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Endoscopic balloon dilation (EBD) is the established endoscopic treatment for short strictures in Crohn's disease. Fully covered self-expandable metal stents (FCSEMS) have been used for endoscopic treatment of patients for whom EBD was unsuccessful. We aimed to determine the efficacy and safety of the two endoscopic treatments in patients with Crohn's disease with stenosis and compare the mean cost of both treatments.This multicentre, open-label, randomised trial was done in 19 tertiary and secondary hospitals in Spain. Patients with Crohn's disease with obstructive symptoms and predominantly fibrotic strictures of less than 10 cm in length were eligible for inclusion. We excluded patients with stenosis treated with SEMS or EBD in the previous year and stenosis not accessible to a colonoscope. Patients were randomly assigned (1:1) to receive either EBD (EBD group) or FCSEMS (FCSEMS group) using a digital en-block randomisation system (block size of four). In the EBD group, dilation was done with a CRE Boston Scientific (Marlborough, MA, USA) pneumatic balloon with the diameter set at the discretion of the endoscopist; a maximum of two sessions of dilation were allowed with a minimum interval of 15-30 days between them. In the FCSEMS group, a 20 mm diameter Taewoong (Gimpo-si, South Korea) fully covered metal stent was placed; stent length was set at the discretion of the endoscopist. The primary outcome was to assess the efficacy of the endoscopic treatment, defined by the proportion of patients free of a new therapeutic intervention (EBD, FCSEMS, or surgery) due to symptomatic recurrence at 1 year of follow-up. Patients were analysed according to the intention-to-treat principle. Adverse events were recorded for all the patients; events were considered associated to be with the procedure when a causal association was possible, probable, or definite. This trial is registered with ClinicalTrials.gov, NCT02395354.From Aug 28, 2013, to Oct 9, 2017, we assessed the eligibility of 99 patients, of whom 19 (19%) patients were excluded. Thus, 80 (81%) patients were randomly assigned to treatment: 39 (49%) patients to the FCSEMS group and 41 (51%) patients to the EBD group. 33 (80%) of 41 patients in the EBD group and 20 (51%) of 39 patients in the FCSEMS group were free of a new therapeutic intervention at 1 year (odds ratio [OR] 3·9 [95% CI 1·4-10·6]; p=0·0061). Two (3%) of 80 patients had severe adverse events (one [2%] patient in the EBD group and one [3%] patient in the FCSEMS group); both patients had perforations.EBD is more effective than FCSEMS for Crohn's disease strictures, with a good safety profile for both treatments.Spanish National Institute of Health, Foundation of Spanish Society of Digestive Endoscopy, Catalan Society of Gastroenterology, and Taweoong.

Despite pharmacological advances, strictures in Crohn's Disease (CD) continues to be an important problem that leads in a high percentage of patients to undergo endoscopic and/or surgical treatments. There are currently no clinical scores or diagnostic tools that allow predicting which patients will develop this complication, and when a stricture is diagnosed, it is usually already well established and clinically relevant. The current role of pharmacological treatment is limited to treat inflammation and once there is significant fibrosis, the only therapeutic options are endoscopic and/or surgical. To establish a correct therapeutic algorithm and based on the current scientific evidence available, the Spanish Group Working on Crohn's Disease and Ulcerative Colitis (GETECCU) has decided to conduct this position statement on the treatment of strictures in CD. This document embraces the three mentioned therapeutic approaches, medical, endoscopic and surgical. Recommendations and therapeutic algorithms are established to help us to choose the most appropriate option based on the characteristics of the stricture and the patient.

