[Flexible endoscopic treatment for Zenker's diverticulum: preliminary results in a single center experience in a public hospital in Argentina.] / Tratamiento del divertículo de Zenker con endoscopio flexible: experiencia en us hospital público de la Arfgentina.

Zenker's diverticulum (ZD) is an acquired protrusion of the esophageal wall. Treatment is reservedfor symptomatic cases. In Argentina, ZD has historically managed exclusively by surgical intervention. In 1995, Ishioka, et al and Mulder, et a1published their experience using flexible endoscopes for diverticulotomy. Since then, a wide variety ofdifferent techniques have been published. Objetive. To present technique modifications and results ofour center. MATERIAL AND METHODS: We reviewed the database of57patients (36 men), with a mean age of 71.9 years (range 37-98), with symptomatic Zenker ' diverticulum, who underwent endoscopic myotomy, from December 1997 to April 2015. All procedures were performed in our center, by the same endoscopist (HM). The most common symptom was dysphagia (94.7%), which was recorded by a 0-4 score (0=no dysphagia, 1 =solids, 2=semisolids, 3=liquids, 4=saliva). The first nine cases were done exposing the septum with a nasogastric tube, and the others with a soft diverticuloscope. Allprocedures were carried out with the patient under deep sedation, adminis- tered by an anesthesiologist. A myotomy was done in all cases with a needle-knife, using a coagulation current, to prevent bleeding. Clips were placed to close mucosalilaps, decrease the risk of unsuspected perforation and postprocedure bleeding. RESULTS: Seventy procedures were performed, in 56 patients. One patient was excluded because of incomplete myotomy due to a severe adverse event. Ninety-eight percent ofpatients had resolution or improvement of the dysphagia score, at 30 days. Three patients with regurgitation as their sole complaint completely resolved their symptom. Median follow-up was 25 months (1-99). Thirty-seven patients were followed for at least 1 year and 97.3% showed a favorable outcome. In 13 cases (22.8%) a reintervention was needed, with positive results in all cases. Bleeding occurred in one patient (1.4%), who required surgery. Another patient required surgical intervention due to technical issues. There were no perforations or infections. CONCLUSION: Treatment of ZD with flexible endoscope is a safe and effective option, with good long-term results. We need randomized clinical trials comparing different therapeutic options to be able to recommend a definitive strategy. Until then, we suggest using the technique with which each center has the most experience and feels most comfortable performing.

Protein-losing enteropathy associated with refractory systemic lupus erythematosus with a good response to rituximab.

A case is presented of a protein-losing enteropathy (PLE) as the initial manifestation of systemic lupus erythematosus (SLE) in a 17 year-old female patient, who presented with ascites, edema and hypoalbuminemia. The diagnosis of SLE was based on the presence of: malar rash, oral ulcers, thrombocytopenia, antinuclear antibodies, IgM anticardiolipin antibody, and lupus anticoagulant. Renal and liver diseases were ruled out. The PLE diagnosis was confirmed with fecal alpha 1-antitrypsin clearance. The PLE was refractory to different lines of immunosuppressive agents like glucocorticoids, cyclophosphamide, azathioprine, and cyclosporine, showing a satisfactory and sustained response with rituximab, allowing steroid sparing and long term remission.