Orientador: Silvana Artioli Schellini / Abstract: Objective: To determine if stents increase the success rate of endoscopic dacryocystorhinostomy (DCR-EN) Method: Systematic review of randomized clinical trials of DCR-EN, comparing surgeries performed with and without stents in children older than 10 years of age and adult patients, with primary lacrimo-nasal duct (LND) obstruction. The outcomes were LND patency and adverse events (complications). We searched the databases of Web of Science, Scopus, Embase, Cochrane, PubMed, Lilacs until May 2018. The RevMan 5.3 software provided by the Cochrane Collaboration was used for meta-analysis. Results: Ten studies involving 887 surgeries were included. Five studies were conducted in India, and each of the others were conducted in Canada, Turkey, Saudi Arabia, China and Finland. Lacrimo-nasal duct patency meta-analysis showed stents did not interfere in the chance of success in relation to non-use of the stents to obtain lacrimal viability (OR 1.62, 95% CI 1.00 to 2.64, I2 = 0%). It was not possible to perform a meta-analysis regarding the adverse effects and a descriptive analysis was made of the general complications and complications due to the stents. Conclusion: The use or no of stents in DCR-EN probably does not make any difference in the NLD patency. Further studies may better define whether there is a trend toward a better success rate with the use of stent. Key words: dacryocystorhinotomy, endoscopic, stent, success, meta-analysis / Resumo: Objetivo: Definir se o uso de stents aumenta a taxa de sucesso da dacriocistorrinostomia endoscópica (DCR-EN). Método: Revisão sistemática de ensaios clínicos randomizados referentes a DCR-EN, comparando as cirurgias realizadas com e sem uso de stents em crianças acima dos 10 anos de idade e adultos, com obstrução adquirida do ducto lacrimo-nasal (DLN). Os desfechos avaliados foram a patência do DLN e os eventos adversos (complicações). Foram pesquisadas as bases de dados: Web of Science, Scopus, Embase, Cochrane, PubMed, Lilacs até maio de 2018. Utilizou-se para metanálise o software RevMan 5.3 fornecido pela Colaboração Cochrane. Resultados: Dez estudos envolvendo 887 cirurgias foram incluidos. Cinco estudos foram realizados na India, um em cada um dos países a seguir: Canada, Turquia, Arabia Saudita, China e Finlândia. A metanálise da patência do DLN mostrou que os stents não interferiram na chance de sucesso em relação ao não uso dos stents para a obtenção de permeabilidade da via lacrimal (OR 1,62, IC 95% 1.00 a 2.64; I2 = 0%). Quanto aos efeitos adversos não foi possível realizar metanálise, tendo sido feita análise descritiva das complicações gerais e complicações dos stents. Conclusão: O uso ou não de stents na DCR-EN provavelmente faz pouca ou nenhuma diferença na patência do DLN. Novos estudos poderão melhor definir se há tendência de melhor taxa de sucesso com o uso de stents. / Mestre

