Factores predictores de supervivencia en pacientes cirróticos con ascitis refractaria tratados con derivación portosistémica percutánea intrahepática (TIPS).

Introducción: El uso de la derivación portosistémica percutánea intrahepática (TIPS) como tratamiento de la ascitis refractaria secundaria a la cirrosis hepática va en aumento. Sin embargo, no existe consenso en relación con los posibles factores predictores relacionados con la supervivencia y que podrían ser de gran utilidad en la selección de pacientes candidatos a dicho tratamiento. El desarrollo de encefalopatía hepática (EH) es la principal complicación tras la implantación de la prótesis. El objetivo del estudio fue identificar factores relacionados con la supervivencia y con el desarrollo de EH recurrente en pacientes cirróticos que recibieron un TIPS como tratamiento de la ascitis refractaria. Métodos: Se llevó a cabo un estudio observacional, retrospectivo y multicéntrico que incluyó a todos los pacientes con cirrosis hepática que recibieron un TIPS como tratamiento de la ascitis refractaria desde 1992. Se recogieron variables demográficas, clínicas, analíticas y hemodinámicas, tanto basales como consecutivas, hasta su fallecimiento, trasplante hepático o hasta el final de su seguimiento. La supervivencia fue analizada mediante un modelo de Kaplan-Meier y los factores predictores de supervivencia mediante un modelo de regresión de Cox. Posteriormente los pacientes que recibieron una prótesis cubierta fueron analizados de manera independiente. Se utilizó un modelo de regresión de riesgos competitivos (Fine-Gray) para identificar los factores predictores de mortalidad o EH recurrente al año de la implantación de TIPS. Resultados: Se incluyeron 198 pacientes (80% recibieron prótesis cubiertas). Los factores predictores de supervivencia fueron la edad (HR 1.03 [CI 95% 1.00 – 1.06]; p=0.022), la albúmina sérica (HR 0.61 [CI 95% 0.39 – 0.95]; p=0.030), el sodio sérico (HR 0.96 [CI 95% 0.92 – 0.99]; p=0.033) y la implantación de prótesis no cubiertas (HR 2.05 [CI 95% 1.18 – 3.59]; p=0.011). En el subgrupo de prótesis cubiertas, los factores relacionados en el análisis multivariante con el desarrollo de EH recurrente o mortalidad a 1 año fueron la edad (sHR 1.05 [CI 95% 1.02 – 1.09]; p=0.001), la creatinina sérica (sHR 1.55 [CI 95% 1.23 – 1.96]; p=0.001) y el sodio sérico (sHR 0.94 [CI 95% 0.90 – 0.99]; p=0.011) basales. Se creó un nomograma basado en estas variables para determinar a priori el riesgo de EH recurrente o mortalidad al año de cada paciente. Conclusiones: La edad, la creatinina y el sodio sérico basales influyen en el desarrollo de EH recurrente/mortalidad a 1 año en los pacientes con cirrosis que reciben un TIPS cubierto como tratamiento de la ascitis refractaria. Un simple nomograma identifica a los pacientes con peor pronóstico y que son, por tanto, peores candidatos a TIPS

Effect of the SARS-CoV-2 pandemic on colorectal cancer diagnosis and prognosis

COVID-19 pandemic; Endoscopy; Screening colonoscopyPandèmia COVID-19; Endoscòpia; Colonoscòpia de cribratgePandemia COVID-19; Endoscopia; Colonoscopia de cribadoBackground and Study Aims Our aim was to determine the impact of the SARS-CoV-2 pandemic on the diagnosis and prognosis of colorectal cancer (CRC). Patients and Methods This prospective cohort study included individuals diagnosed with CRC between March 13, 2019 and June 20, 2021 across 21 Spanish hospitals. Two time periods were compared: prepandemic (from March 13, 2019 to March 13, 2020) and pandemic (from March 14, 2020 to June 20, 2021, lockdown period and 1 year after lockdown). Results We observed a 46.9% decrease in the number of CRC diagnoses (95% confidence interval (CI): 45.1%–48.7%) during the lockdown and 29.7% decrease (95% CI: 28.1%–31.4%) in the year after the lockdown. The proportion of patients diagnosed at stage I significantly decreased during the pandemic (21.7% vs. 19.0%; p = 0.025). Centers that applied universal preprocedure SARS-CoV-2 PCR testing experienced a higher reduction in the number of colonoscopies performed during the pandemic post-lockdown (34.0% reduction; 95% CI: 33.6%–34.4% vs. 13.7; 95% CI: 13.4%–13.9%) and in the number of CRCs diagnosed (34.1% reduction; 95% CI: 31.4%–36.8% vs. 26.7%; 95% CI: 24.6%–28.8%). Curative treatment was received by 87.5% of patients diagnosed with rectal cancer prepandemic and 80.7% of patients during the pandemic post-lockdown period (p = 0.002). Conclusions The COVID-19 pandemic has led to a decrease in the number of diagnosed CRC cases and in the proportion of stage I CRC. The reduction in the number of colonoscopies and CRC diagnoses was higher in centers that applied universal SARS-CoV-2 PCR screening before colonoscopy. In addition, the COVID-19 pandemic has affected curative treatment of rectal cancers.This work was supported by ISABIAL UPG-20-096 grant and Instituto de Salud Carlos III (PI20/01527), Asociación para la Investigación en Gastroenterología de la Provincia de Alicante (AIGPA), a private association that promotes research in gastrointestinal diseases in Alicante, supported the logistical aspects of the study. This association declare no conflicts of interest

