of pancreatitis relapse.

[Comparison between two 13C-urea breath tests for the diagnosis of Helicobacter pylori infection: isotope ratio mass spectrometer versus infrared spectrometer]

OBJECTIVES

To compare the accuracy of the breath test using the isotope ratio mass spectrometer (IRMS) versus the nondispersive isotope-selective infrared spectrometer (NDIRS) in the diagnosis of Helicobacter pylori infection.

METHOD

Multicenter study in 4 Spanish hospitals. One group of dyspeptic patients who had not undergone prior eradication therapy and another group of patients with gastric ulcer or gastrointestinal bleeding due to gastroduodenal ulcer receiving H. pylori eradication therapy were included in the study. A reference standard based on histology and the rapid urease test was used. The breast test (TAU-KIT, Isomed S.L., Madrid, Spain) was performed with citric acid and 100 mg of 13C-urea. Samples of expired air were collected in tubes and bags for reading with the IRMS (ABCA, PDZ, Crewe, Manchester, England) and the NDIRS (UBiT-IR200, Otsuka Electronics, Co, Osaka, Japan), respectively. The endoscopist, pathologist and person responsible for reading the urease test and both breath tests were blinded to the results of the other diagnostic methods.

RESULTS

Forty-one patients were included. The prevalence of H. pylori was 26%. No differences were found on comparing the mean values obtained with the IRMS and the NDIRS: 13 (standard deviation) (24) and 14 (25) delta units, respectively. The area under the ROC curve for the IRMS and the NDIRS was 0.96. The diagnostic accuracy for the best cut-off point with the IRMS and the NDIRS was, respectively: sensitivity (90 and 100%), specificity (96 and 89%), positive predictive value (90 and 77%), negative predictive value (96 and 100%), + likelihaod ratio (25 and 9.3) and (0.1 and 0). A close correlation was found between the values of the IRMS and those of the NDIRS (lineal regression equation, Y = 1.1 + 1.004. X; r = 0.97).

CONCLUSION

Both the spectrometers used to evaluate the breath test, the IRMS and the NDIRS, offer a high degree of accuracy in the diagnosis of H. pylori infection.

Validation of the 13c-urea breath test for the initial diagnosis of helicobacter pylori infection and to confirm eradication after treatment

OBJECTIVES

the breath test with 13C-urea (UBT) is a method widely used in Spain, but its diagnostic accuracy has not been evaluated in a clinical trial until now. Our objective was to validate the UBT (TAU-KIT) both as an initial diagnostic method for the detection of H. pylori infection and as a method to confirm eradication.

METHODS

a multi-centre study in 7 Spanish hospitals was performed. A group of dyspeptic patients who had not previously received eradication treatment was included, and a second group of patients with gastric ulcer or upper gastrointestinal bleeding due to peptic ulcer was also included (eradication of H. pylori was confirmed 6 to 8 weeks after treatment completion with omeprazole, clarithromycin and amoxycillin). In both groups an endoscopy was performed with biopsies for histology and rapid urease test. Patients were considered infected if both tests yielded positive results, and not infected when both tests were negative. The UBT 13C-urea (TAU-KIT, Isomed S.L., Madrid, Spain) was performed with citric acid and 100 mg of 13C-urea. The pathologist and persons responsible for endoscopy, urease test and UBT were all unaware of the results from the other diagnostic methods.

RESULTS

in the pre-treatment group (36 patients) the prevalence of H. pylori was 72%, the area under the ROC curve for the diagnosis of infection with the UBT was 0.99, and the best cut-off point was 5 units, with the following results: sensitivity= 96% (95% CI = 81-99%), specificity= 100% (69-100%), positive predictive value (PPV) = 100% (87-100%), negative predictive value (NPV) = 92% (59-100%), likelihood ratio (LR) + = infinity, and LR- = 0.04. In the post-treatment group (85 patients) the prevalence of H. pylori was 16%, the area under the ROC curve was 0.99, and the best cut point was 4.6, with the following results: sensitivity= 100% (77-100%), specificity = 97% (90-99%), PPV = 88% (62-98%), NPV = 100% (95-100%), LR+ = 35, and LR- = 0.

CONCLUSION

UBT provides excellent accuracy both for the initial diagnosis of H. pylori infection and to confirm eradication after treatment.

