Manejo de perforaciones, fugas y fístulas del tracto gastrointestinal con clip sobre el endoscopio. Experiencia de un centro oncológico Latinoamericano / Management of perforations, leaks and fistulas of the gastrointestinal tract with over the scope clip. Experience at a Latin American cancer center

Introducción. Las fístulas derivadas de enfermedades neoplásicas del tracto digestivo, así como las fugas posteriores a procedimientos quirúrgicos, no son infrecuentes y ocasionan una morbilidad importante cuando se manejan de forma quirúrgica. También durante los procedimientos endoscópicos se pueden presentar perforaciones y, si se logra un manejo no operatorio, se alcanza una adecuada recuperación. El objetivo de este estudio fue describir las características clínicas y los resultados de los pacientes con perforaciones, fístulas y fugas del tracto gastrointestinal, manejadas endoscópicamente con clip sobre el endoscopio. Métodos. Estudio descriptivo, retrospectivo, de pacientes con perforación, fuga o fístula postoperatoria, llevados a endoscopía digestiva con colocación de clip sobre el endoscopio, en el Instituto Nacional de Cancerología en Bogotá, D.C., Colombia, entre enero de 2016 y abril de 2020. Resultados. Se incluyeron 21 pacientes, 52,4 % de ellos mujeres. La mediana de edad fue de 66 años y del diámetro del defecto fue de 9 mm. En el 95 % se logró éxito técnico. Hubo éxito clínico temprano en el 85,7 % de los casos. El 76,1 % de los pacientes permanecieron sin síntomas a los 3 meses de seguimiento. Conclusiones. El manejo de perforaciones, fugas y fístulas con clip sobre el endoscopio parece ser factible y seguro. En la mayoría de estos pacientes se logró la liberación del clip y la identificación endoscópica del cierre inmediatamente después del procedimiento; sin embargo, en el caso de las fístulas, no se alcanzó el éxito clínico tardío en todos los casos

Introduction. Fistula of the digestive tract derived from neoplastic diseases as well as leaks following surgical procedures are not uncommon and usually cause significant morbidity when are managed surgically. Diagnostic and therapeutic endoscopic procedures may present perforations during their performance; if they are managed non-operatively, an adequate recovery is obtained. The purpose of this study was to describe the clinical characteristics and the short- and long-term outcomes of patients with perforations, fistulas and leaks of the gastrointestinal tract managed endoscopically with over the scope clip (OTSC). Methods. Descriptive, retrospective study of patients brought to digestive endoscopy with OTSC placement with diagnosis of postoperative perforation, leak or fistula at the National Cancer Institute in Bogota, Colombia, between January 2016 and April 2020. Results. Twenty-one patients were taken for OTSC application for the management of perforations, leaks and fistulas of the gastrointestinal tract, 52.4% of them were women. The median age was 66 years. The median diameter of the defect was 9 mm. Technical success was achieved in 95%. Early clinical success was described in 85.7% of the cases; 76.1% of patients remained symptom-free at 3-month follow-up. Conclusions. Management of perforations, leaks and fistulas with OTSC appears to be feasible and safe. In most of these patients, clip release and endoscopic identification of closure was achieved immediately after management; however, in the case of fistulas, late clinical success was not achieved in all cases

Invaginación sigmoidea en un adulto. ¿Está indicada la reducción endoscópica preoperatoria? / Sigmoid invagination in an adult. Is preoperative endoscopic reduction indicated?

Introducción. La invaginación intestinal o intususcepción es el deslizamiento de una parte del intestino dentro de otra adyacente. Es la causa más común de obstrucción intestinal en niños entre 3 meses y 6 años de edad, con una baja incidencia en adultos, correspondiente al 1 % del total de los cuadros obstructivos en el adulto. Su localización en colon es poco frecuente, pero conviene prestar especial atención por su asociación a lesiones malignas. Caso clínico. Varón de 39 años que acude a Urgencias con cuadro de obstrucción intestinal secundario a una invaginación en sigmoide. Se intenta reducción endoscópica, sin éxito, por lo que se indicó cirugía urgente, realizando sigmoidectomía y anastomosis colorrectal. El resultado anatomopatológico informó un adenoma de gran tamaño como causante de la invaginación. Conclusión. Existen controversias respecto al manejo endoscópico en invaginación intestinal en los adultos, especialmente en el colon, debido al elevado porcentaje de etiología tumoral maligna, recomendándose actualmente la resección en bloque sin reducción, para minimizar el riesgo de potencial siembra tumoral.

Introduction. Intestinal invagination or intussusception is the sliding of one part of the intestine into the adjacent one. It is the most common cause of intestinal obstruction in children between 3 months and 6 years of age, with a low incidence in adults, corresponding to 1% of all obstructive conditions in adults. Its location in the colon is rare, but special attention should be paid due to its association with malignant lesions. Case report. A 39-year-old male admitted to the emergency department with symptoms of intestinal obstruction secondary to a sigmoid intussusception. Endoscopic reduction was attempted, without success, so urgent surgery was indicated, performing sigmoidectomy and colorectal anastomosis. The pathology result reported a large adenoma as the cause of invagination. Conclusion. There are controversies regarding the endoscopic management of intussusception in adults, especially in the colon, due to the high percentage of malignant tumor etiology, currently recommending en bloc resection without reduction, to minimize the risk of potential tumor seeding.