Resumen Introduccion El uso de un stent metalico autoexpandible como puente a la cirugia del cancer de colon izquierdo en oclusion se ha senalado como tratamiento alternativo a la cirugia de urgencia. El objetivo del presente estudio fue comparar la morbimortalidad, el coste-beneficio y los resultados oncologicos a largo plazo de ambas opciones terapeuticas. Metodos Se trata de un estudio prospectivo, comparativo, controlado y no aleatorizado (2005-2010) realizado en una unidad especializada. El estudio agrupo a 82 pacientes con cancer de colon izquierdo en oclusion tratados mediante stent como puente a la cirugia (n = 27) o cirugia de urgencia (n = 55), intervenidos con intencion curativa local. Las principales variables del estudio (morbimortalidad postoperatoria, coste-beneficio, tasa de estomas y resultados oncologicos a largo plazo) fueron comparados sobre la base de un analisis «con intencion de tratar». Resultados No se encontraron diferencias estadisticamente significativas entre los dos grupos en terminos de datos preoperatorios y caracteristicas tumorales. La tasa de exito tecnico en la colocacion de la endoprotesis fue del 88,9% (con un 11,1% de perforaciones derivadas del stent), y el exito clinico fue del 81,4%. No se observo diferencia alguna en cuanto a los indices de morbimortalidad postoperatoria. La tasa de anastomosis primaria fue superior en el grupo «stent como puente a la cirugia», en comparacion al grupo «cirugia de urgencia» (77,8% frente a 56,4%; p = 0,05). Los costes medios por paciente en el grupo «cirugia de urgencia» resultaron ser mas elevados (+1.391,9 €) que en el grupo «stent como puente a la cirugia». No se produjeron diferencias estadisticamente significativas en cuanto a resulados oncologicos a largo plazo. Conclusiones El uso de stents metalicos autoexpandibles como puente a la cirugia constituye una opcion segura para el tratamiento urgente del cancer de colon izquierdo en oclusion, con resultados oncologicos similares a largo plazo en comparacion a la cirugia de urgencia, con menor coste economico y una tasa superior de anastomosis primarias, evitando numerosos estomas.

Introduction: The use of a self-expanding metallic stent as a bridge to surgery in acute malignant left colonic obstruction has been suggested as an alternative treatment to emergency surgery. The aim of the present study was to compare the morbi-mortality, cost-benefit and long-term oncological outcomes of both therapeutic options. Methods: This is a prospective, comparative, controlled, non-randomized study (2005-2010) performed in a specialized unit. The study included 82 patients with left colon cancer obstruction treated by stent as a bridge to surgery (n = 27) or emergency surgery (n = 55) operated with local curative intention. The main outcome measures (postoperative morbimortaliy, cost-benefit, stoma rate and long-term oncological outcomes) were compared based on an "intention-to-treat'' analysis. Results: There were no significant statistical differences between the two groups in terms of preoperative data and tumor characteristics. The technically successful stenting rate was 88.9% (11.1% perforation during stent placement) and clinical success was 81.4%. No difference was observed in postoperative morbi-mortality rates. The primary anastomosis rate was higher in the bridge to surgery group compared to the emergency surgery group (77.8% vs. 56.4%; P =.05). The mean costs in the emergency surgery group resulted to be (Sic)1,391.9 more expensive per patient than in the bridge to surgery group. There was no significant statistical difference in oncological long-term outcomes. Conclusions: The use of self-expanding metalllic stents as a bridge to surgery is a safe option in the urgent treatment of obstructive left colon cancer, with similar short and long-term results compared to direct surgery, inferior mean costs and a higher rate of primary anastomosis. (C) 2017 AEC. Published by Elsevier Espanna, S.L.U. All rights reserved.