Objetivo: Determinar la eficacia y seguridad de la técnica de doble guía en pacientes con canulación difícil durante una CPRE. Materiales y métodos: El presente estudio se realizó, entre el mes de enero del 2015 y julio del 2016. Se procedió a sintetizar la data, de éxito y complicaciones de la TDG en pacientes con canulación difícil y cuando la inserción de la guía en el conducto pancreático fue hecha involuntariamente después de una técnica estándar. Resultados: 24 pacientes sometidos a una CPRE con TDG; 17 fueron mujeres (70,8%) y 7 varones (29,2%). La edad promedio fue 65,21±16,49 años. La indicación más frecuente fue coledocolitiasis en 62,5 %, luego colangiocarcinoma, 12,5 %. El diagnóstico final post CPRE, fue coledocolitiasis en 45,8%, seguido por fibrosis de papila, 29,2%. El éxito de la técnica de la doble guía fue de 87,5%. Hubo 3 casos de canulación frustra con la TDG, dos pacientes presentaron pancreatitis post CPRE (8,3%), no hubo casos de perforaciones. Conclusiones: La TDG es una alternativa eficaz a la CPRE catalogada como de canulación difícil por técnica convencional, sea cual fuere la etiología, con un alto porcentaje de éxito técnico y con una tasa baja de pancreatitis post CPRE, semejante a la reportada en otros países. / Objective: To determine the efficacy and safety of double guidewire technique in patients with difficult biliary cannulation during ERCP. Materials and methods: We conducted a retrospective cohort study of all ERCPs performed between January 2015 and July 2016. DGT was performed in patients for whom biliary cannulation was difficult and guidewire insertion into the pancreatic duct (PD) was inadvertently achieved while attempting the standard WGC technique. Results: 24 patients were enrolled with ERCP and DGT; 17 were female (70.8%) and 7 male (29.2%). The average age was 65.21±16.49 years. The most frequent indication was choledocholithiasis (62.5%), then cholangiocarcinoma (12.5%). Post ERCP diagnosis was choledocholithiasis (45.8%), and papillary fibrosis (29.2%). The success of DGT was 87.5%. Three cases of failure cannulation with the DGT were reported, two patients had pancreatitis post ERCP (8.3%), there were no cases of perforations. Conclusions: TDG, is an effective alternative to difficult biliary cannulation during ERCP with conventional methods; with a high success rate and low rate of post ERCP pancreatitis, similarly to reported in other countries.

京都大学 / 0048 / 新制・課程博士 / 博士(医学) / 甲第22330号 / 医博第4571号 / 新制||医||1041(附属図書館) / 京都大学大学院医学研究科医学専攻 / (主査)教授 小西 靖彦, 教授 妹尾 浩, 教授 湊谷 謙司 / 学位規則第4条第1項該当 / Doctor of Medical Science / Kyoto University / DFAM

Endoscopic retrograde cholangiopancreatography (ERCP) is an invasive procedure with significant complications. Splenic hematoma is an extremely rare but known complication following ERCP that has been increasingly reported in the past several years. We report the case of a 44-year-old patient with a history of sleeve gastrectomy who underwent an ERCP that was complicated by both acute pancreatitis and splenic hematoma. She was managed conservatively under close monitoring in the intensive care unit. Clinicians should be aware of this potentially life-threatening complication to make a prompt diagnosis and begin early appropriate management.

Percutaneous endoscopic gastrostomy (PEG) is currently a popular method of administering enteral feeding. Most of these patients are elderly, debilitated, and chronically ill. They are on a number of medications and have multiple diseases. With impaired consciousness and swallowing disability, these patients are prone to develop pneumonia. In order to identify possible risk factors, we followed 24 men who underwent PEG for the occurrence of pneumonia or until they died. We then analyzed the medical records of these patients for potential risk factors for pneumonia. The presence of esophagitis during PEG placement endoscopy and history of pneumonia prior to PEG were significant risk factors. Advanced age and cerebrovascular accident (CVA) tended to indicate a higher risk of pneumonia. Taking these risk factors into consideration may be beneficial in the management of such patients.