Aspectos clinicoepidemiológicos, endoscópicos e histológicos en ancianos con cáncer gástrico / Some clinical-epidemiological, endoscopic and histological aspects in elderly with gastric cancer

Introducción: El cáncer gástrico ocupa el quinto lugar en incidencia de todos los tipos de neoplasias malignas y la segunda causa de muerte por cáncer en el mundo, pues la mayoría de los pacientes presentan más de 60 años de edad al ser diagnosticados. Objetivo: Caracterizar a ancianos con cáncer gástrico según variables de interés. Métodos: Se realizó un estudio observacional y descriptivo, de serie de casos, de 56 pacientes mayores de 60 años con diagnóstico endoscópico e histológico de cáncer gástrico, quienes fueron ingresados en el Hospital Provincial Clínico-Quirúrgico Docente Saturnino Lora de Santiago de Cuba, en el período 2016-2019. Resultados: En la serie predominaron los ancianos de 60-69 años de edad (46,4 %), principalmente del sexo masculino (67,8 %), y los síntomas más frecuentes fueron la epigastralgia (82,1 %) y la saciedad precoz (67,8 %). Entre las características más relevantes de las lesiones tumorales figuraron la localización antropilórica (55,3 %), la forma ulcerada en la endoscopia (51,7 %) y la variedad hística adenocarcinoma moderadamente diferenciado (43,4 %); asimismo, se determinó la existencia de Helicobacter pylori en 52,5 % de los resultados anatomopatológicos de las biopsias. Conclusiones: Resulta importante considerar la presencia de un adenocarcinoma gástrico en los pacientes mayores de 60 años que refieran síntomas digestivos, sobre todos si son hombres y padecen epigastralgia, más aún si al realizarle la esofagogastroduodenoscopia se observa una lesión ulcerada de localización antropilórica.

Introduction: Gastric cancer occupies the fifth place in incidence among all types of malignancies and is the second cause of death in the world, as most of the patients are more than 60 years when being diagnosed. Objective: To characterize aged patients according to variables of interests. Methods: An observational, descriptive and series of cases study was carried out in 56 patients older than 60 years with endoscopic and histologic diagnosis of gastric cancer, who were admitted in Saturnino Lora Teaching Provincial Clinical-Surgical Hospital, during 2016-2019. Results: Elderly in the age group 60-69 years predominated (46.4 %), mainly of the male sex (67.8 %), and the most frequent symptoms were epigastralgia (82.1 %) and the early fullness sensation (67.8 %). Among the most relevant characteristics of the tumoral lesions there were the antropiloric location (55.3 %), the ulcerated presentation in the endoscopy (51.7 %), and the histic variety mildly differentiated adenocarcinoma (43.4 %), likewise, the existence of Helicobacter pylori was confirmed in 52,5 % of the pathological biopsy results. Conclusions: It is interesting to consider the presence of a gastric adenocarcinoma in patients older than 60 years expressing gastric symptoms, mainly if they are men or suffer from epigastralgia, even more if when carrying out the esophagogastroduodenoscopy, an ulcerated lesion of antropiloric location is observed.

Bezoar de dinero: reporte de bezoar atípico, su manejo y una revisión de la literatura / Money Bezoar: Report of atypical bezoar, its treatment, and a literature review

Resumen Objetivos: Presentar el manejo laparoscópico en un caso de bezoar atípico y una revisión de la literatura. Materiales y métodos: Se presenta el caso de un paciente de sexo masculino de 67 años con síndrome pilórico debido a una obstrucción intestinal por cuerpo extraño. Resultados: Se encuentra como hallazgo endoscópico un bezoar atípico (bezoar de dinero) impactado en la región prepilórica sin posibilidad de resolución por este medio, por lo cual se considera el manejo laparoscópico. Discusión: Los bezoares se definen como cualquier objeto el cual tuvo una ingesta voluntaria o involuntaria, que se aloja en alguna parte del tracto gastrointestinal superior, con mayor frecuencia a nivel gástrico, y no se puede digerir por los mecanismos fisiológicos del cuerpo; además, se clasifican según su composición. Conclusiones: En pacientes con obstrucción intestinal alta debido a cuerpos extraños en los cuales el manejo endoscópico falla, el manejo quirúrgico mínimamente invasivo con cirugía laparoscópica es viable y eficaz.

Abstract Objectives: To describe the laparoscopic management of an atypical bezoar case and present a literature review. Materials and methods: This is the case of a 67-year-old male patient with pyloric stenosis due to intestinal obstruction by a foreign body. Results: The endoscopic finding was an atypical bezoar (Money bezoar) in the prepyloric region with no possible resolution by this route, so laparoscopic treatment was considered. Discussion: Bezoars are defined as any object that was voluntarily or involuntarily swollen and is obstructing some part of the upper gastrointestinal tract, usually the stomach, and cannot be digested using the physiological mechanisms of the body. They are categorized based on their composition. Conclusions: When endoscopic treatment fails to relieve upper gastrointestinal tract obstruction caused by foreign bodies, minimally invasive surgical treatment with laparoscopic surgery is a viable and efficient option.