Background & Aims: The aim of this study was to establish a simple method to exclude the possibility of pelvic floor dyssynergia (PFD) in constipated patients and thus avoid unnecessary expensive physiologic studies. Methods: Patients with suspicion of functional constipation (FC) were studied prospectively between 1994 and 2002, excluding those with severe systemic, psychological, or symptomatic anorectal/colonic disorders or taking medications that might modify symptoms or results of studies. Diagnosis of PFD was established retrospectively by manometric plus defecographic findings according to Rome II criteria. Two groups of patients were identified: FC without PFD (FC group) and PFD group. A 30-day symptom diary and balloon expulsion test results were evaluated in all patients. Clinical differences and results of the expulsion test were statistically compared between groups. Results: Of 359 patients evaluated, 130 were included (FC group, 106; PFD group, 24). According to data from the diary, only anal pain was more frequent in the PFD group compared with the FC group (anal pain in >25% of defecations, 70.8% vs. 40.6%; P 2 test). The expulsion test was pathologic in 21 of 24 patients with PFD and 12 of 106 without PFD. The specificity and negative predictive value of the test for excluding PFD were 89% and 97%, respectively. Conclusions: The balloon expulsion test is a simple and useful screening procedure to identify constipated patients who do not have PFD. Symptoms are not enough to differentiate between subtypes of constipation.

Antecedentes El examen de la Latencia Motora Terminal de Nervios Pudendos (LMTNP) se utiliza habitualmente para valorar la existencia o no de Neuropatia Pudenda (NP). Sin embargo, la utilidad de esta tecnica es motivo de controversia dado que unicamente evalua las fibras nerviosas de conduccion rapida. Objetivos Establecer la prevalencia de NP medida mediante la LMTNP en pacientes con Incontinencia anal (IA) y evaluar la relacion existente entre NP y funcion ano-rectal en estos pacientes. Metodos Se revisaron un total de 380 pacientes con IA, 348 (91,6%) mujeres, con edad media de 59 anos (rango 15–84 anos). Todos ellos fueron estudiados mediante ecografia endoanal, manometria ano- rectal, estudio de sensibilidad rectal, test de retencion intra-rectal de liquidos (1500 ml), asi como LMTNP. Ademas, un subgrupo de 121 pacientes completaron tratamiento con biofeedback (BF). Los datos obtenidos fueron analizados mediante el test t de Student para dos muestras independientes asi como el estadistico chi-cuadrado. Resultados Para un punto de corte menor de 2,2 ms como valor normal del estudio de LMTNP, 150 pacientes (39,5%) presentaron NP, siendo esta bilateral en 82 pacientes (21,6%). La NP, sea unilateral (unilateral vs no NP) o bilateral (bilateral vs no NP), no se asocia a una disminucion de la presion media de reposo, presion media de contraccion voluntaria o del indice de gravedad de la incontinencia (score de Miller). Tampoco se objetiva asociacion significativa entre la existencia de NP y anormalidades en la sensibilidad rectal ni con un menor porcentaje de retencion en el test de perfusion intra-rectal de liquidos (ver tabla adjunta). De los 107 pacientes que en ecografia endoanal presentaban un aparato esfinteriano anal intacto, un 35% mostraban un alargamiento de la LMTNP de forma unilateral, y un 20% bilateralmente, porcentajes similares a los encontrados en pacientes con lesion esfinteriana. Tampoco se ha observado relacion entre la existencia de NP y resultados clinicos tras tratamiento con BF. Se han obtenido resultados similares, al aplicar en el test de LMTNP un valor de corte de normalidad de menos de 2,4 ms. Conclusiones La NP evaluada mediante el test de LMTNP es una alteracion frecuente en individuos con IA y su presencia no se asocia con descensos en las presiones del canal anal, existencia de sensibilidad rectal patologica ni con disminucion del porcentaje de retencion intra-rectal de liquidos. Los hallazgos del estudio de LMTNP no son predictores de los resultados obtenidos con BF. Por todo ello, la LMTNP no puede ser recomendada para la evaluacion de pacientes con IA. PNTML resultados Presion basal (mmHg) Presion Contraccion Voluntaria (mmHg) Sensibilidad Rectal (ml) Retencion Liquidos (%) Bilateral ⩾ 2.2 ms (n=82) 52±28 105±52 35±19 47±27 Normal 51±26 104±54 34±21 49±28 Unilateral ⩾ 2.2 ms (n=150) 50±25 107±48 35±18 47±29

