Anticoagulants and antiplatelet agents are widely used in the prophylaxis and management of thromboembolic and cardiovascular diseases. Gastrointestinal bleeding is a well-known complication of these agents. Modification of anticoagulant and antiplatelet therapy is often required in patients undergoing surgical procedures and specific recommendations for the perioperative period have been issued. Fewer data exist with regard to the use of these agents around the time of endoscopic procedures. A survey of the American Society for Gastrointestinal Endoscopy (ASGE), performed several years ago, showed a wide variation between endoscopists in the management of anticoagulants and antiplatelet agents in the periendoscopic period. Subsequently, guidelines have been proposed by the ASGE as well as the German Society for Gastroenterology (DGVS). The aim of this study was to investigate the current practices among German endoscopists regarding the use of these medications in patients undergoing endoscopic procedures and to assess their adherence to published guidelines. Our data demonstrate that, in spite of the dissemination of guidelines, there is still a wide variation in the periendoscopic management of patients who are at increased risk for bleeding due to anticoagulants, especially in patients taking antiplatelet agents.
An 18-month-old girl was admitted for left pyelonephritis; voiding cysto-urethrography (VCUG) showed left stage III re¯ux and IVU showed symmetrical excretion with a size asymmetry (right 8.2 cm, left 6.3 cm). Follow-up under prophylactic antibiotics was started, with no recurrent UTIs documented. A VCUG assessment one year later showed persistent stage III re¯ux. She was treated using submucosal injections of PTFE paste (0.5 mL PTFE). The postoperative course was unremarkable. A VCUG 6 months later showed that the re¯ux had resolved. The child, regularly followed for asthma, had no further UTIs. When aged 9 years, she presented with chronic left¯ank pain. Ultrasonography showed a very small left kidney and the intravesical PTFE was no longer identi®able. VCUG again con®rmed the good long-term result of the cure of re¯ux, but MAG-3 scintigraphy showed reduced left renal function (<10%). An endoscopic left-sided nephroureterectomy was performed and the postoperative course was uneventful, with complete pain relief. Macroscopic examination of the kidney (6r3r2 cm, with a 7.5 cm ureter) revealed upper cortical cicatricial depressions and total cortical atrophy of the inferior pole. Microscopically, the cortical atrophy was caused by chronic pyelonephritis and, in the inferior pole, an evolutive gigantocellular resorption process (granulomatous) developed through contact with exogenous round particles (5±100 mm) with ®nely crenellated borders, slightly birefringent in polarized light (Fig. 1a,b). Spectrometric analysis con®rmed that these particles were PTFE.
CommentThe endoscopic treatment of re¯ux by injection with submucosal PTFE paste was introduced by Matouschek in 1981 [1]. A problem with this technique is that it introduces foreign bodies, and thus raises questions of local and general tolerance [2]. The migration of the PTFE particles to the lungs and brain has been con®rmed experimentally [3]. Cases of acute pneumopathy, with PTFE in lung biopsies, have been described in adults [4]. In children, migration to the terminal ureter and the perivesical lymphatic vessels, with no clinical consequences, has been reported; we have encountered three such cases. The clinical consequences of particle migration are unknown; long-term follow-up studies are rare [5]. Thus the present case represents the ®rst of clinical symptomatology and destruction of the kidney associated with presence of PTFE in the renal parenchyma. The relationship among these three elements remains to be con®rmed and there are several questions.There are several possible routes by which the particles could migrate. The ®rst is through the injection track, with secondary intraparenchymal in®ltration by the PTFE particles. There was a pelvic and peritubular distribution of the particles but this proposal supposes that the urothelium is breached, so that the PTFE becomes incorporated into the tissues. Furthermore, the delay between injection and symptoms (7 years) seems too long for this route. The second route is vascular, probably not lymphatic but...
FUFOX was efficient for additional tumour control in 70% of patients pretreated with CPT-11/5-FU based regimens. Sequential palliative treatment can lead to prolonged survival.
Simulation training plays an essential role in aviation and minimizes the risk for human errors. In the current study it is clearly shown that simulation training is also useful in gastrointestinal endoscopy. The newly developed workshop may thus be of crucial importance to improve personal crisis management. Simulation also leads to an improvement of endoscopic and emergency skills. Accordingly, simulation training should be recommended or offered as an education option in gastrointestinal endoscopy.
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