Background: Endoscopic ear surgery has gained acceptance as a complementary tool to microscopic ear surgery, but perhaps not so much as an instrument for exclusive use.With this approach becoming popular, there is scarce data on cholesteatoma recidivism and hearing outcomes, when exclusively used. Objectives: Auditing outcomes of endoscopic ear surgery for the surgical management of cholesteatoma in the Groote Schuur hospital (above13 year age group) and the Red Cross War Memorial Children’s hospital (below 13 year age group) , with a secondary aim of comparing recidivism and hearing outcomes of 4 different surgical techniques for cholesteatoma resection, namely, exclusive endoscopic (EES), microscopic canal wall down (CWD), microscopic canal wall up (CWU) and combined endoscopic-microscopic techniques. Methods: A retrospective chart review was conducted at our two tertiary academic referral hospitals in Cape Town, namely, Red Cross War Memorial Children’s Hospital and Groote Schuur Hospital from January 2012 to December 2016. Results: A total of 128 cholesteatoma ear surgeries were done; 110 patients were above the age of 13 years and 18 patients were below the age of 13 years. Eight Red Cross patients underwent EES, 7 had CWU, 2 had CWD and 1 had a combined technique. Overall recidivism rate in this population was 33% (6/18), of which 2 were approached exclusively endoscopically, 2 underwent a microscopic CWU, 1 had a CWD and 1 had combined endoscopic-microscopic approach. The mean postoperative hearing in this group was 40dB compared to a preoperative mean of 50,3 decibels (dB). In the Groote Schuur group, 23 underwent an exclusive endoscopic approach; 42 had a CWU, 40 had a CWD and 5 had a combined endoscopic-microscopic approach. Overall recidivism rate for the above 13 year old group was 17% (19/110). Of those, 7 were from the endoscopic group, 8 from the CWU group, 1 from CWD group and 3 from the combined technique group. Mean postoperative hearing was 47,4dB compared to a preoperative hearing of 48,4dB. Conclusions: The CWD technique demonstrated superior outcomes in both the above and below 13 year age groups. In the above 13 year old group, the EES approach had the same recurrence rate as CWU. While paediatric cholesteatomas have much higher recidivism rates compared to adults, our below 13 year old group was too small to conclude any statistical significant differences between the different approaches, and therefore, further studies are required in this age group. Management of cholesteatoma requires a highly individualized approach that takes into account anatomic, clinical and social factors to determine the most appropriate surgical treatment paradigm

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Includes bibliography (leaves 249-291). / xxiv, 291, [52] leaves : / Title page, contents and abstract only. The complete thesis in print form is available from the University Library. / Discusses and evaluates the role of intra-operative ultrasound in colorectal surgery ; techniques of laparoscopic surgery and the impact on the incidence of hypothermia during surgery ; advanced prognostic techniques in colorectal cancer ; the impact of ambulatory anorectal surgery ; and, the potential of an information video to decrease the anxiety of patients through imparting essential information to patients. / Thesis (M.D.)--University of Adelaide, Dept. of Surgery, 1999

<p>Transcatheter Arterial Embolization (TAE) is a method in which a catheter is inserted into an artery under fluoroscopy guidance. By using material that creates a thrombus, inserted through the catheter, the artery can be occluded and the bleeding stopped.</p><p>Endoscopy is the treatment of choice in upper gastrointestinal (GI) bleeding, but 10% to 30% of patients rebleed and needs other treatment options. Post Partum Hemorrhage (PPH) may evolve rapidly and can become life threatening. Obstetrical treatment will manage most cases, but in some cases emergency surgery is needed and in the worst case hysterectomy.</p><p>The primary aim of this thesis was to evaluate the clinical usefulness, improve the TAE technique and compare the outcome of TAE with surgery used as “salvage therapy” in patients with upper GI bleeding. Evaluate TAE technique and the long-term effect on the menstrual cycle and fertility in severe PPH.</p><p>To evaluate the clinical usefulness 13 patients were treated with TAE after endoscopic treatment failure and 5 were treated for recurrent hemorrhage after emergency surgery. </p><p>The clinical outcome and mortality rate of 40 patients treated with TAE was compared with 51 patients treated with surgery of upper GI bleedings. </p><p>In 13 patients the ulcer was marked with placement of a metallic clip at endoscopy to be able to locate the exact site of the bleeding ulcer during the TAE procedure.</p><p>A retrospective study of 20 patients with severe PPH treated with bilateral TAE of the uterine artery was performed. </p><p>TAE was found to be effective and an alternative to emergency surgery for control of massive upper GI bleeding. The 30-day mortality was lower in the TAE group (3%) compared to the surgical group (14%). </p><p>By marking the bleeding ulcer at endoscopy using a metallic clip the site of bleeding could be identified on angiography without extravasation of contrast media.</p><p>No major impact on fertility or menstruation cycle was found in patients treated with TAE in PPH. TAE in PPH is safe and have no major long-term side effect. By using TAE in PPH hysterectomy can be avoided.</p>