Introduccion El estrenimiento es un sintoma relatado por el paciente y el medico verifica que cumple los criterios consensuados para sentar el diagnostico de ECF. Para algunos autores el TTC seria el metodo objetivo para la definicion de estrenimiento. Objetivos Relacionar los datos clinicos recogidos mediante diario de 30 dias con el TTC determinado por marcadores radioopacos en pacientes con ECF. Material y metodos Grupo de estudio constituido por 220 pacientes diagnosticados de ECF (Roma II) de edad media 38,3±15 anos (IC95% 36,3–40,3, mediana 37 anos), integrado por 204 mujeres (38,4±15,2, IC95% 36,3–40,5, mediana 37) y 16 hombres (36,1±12,9, IC95% 29,2–43, mediana 31,5 anos). Se han recogido los datos sobre habito intestinal (frecuencia, consistencia de las heces, sintomas defecatorios, uso y tipo de laxantes) mediante diario de 30 dias y se ha determinado tiempo de transito colonico (TTC) con marcadores radioopacos; como valores de normalidad se han tomado los referidos por el Grupo Espanol de Motilidad Digestiva (GEMD) (transito lento > IC95%), ajustados por sexo. La comparacion de variables cualitativas se ha realizado mediante el estadistico chi-cuadrado y las variables cuantitativas por la t de Student para muestras independientes; se ha tomado como limite de significatividad estadistica una p Resultados El TTC medio es de 76,6±54,4 horas (IC95% 69,4–83,7, mediana 69,6 horas); superior en las mujeres (78,5±53,5) respecto a los hombres (51,9±47,1), sin alcanzar significatividad estadistica (p=0,055). Solo en el 32,7% de los pacientes se objetiva un TTC superior al IC95% del grupo de sujetos sanos (64,4 horas en hombres y 92,5 horas en mujeres) (GEMD): 33,8% en mujeres y 31,5% en hombres. En nuestro grupo de estudio, el sexo y la edad (cuartiles) no se relacionan con un TTC alargado (p=1.000 y p=0,652, respectivamente). En la Tabla se especifican las relaciones entre los datos recogidos en el diario (30 dias) y el resultado del TTC (normal/lento). Datos diario 30 dias TTC TTC > IC95% (n. 74) P Toma laxantes 84,9% 87,8% 0,425 Deposiciones/semana 5,90±3,79 4,53±2,10 0,005 Numero dias sin deposicion 10,43±6,62 14,49±6,17 0,000 % dias sin deposicion 36,97±22,74 51,39±21,39 0,000 % deposiciones bolas/duras 45,58±33,84 48,87±34,05 0,952 % deposiciones normales/blandas 51,39±33,52 51,23±30,07 0,974 % esfuerzo defecatorio 62,68±30,53 65,43±35,19 0,556 % evacuacion incompleta 47,32±37,62 41,99±39,60 0,337 % dolor anal con deposicion 35,34±35,29 35,85±40,13 0,925 % dolor abdominal con deposicion 30,08±34,64 42,56±39,91 0,026 Conclusiones El TTC aisladamente no puede utilizarse para la definicion de ECF en pacientes que cumplen criterios clinicos segun Roma II. Solo se observa relacion del TTC lento con la frecuencia defecatoria y dolor abdominal, pero no con las caracteristicas de las heces y sintomas defecatorios.

Late Recurrence Of Anal Fissure ARer Conservative Therapy With Botufinum Toxin Miguel Minguez, Dept of Gastroenterology, Univ Clin Hosp, Valencia Spain; Alejandro Espi, Dept of Surg, Univ Clio Hosp, Valencia Spain; Vicente Sanchiz, Isabel Pascual, Dept of Gastroenterology, Univ Clin Hosp, Valencia Spain; Eduardo Garcia-Granero, Dept of Surg, Univ Clin Hosp, Valencia Spain; Andres Pena, Francisco Mora, Pedro Almela, Vicente Hernandez, Paloma Lluch, Cirilo Amoros, Adolfo Benages, Dept of Gastroenterology, Univ Clin Hosp, Valencia Spain