How accurate is preoperative diagnosis by endoscopic biopsies in ampullary tumours?

INTRODUCTION

The benign or malignant nature of ampullary tumours has prognostic and therapeutic implications. On the other hand the difficulty of reaching a correct preoperative diagnosis in these lesions is well known, even when we have a histological study obtained by endoscopic biopsies.

MATERIAL AND METHODS

We review all ERCP's in which biopsies of the papilla were taken, performed between January 1991 and September 2000. We analyse the concordance rate between preoperative diagnosis (endoscopic biopsies obtained during ERCP) and definitive diagnosis (surgical specimen) (n = 32), and the possible influence of previous sphincterotomy in our results.

RESULTS

In the 32 patients studied global accuracy between pre- and postsurgical diagnosis was 68.7%. This accuracy was markedly higher in the group with ampullary cancer (82.7%) than in the group with ampullary adenoma (50%) (p = 0.12). In the group of patients with sphincterotomy accuracy was 56.25% and increased up to 81.25% in the group of patients without sphincterotomy, although statistical significance was not reached (p = 0.25).

CONCLUSIONS

In our series, the accuracy of endoscopic biopsies is higher in the adenocarcinoma group than in the adenoma group, obtaining better results in patients without previous sphincterotomy. The impossibility of a preoperative and absolutely certain confirmation of the benign or malignant nature of ampullary tumours forces us to be cautious in deciding type of surgical resection.

[Abdominal pain and infection by the varicella-zoster virus following bone marrow transplant]

Infection by the varicella-zoster virus (VZV) is an important cause of morbidity and mortality in patients who have received a bone marrow transplantation (BMT), both autologue and alogenic. Infection is generally produced in the first post-transplant year and, in its disseminated form, it can show itself through abdominal pain that translates the visceral affectation, pain that can precede the appearance of the characteristic cutaneous lesions by days, making diagnosis difficult. The clinical case described belongs to a patient who, 10 months after a bone marrow transplant, showed an infection by varicella-zoster virus, manifested through abdominal pain due to hepatic affectation, with an interval of 2 days between the start of pain and the appearance of cutaneous lesions. The diagnosis and treatment of these patients is discussed.

Digestive anisakiasis: clinical manifestations and diagnosis according to localization

OBJECTIVES

Digestive anisakiasis is a parasitic disease whose clinical manifestations depend on the effect of Anisakis simplex on the digestive tract wall. Larvae are acquired by eating raw or poorly cooked fish. It is estimated that this entity is currently under-diagnosed, although publications are becoming increasingly common. We analyse our series of digestive anisakiasis checking localization and studying its relationship with symptoms and method of diagnosis.

PATIENTS AND METHOD

We review 23 cases of digestive anisakiasis registered between 1989 and 2001, and confirmed by the measurement of specific serum Ig E antibodies. We analyse clinical symptoms and method of diagnosis according to whether localization was gastro-duodenal or intestinal, evaluating whether surgical intervention was needed for a correct diagnosis. The statistical analysis is made using Fisher's test.

RESULTS

23 patients were included between 1989 and 2001, 8 with gastro-duodenal localization and 15 with intestinal localization. All patients with intestinal localization had abdominal pain. Symptoms were less severe for gastro-duodenal cases, and diagnosis was made by clinical suspicion and subsequent gastroscopy, whereas more than a half of intestinal cases required histological examination of a surgical specimen for correct diagnosis. In the remaining half, diagnosis was made by abdominal ultrasonography. We also observed that the need for surgery has decreased with time from 6/6 cases in the 1989-1996 period of time to 2/9 in the 1997-2001 period of time.

CONCLUSIONS

Clinical manifestations of anisakiasis vary depending on localization, symptoms being more severe in intestinal forms. The diagnosis of gastro-duodenal anisakiasis did not need surgery and was based mainly on gastroscopy findings, whereas intestinal forms frequently required histological examination of the surgical specimen. In our hospital, a higher index of clinical suspicion allowed us to diagnose intestinal anisakiasis without examination of surgical specimens in the last years.

[Upper digestive haemorrhage due to Mallory-Weiss syndrome. Role of endoscopic sclerotherapy]

BACKGROUND

Although Mallory-Weiss syndrome is responsible for between 0.5 and 17% of the cases of upper digestive haemorrhage, the information existing on the endoscopic treatment of this syndrome is scarce.