Mercaptopurine and inflammatory bowel disease: the other thiopurine

Background: Data about use and effectiveness of mercaptopurine in inflammatory bowel disease are relatively limited. Aims: To assess the possible therapeutic indications, efficacy and safety of mercaptopurine as an alternative to azathioprine in inflammatory bowel disease. Methods: Retrospective observational study in patients treated with mercaptopurine in a total cohort of 1,574 patients with inflammatory bowel disease. Results: One hundred and fifty-two patients received mercaptopurine, 15.7% of these patients as an initial thiopurine, 5.3% after azathioprine failure, and 79% after azathioprine intolerance. In 52.6% of patients (n = 80), adverse effects of mercaptopurine occurred, resulting in withdrawal in 49 of them. Mercaptopurine was effective in 39% of cases (95% CI 31-48%). In the remaining patients, failure was due mainly to withdrawal due to side effects (55.1%) and therapeutic step-up (33.7%). The average total time of mercaptopurine exposure was 36 months (IQR: 2-60). Myelotoxicity with mercaptopurine was more common in patients with intermediate TPMT activity than in those with normal activity (p = 0.046). Conclusions: In our setting, mercaptopurine is primarily used as a rescue therapy in patients with azathioprine adverse effects. This could explain its modest efficacy and the high rate of adverse effects. However, this drug is still an alternative in this group of patients, before a therapeutic step-up to biologics is considered

Prospective multicenter study to identify optimal target population for motorized spiral enteroscopy

Abstract Motorized spiral enteroscopy (MSE) enhances small bowel exploration, but the optimal target population for this technique is unknown. We aimed to identify the target population for MSE by evaluating its efficacy and safety, as well as detecting predictors of efficacy. A prospective multicenter observational study was conducted at 9 tertiary hospitals in Spain, enrolling patients between June 2020–2022. Analyzed data included demographics, indications for the procedure, exploration time, depth of maximum insertion (DMI), technical success, diagnostic yield, interventional yield, and adverse events (AE) up to 14 days from enteroscopy. Patients with prior gastrointestinal surgery, unsuccessful balloon enteroscopy and small bowel strictures were analyzed. A total of 326 enteroscopies (66.6% oral route) were performed in 294 patients (55.1% males, 65 years ± 21). Prior abdominal surgery was present in 50% of procedures (13.5% gastrointestinal surgery). Lower DMI (162 vs 275 cm, p = 0.037) and diagnostic yield (47.7 vs 67.5%, p = 0.016) were observed in patients with prior gastrointestinal surgery. MSE showed 92.2% technical success and 56.9% diagnostic yield after unsuccessful balloon enteroscopy (n = 51). In suspected small bowel strictures (n = 49), the finding was confirmed in 23 procedures (46.9%). The total AE rate was 10.7% (1.8% classified as major events) with no differences related to prior gastrointestinal/abdominal surgery, unsuccessful enteroscopy, or suspected small bowel strictures. The study demonstrates that MSE has a lower diagnostic yield and DMI in patients with prior gastrointestinal surgery but is feasible after unsuccessful balloon-enteroscopy and in suspected small bowel strictures without safety concerns

Effect of the SARS‐CoV‐2 pandemic on colorectal cancer diagnosis and prognosis

Abstract Background and Study Aims Our aim was to determine the impact of the SARS‐CoV‐2 pandemic on the diagnosis and prognosis of colorectal cancer (CRC). Patients and Methods This prospective cohort study included individuals diagnosed with CRC between March 13, 2019 and June 20, 2021 across 21 Spanish hospitals. Two time periods were compared: prepandemic (from March 13, 2019 to March 13, 2020) and pandemic (from March 14, 2020 to June 20, 2021, lockdown period and 1 year after lockdown). Results We observed a 46.9% decrease in the number of CRC diagnoses (95% confidence interval (CI): 45.1%–48.7%) during the lockdown and 29.7% decrease (95% CI: 28.1%–31.4%) in the year after the lockdown. The proportion of patients diagnosed at stage I significantly decreased during the pandemic (21.7% vs. 19.0%; p = 0.025). Centers that applied universal preprocedure SARS‐CoV‐2 PCR testing experienced a higher reduction in the number of colonoscopies performed during the pandemic post‐lockdown (34.0% reduction; 95% CI: 33.6%–34.4% vs. 13.7; 95% CI: 13.4%–13.9%) and in the number of CRCs diagnosed (34.1% reduction; 95% CI: 31.4%–36.8% vs. 26.7%; 95% CI: 24.6%–28.8%). Curative treatment was received by 87.5% of patients diagnosed with rectal cancer prepandemic and 80.7% of patients during the pandemic post‐lockdown period (p = 0.002). Conclusions The COVID‐19 pandemic has led to a decrease in the number of diagnosed CRC cases and in the proportion of stage I CRC. The reduction in the number of colonoscopies and CRC diagnoses was higher in centers that applied universal SARS‐CoV‐2 PCR screening before colonoscopy. In addition, the COVID‐19 pandemic has affected curative treatment of rectal cancers