Revista Espanola De Enfermedades Digestivas最新文献

Background: cholecystectomy is the treatment of choice for symptomatic cholelithiasis, although its safety in very elderly patients remains a cause for concern. Accurate risk prediction tools are essential to guide decision-making in this vulnerable population.

Methods: a retrospective cohort study was conducted that included patients ≥85 years of age who underwent cholecystectomy for symptomatic cholelithiasis in a tertiary hospital. Clinical and surgical variables were collected, and postoperative complications were classified according to Clavien-Dindo. The American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) risk calculator was applied to each patient. Discrimination was evaluated using the area under the curve (AUC) and calibration using the Brier score, Spiegelhalter test, standardized differences (d-values), and overlap between observed and predicted probabilities.

Results: eighty-five patients were included, 65 (76.5%) elective and 20 (23.5%) urgent. Overall morbidity was 32.9% and mortality was 4.7%, both significantly higher in urgent surgery (60% and 15%) than in elective surgery (24.6% and 1.5%). The ACS-NSQIP showed good discrimination in the overall cohort for any complication (AUC 0.741) and serious complications (AUC 0.760), with satisfactory performance for cardiac complications, surgical site infection, and mortality, but limited performance for renal failure and sepsis. In elective surgery, calibration was adequate, with concordance between observed and predicted outcomes. In urgent surgery, the model markedly underestimated the actual risk, especially for complications (60% vs. 17%) and mortality (15% vs. 3.3%).

Conclusions: in patients ≥85 years of age, ACS-NSQIP adequately predicts risk in elective cholecystectomies but underestimates morbidity and mortality in urgent surgery. The incorporation of frailty parameters and geriatric assessment could improve perioperative decision-making in this high-risk population.

Background and aims: Electron microscopy (EM) has provided key insights into hepatocellular alterations in MASLD, but most studies relied on percutaneous biopsies and primarily focused on selected features such as megamitochondria or autophagic vesicles. We aimed to evaluate the feasibility of ultrastructural analysis in transjugular biopsies and to provide a comprehensive description of hepatocellular changes in patients with MASLD.

Methods: Patients with MASLD, well characterized by hepatic venous pressure gradient (HVPG) and stratified by fibrosis stage, portal hypertension, and MASH status, were prospectively enrolled. 18G transjugular liver biopsies were processed for EM. Hepatocellular alterations were systematically assessed, including mitochondrial, endoplasmic reticulum (ER), autophagic, cytoskeletal, and nuclear changes.

Results: Eighteen patients were included; 8 (44.4%) had advanced fibrosis (F3-F4), 12 (66.7%) fulfilled diagnostic criteria for MASH, and 7 (38.9%) had portal hypertension (HVPG ≥6 mmHg). Transjugular specimens consistently yielded tissue suitable for high-quality ultrastructural assessment. The most frequent alterations were mitochondrial swelling, ER cisterns dilation, and accumulation of autophagic vesicles, reflecting cellular stress responses linked to hepatocellular injury, inflammation, and fibrogenesis. Cytoskeletal adaptations, specifically reinforcement of the cortical actin cytoskeleton and hypertrophy of adherens junctions, were also observed. These changes were observed across the fibrosis, portal pressure, and MASH subgroups.

Conclusions: Transjugular liver biopsies are suitable for EM studies in MASLD. The observed hepatocellular alterations appear to reflect core cellular stress responses and were noted consistently throughout the cohort. These findings provide a framework for integrating ultrastructural data into mechanistic and translational research in MASLD.

The consumption of added sugars and artificial sweeteners has risen exponentially in recent decades, driven by industrial availability, food processing, and Western dietary patterns. This narrative review, adopting a critical and multidisciplinary perspective, traces the history of sugar in the human diet, examines the evolution and safety of noncaloric sweeteners, and analyzes their impact on the gut microbiota. Drawing on experimental evidence and recent clinical studies, it explores how excessive intake of sugars and sweeteners can induce dysbiosis by reducing bacterial diversity, promoting the growth of proinflammatory microorganisms, altering short-chain fatty acid production, and compromising epithelial barrier integrity. The pathogenic role of these alterations is discussed in relation to digestive and metabolic disorders such as obesity, type 2 diabetes, metabolic dysfunction-associated steatotic liver disease, and inflammatory bowel disease. The review also considers the social and commercial determinants that perpetuate population exposure to dysbiotic dietary patterns, particularly in contexts of socioeconomic vulnerability. It proposes an integrated approach to addressing the clinical impact of sugar and sweetener consumption-encompassing public health measures, real-food-based dietary interventions, structured nutritional education, and regulation of the food environment. Overall, it underscores the need to reconceptualize intestinal dysbiosis not merely as a biological phenomenon but as a deeply social one requiring coordinated strategies across primary care, digestive health, and nutrition policy.