MATERIAL AND METHODS

We made a retrospective study of 71 patients with haemorrhage due to Mallory-Weiss syndrome, dividing them into two groups according to the treatment they had received (medical or medical-endoscopic). Hence, 60 patients (30 with clean laceration, 9 with signs of prior haemostasia and 21 with fresh clotting) had been treated with procinetics and/or antisecretories alone, while the 11 remaining (8 with active haemorrhage, 2 with visible vessel and 1 with fresh clotting) had also received endoscopic treatment with sclerotherapy. We compared the clinical and analytical characteristics and the evolution of both groups of patients, analysing the data by means of the Mann-Whitney U and the chi 2 test.

RESULTS

The endoscopic sclerosis group showed maelenas more frequently and more severe analytical data of haemorrhage (p<0.01). Endoscopic sclerosis brought initial control of the haemorrhage in all the patients, with a low index of haemorrhage relapse, similar to the group receiving exclusively medical treatment.

CONCLUSIONS

In our series, the patients with Mallory-Weiss syndrome with active bleeding or visible vessel presented a haemorrhage with a greater clinical and analytical repercussion. In this group of patients, endoscopic sclerotherapy controlled the haemorrhage and/or prevented rebleeding, in the absence of complications.

[Cost effectiveness study on the use of somatostatin for reduction of acute pancreatitis after ERCP]

OBJECTIVES

Recent studies show that intravenous injection of somatostatin before endoscopic retrograde cholangiopancreatography (ERCP) is associated with a significant reduction in the rate of post-ERCP acute pancreatitis. The lack of data in our environment led us to study the possible economic benefits of somatostatin administration, obtained through the reduction of costs due to post-ERCP acute pancreatitis.

MATERIAL AND METHODS

Theoretical study of the direct costs of post-ERCP acute pancreatitis using Markov's tree decisions. The costs of the group pre-treated with intravenous administration of 3 mg of somatostatin were compared with those of the control group. Post-ERCP rates of pancreatitis of 10% were accepted in the control group and rates of 3% were accepted in the somatostatin group. The costs of the different types of pancreatitis were as follows: costs with and without complications and with surgical intervention were based on the diagnosis related group-weights applied by the Ministry of Health in the Contract-program of the Health Service of Navarre for 1999. A sensitivity analysis was carried out to determine the rate of post-ERCP pancreatitis from which an economic benefit would be obtained in the group pre-treated with somatostatin.

RESULTS

Mean theoretical cost per procedure was 121,640 pesetas for the control group and 105,539 for the group pre-treated with somatostatin. Saving per patient was 13.26% (16,101 pesetas). The sensitivity analysis revealed that in the control group premedication produced an economic benefit starting from a pancreatitis rate of 4.2%.

CONCLUSIONS

Independently of the clinical benefit signifying the reduction of post-ERCP pancreatitis, somatostatin administration led to a saving of 16,101 pesetas per patient. Accepting that the pancreatitis rate in the treated group was proportionately reduced, the sensitivity analysis showed that premedication produced an economic benefit starting from a pancreatitis rate of 4.2% in the control group.

[Helicobacter pylori infection. The Spanish consensus report. The Spanish Consensus Conference Group]

OBJECTIVES

taking into account the small amount of infection eradication treatments carried out in our country and some characteristics arising from the resistances to some antibiotics, the Spanish Club for the Study of Helicobacter pylori decided to organize a Spanish Consensus Conference to clarify the use of the different infection diagnostic tests, to establish the exact indications of its diagnosis and treatment, to recommend the best treatment guidelines for our country and to promote the use of eradication treatments in adequate indications.

DESIGN

on April 23, 1999 in Madrid, physicians who were experts in infection by Helicobacter pylori representing the different Scientific Societies of our country were gathered. Prior to this, three work areas, diagnosis, indications and treatments, were created and the participants freely joined them. One month before the conference, all of the participants were sent the questions which would be debated. An 80% consensus level, always based on scientific evidence, was required for a recommendation. In the first session, a meeting by work areas was held and in a second session, all of the recommendations were voted on in the meeting of the representatives.