Eosinophilic enteritis is a rare immune-mediated disorder for which systemic corticosteroids remain the mainstay of treatment during acute flares, although no standardized maintenance therapy exists and some patients develop recurrent disease requiring repeated steroid courses. We report the case of a 27-year-old man with steroid-dependent eosinophilic enteritis characterized by recurrent flares with abdominal pain, diarrhea, ascites, and peripheral eosinophilia. After exclusion of alternative causes of eosinophilia through a multidisciplinary evaluation, off-label dupilumab was initiated, allowing complete corticosteroid withdrawal, with good tolerability. After one year of follow-up, he maintained remission and was able to reintroduce previously restricted foods, supporting its potential role as a steroid-sparing maintenance therapy in selected patients with eosinophilic enteritis.

Background: atrial fibrillation (AF) is the most prevalent cardiac arrhythmia, constituting a significant risk factor for stroke and systemic embolism. Oral anticoagulation (OAC) remains the primary strategy for stroke prevention, however, a subset of patients must discontinue it due to adverse events. Percutaneous left atrial appendage closure (LAAC) involves the mechanical occlusion of the left atrial appendage, an embryonic remnant in the left atrium of the heart where most thrombi form in patients with AF. It offers an alternative to long-term OAC for stroke prevention.

Methods: this article provides an overview of the LAAC procedure, its indications, and the current evidence (including clinical trials, meta-analyses, and real-world practice studies) regarding gastrointestinal bleeding (GIB) secondary to OAC.

Results: The PROTECT-AF and PREVAIL RCTs included 1114 patients with non-valvular AF, randomized 2:1 to LAAC or warfarin. Differences in major bleeding favoured LAAC (HR 0.48; 95% CI: 0.32-0.71). In the PRAGUE-17 trial, LAAC was non-inferior to DOAC in preventing major AF-related cardiovascular, neurological and bleeding events among patients at high risk for stroke and bleeding. In the long-term follow-up, the noninferiority of LAAC was maintained after 4 years (annual rate of nonprocedural clinically relevant bleeding, including GIB, was 7.42% for DOAC vs 3.76% for LAAC). In the OPTION trial, LAAC reduced non-procedure-related major or clinically relevant nonmajor bleeding at 36 months compared to OAC in patients undergoing catheter-based AF ablation. In a real-world study about LAAC in 43 anticoagulated patients with previous GIB, hospitalization need, number of endoscopic procedures, as well as iron intravenous doses and packed red cells administered decreased after LAAC. In cirrhosis, LAAC appears to be associated with an increased risk of complications (renal failure, cardiac tamponade, GIB) and readmissions.

Conclusions: LAAC offers a treatment option for stroke prevention in AF patients in whom lifelong anticoagulation is contraindicated due to recurrent GIB, chronic anaemia or high bleeding risk. In cirrhotic patients, careful selection and shared decision-making are critical due to its higher complications risk.

Failure of infliximab (IFX) therapy is often associated with pharmacokinetic challenges, frequently linked to the development of anti-infliximab antibodies (ATI). ATI formation is a key factor contributing to therapeutic failure and significant safety concerns, as these antibodies can trigger severe infusion-related reactions that may require treatment discontinuation. In Spain, most available ATI detection assays are sensitivity-based, identifying antibodies only in the absence of circulating IFX. In contrast, tolerance assays can detect ATI even in the presence of IFX, offering distinct advantages in managing immunogenicity. We report the case of a 29-year-old female with corticosteroid-refractory ulcerative colitis undergoing IFX treatment. The patient experienced an infusion reaction during her sixth dose. Blood tests revealed IFX trough levels of 10.6 µg/mL, free ATI <0.2 UA/mL, and total ATI >250 UA/mL. This case highlights the utility of tolerance assays in promptly assessing ATI during infusion reactions, enabling real-time therapeutic adjustments. While measuring free ATI is generally more informative in clinical practice, total antibody levels may provide valuable complementary insights, particularly in cases of suspected immunogenicity during infusion reactions.

Background: Cholecystectomy has traditionally been the mainstay of treatment for symptomatic gallstones; however, the complications of cholecystectomy have led to the adoption of minimally invasive gallbladder-preserving approaches in some patients. A simple but highly effective technique is currently lacking. This study aimed to evaluate the feasibility and safety of a novel endoscopic transgastric gallbladder-preserving cholecystolithotomy (GPC) for this condition.

Methods: This was a single-arm prospective clinical study involving 23 patients with symptomatic gallstones enrolled between July 2018 and August 2020. All patients underwent a novel endoscopic transgastric GPC, in which we performed the cholecystogastrostomy via transgastric natural orifice translumenal endoscopic surgery (NOTES) using a gallbladder stent as the passage before advanced endoscopic cholecystolithotomy. Technical success, therapeutic efficacy, and procedure-related complications were evaluated.

Results: The technical success rate of transgastric NOTES-guided cholecystogastric stent placement was 95.7% (22/23). One case which failed due to an intraoperative finding of pericholecystic adhesions was subsequently converted to cholecystectomy. Among the 22 patients who achieved technical success, 19 underwent a simple cholecystolithotomy using a basket or balloon. In the remaining three patients, two required lithotripsy for large gallstones and the other for an incarcerated calculus using an ultraslim endoscope on retrial. All 22 patients achieved wound healing within 4 days postoperatively. Common procedure-related complications were hemorrhage and infection, all of which were mild and temporal. The overall stone recurrence rate was 9.1% at the 3-year follow-up.

Conclusion: The novel endoscopic transgastric GPC could be a safe and effective alternative endoscopic approach for GPC.

Purpose: This meta-analysis evaluated changes in ferroptosis-related factors during intestinal ischemia-reperfusion injury by integrating data from animal experiments.

Methods: Five databases were searched and 11 studies were selected from an initial pool of 105 publications. Primary indicators included Chiu's score, Fe²⁺, and Glutathione Peroxidase 4 (GPX4), while secondary metrics included malondialdehyde (MDA), glutathione (GSH), reduced glutathione/oxidized glutathione (GSH/GSSG), solute carrier family 7 member 11 (SLC7A11), ferritin heavy chain 1 (FTH1), and Superoxide Dismutase (SOD). Sensitivity analyses were performed to assess heterogeneity and ensure the stability of the results. Funnel plots were employed to address publication bias. Statistical analyses were conducted using Review Manager 5.3.

Results: The meta-analysis of the eleven selected studies indicated that intestinal IRI significantly increased Chiu's score (standard mean difference: 4.97, P < 0.00001) and oxidative stress markers such as MDA (5.41, P < 0.00001) while decreasing SOD levels (5.64, P = 0.01). Ferroptosis was significantly increased during intestinal IRI, as shown by the elevation of Fe²⁺ (4.31, P < 0.00001) and reductions in GPX4 (-4.43, P < 0.00001), GSH (-2.45, P < 0.00001), GSH/GSSG (-3.69, P < 0.00001), SLC7A11 (-3.61, P = 0.02), and FTH1 (-3.10, P < 0.0001).

Conclusion: Intestinal IRI leads to increased Chiu's score, MDA, and Fe²⁺ levels, alongside decreased levels of GPX4, GSH, GSH/GSSG, FTH1, and SLC7A11, all of which are associated with the promotion of ferroptosis. The ischemia model employing 45 minutes of ischemia appears to yield superior outcomes regarding the evaluated markers.

Introduction: Studies suggest that older individuals are at risk colorectal cancer postoperative complications following colorectal cancer owing to preoperative sarcopenia, and the prevention of these complication is crucial. The Prognostic Nutritional Index is a preoperative nutritional assessment, and its association with postoperative complications and sarcopenia have been previously reported.

Purpose: A reduction in skeletal muscle mass is essential for diagnosing sarcopenia, there are no available biomarkers that evaluate this. Thus, we focused on titin, a giant elastic protein present in skeletal muscle.

Material and methods: This study was conducted as a prospective observational cohort study. A total of 105 patients who underwent colorectal cancer surgery in our department were included in the study. The patients were divided into two groups: those with and those without postoperative complications of Clavien-Dindo classification II or higher, and those with Prognostic Nutritional Index of 40 or higher or lower. Using blood samples, nutritional markers, inflammatory markers, urinary titin, and psoas volume, univariate and multivariate analyses were performed between the two groups to examine risk factors.

Results: Postoperative complication group comprised 12 patients, and comparisons between the two groups revealed a trend toward higher urinary titin in the group with complications with significant differences in univariate and multivariate analysis. The group with Prognostic Nutritional Index of <40 comprised 15 patients, and both analysis showed a trend toward higher urinary titin in the Prognostic Nutritional Index of <40 group with significant differences.

Conclusion: Urinary titin may serve as a potential marker associated with postoperative complications.

Aims: To determine the efficacy and safety of endoscopic resection of appendiceal orifice (AO) lesions. Primary endpoints were recurrence rate and the need for additional interventions during a clinical follow-up of at least 12 months and/or one surveillance colonoscopy.

Methods: Retrospective analysis of consecutive endoscopic resection of appendiceal lesions performed at eight centers in Spain between January 2016 and July 2023. Endoscopic resection techniques included endoscopic mucosal resection, underwater EMR (UEMR), endoscopic full-thickness resection, or endoscopic submucosal dissection.

Results: A total of 97 lesions were treated (median size 18 mm), 32 showing deep intra-appendicular involvement, and 62 having ≥50% circumferential involvement. UEMR was used in 52% of cases. Technical success was 93% (48% en-bloc resection). There were 6 intraprocedural and 1 postprocedural bleeding and 1 intraprocedural perforation managed endoscopically, but no cases of early post-resection appendicitis. During a median endoscopic follow-up of 23 months (n=51), 13 recurrences (25%) were identified (median time 10 months[IQR]=9-20). Piecemeal resection was significantly associated with recurrence (univariate). Deep AO extension, size ≥2cm and previous manipulation were significantly associated with piecemeal resection (multivariate). Surgery was required in 12 cases due to incomplete resection (n=7), malignancy (n=1), residual adenoma (n=2) and delayed post-resection appendicitis (n=2; at 11- and 56-months post-resection).

Conclusions: Endoscopic management of AO lesions is effective and safe. However, recurrence risk emphasizes the need for long-term follow-up. Further research is required to assess delayed appendicitis risk and the optimal management of deep extension AO lesions.