CONCLUSIONS

the conference recommends the eradication of the infection in all the gastric or duodenal ulcers, in the erosive duodenitis, in the MALT lymphomas and in gastrectomized patients due to gastric cancer with residual stomach. In the de novo diagnoses of gastroduodenal ulcer, the rapid test of urease is recommended, and a histological study is recommended only if it is negative. In the case of a history of ulcers and also to know the eradication treatment result, the C13 urea breath test is recommended. The culture is reserved for primary treatment and rescue treatment failures so as to select the adequate antibiotic. The primary treatment regimes recommended for our country mean the combination of amoxicillin, clarithromycin and any proton pump inhibitor or with Ranitidine bismuth citrate. If there is allergy to penicillin, amoxycillin will be substituted by metronidazol.

Multivariate analysis of prognostic factors in resected colorectal cancer: a new prognostic index

OBJECTIVE

We analysed different clinicopathological variables in colorectal cancer and their independent prognostic significance in order to elaborate a prognostic index, which may be used to categorize patients into homogeneous groups and indicate adjuvant therapy.

DESIGN

Retrospective study.

METHODS

Patients (n = 108) undergoing surgery for colorectal cancer were studied (5-year-survival was controlled). Different clinicopathological variables and biological parameters (tumoural ploidy, proliferating cell nuclear antigen PCNA and nucleolar organizing regions NORs) were analysed. The Kaplan-Meier method and log-rank test were used for univariate analysis and the Cox regression method was used for multivariate analysis.

RESULTS

Some variables with prognostic effect in univariate analysis (e.g. rectal bleeding, altered bowel habit, intestinal obstruction, type of surgery, histological type, venous and neural invasion and invasive margin) did not have independent prognostic significance after Cox analysis. Final multivariate analysis model was defined by five parameters: postoperative carcinoembryonic antigen, Astler-Coller-Turnbull staging, histological grade, lymphatic invasion and tumour ploidy. A new prognostic index was elaborated that provided information to group patients in three prognostic categories of different risk: high, medium and low.

CONCLUSION

The prognostic index allowed categorization of patients into different risk groups with identical tumoural stage and histological grade. Therefore, this index provides better prognostic information that may be helpful when selecting patients for adjuvant therapy.

[Giant gastric stromal tumor simulating a focal hepatic lesion]

Gastrointestinal stromal tumors (GIST), are unusual malignancies regarded for many years as being basically of smooth muscle nature and designated as leiomyomas, leiomyosarcomas or leiomyoblastomas. Histogenesis has been debated, though it is presently accepted that they are characterized by poorly differentiated cells, including tumors showing differentiation towards smooth muscle, neural elements, dual differentiation or lack of differentiation. Another group with ultrastructural and immunohistochemical features similar to those of gastrointestinal autonomic plexus has been described and designated as GAN tumors. Diagnosis and classification of these tumors are not possible using conventional pathological techniques, making ultrastructural and immunohistochemical studies necessary. Accurate classification is clinically essential due to prognostic implications. GIST present with few clinical symptoms even in cases of large tumors and are quite often incidentally found during surgical procedures or in postmortem studies. We report a case of a giant gastric stromal tumor showing differentiation towards smooth muscle which presented as a focal hepatic lesion.

[Eosinophilic esophagitis: an underdiagnosed entity?]

Eosinophilic esophagitis is an exceptional entity, although the number of published cases has increased three times during the last 3 years. We report the case of an 18-year-old male with a long esophageal stenosis due to eosinophilic esophagitis. Clinical, radiologic, endoscopic and manometric outcome was satisfactory after prednisone therapy. Although isolated esophageal involvement may occur, disseminated eosinophilic esophago-gastro-intestinal disease is more frequent. The disease is usually diagnosed in young male patients, presenting with dysphagia and, to a lesser extent, chest pain. Previous allergic conditions are reported in 80% of cases and peripheral eosinophilia is present in 80% of patients. Esophageal stenosis is present in 72% of cases and manometric alterations are found in 47% of patients. Radiographic findings are nonspecific and include stenosis and rigidity. Endoscopic features are not specific either, but diagnosis may be achieved by endoscopic biopsy. Corticosteroids and sodium chromoglycate have proved to be useful, with good therapeutic response being reported in 90% of patients with this underestimated disease.