Ingesta de cuerpos extraños magnéticos en la edad pediátrica. Caso clínico de localización y extracción endoscópica con ayuda de un imán / Ingestion of magnetic foreign bodies during the paediatric age. Case report, location and endoscopic extraction aided by a magnet

La ingesta accidental de más de un imán puede producir complicaciones graves. Los protocolos actuales recomiendan la extracción endoscópica de ser posible. El objetivo de este trabajo es presentar un caso clínico de una ingesta de dos imanes y la técnica endoscópica de extracción. Niño de 11 años que acudió a Urgencias tras la ingesta de dos imanes, asintomático. En la radiografía de abdomen, se identificaron dos cuerpos extraños radiopacos, aparentemente unidos, en la cámara gástrica. Se realizó una endoscopía bajo anestesia general en quirófano. Para facilitar la extracción, se colocó, encima de la pared abdominal, a nivel gástrico, un imán de neodimio. En la endoscopía, se observaron dos pequeños imanes localizados y fijados en la cara anterior del estómago. Una vez localizados, se retiró el imán externo y se procedió a su extracción con cesta

The ingestion of more than one magnet can cause multiple complications. Current protocols recommend endoscopic extraction if possible. We report a patient who swallowed two magnets and the endoscopic extraction technique. An 11-yearold boy presented at the Emergency Room after ingesting two small magnets, being asymptomatic. In the abdominal x-ray two radiopaque bodies were identified at the gastric chamber, apparently together. A gastroscopy was done in the operating room under general anaesthesia. To enable the extraction, a neodymium magnet was placed externally at the abdominal wall. In the endoscopic image, the two magnets were fixed to the anterior gastric wall. Once located, the neodymium magnet was removed and the two magnets were retrieved with an endoscopic basket.

Manejo endovascular de la hemorragia digestiva, experiencia del Hospital Universitario Clínica San Rafael / Endovascular management of gastrointestinal bleeding, experienceat Hospital Universitario Clínica San Rafael

Introducción. La hemorragia digestiva ocasiona el 2 % de las hospitalizaciones; se clasifica en alta o baja, y la primera se presenta en el 80 % de casos. Después de la estabilización hemodinámica, se determinan la causa y el tratamiento mediante la endoscopia; no obstante, esta falla en 10 a 20 % de los casos, y del 15 al 20 % requieren cirugía mayor, con una mortalidad de más del 40 %. El tratamiento para la hemorragia digestiva mediante la formación de émbolos de los vasos mesentéricos, es una conducta bien establecida, produce buenos resultados, evita la cirugía y disminuye la morbimortalidad. Objetivos. Determinar la indicación y el éxito del tratamiento endovascular para la hemorragia digestiva en nuestra institución. Materiales y métodos. Estudio retrospectivo y descriptivo, se incluyeron 10 pacientes que requirieron la urgente formación de émbolos por falla o imposibilidad del manejo endoscópico, y que presentaban gran riesgo quirúr-gico y anestésico con la técnica abierta. Se evaluaron la causa de la hemorragia, la arteria comprometida, los hallazgos angiográficos, la hemoglobina antes y después de la formación de los émbolos, la reincidencia de la hemorragia, las complicaciones, la necesidad de intervención quirúrgica, la eficacia del procedimiento y la mortalidad a 30 días. Resultados. Todos los pacientes se intervinieron por vía endovascular, para la oclusión selectiva de las arterias comprometidas. La hemorragia se controló en todos ellos. Se presentaron dos muertes tempranas (<30 días) no asociadas con el procedimiento. No hubo complicaciones secundarias a la formación de los émbolos o al acceso percutáneo y, tampoco, necesidad de cirugías mayores posteriores para controlar la hemorragia. Conclusión. Los métodos endovasculares para controlar la hemorragia digestiva son eficaces, no se acompañan de complicaciones, y disminuyen la morbimortalidad y la necesidad de cirugías mayores. Se requieren estudios con mayor número de pacientes para lograr un mayor grado de certeza

Introduction: Gastrointestinal bleeding is a common problem, which represents 2% of hospitalizations. It is classified as high or low depending on their origin; 80% of cases are high bleeders. After hemodynamic stabilization, endoscopy is very important to determine the cause and carry out treatment, which in some cases is unsuccessful or cannot be performed, and 15% -20% will require major surgery with a mortality rate of over 40%. Occlusion of mesenteric vessels, as a treatment for gastrointestinal bleeding is a well defined and successful therapeutic, avoiding major surgery and reducing morbidity and mortality, it is a procedure with very low incidence of complications and repeated bleeding. We studied: the cause of bleeding, the compromised artery, the angiographic findings, the pre and post embolization hemoglobin, re-bleeding complications, need for additional surgery after embolization effectiveness of the procedure to control bleeding, and mortality at 30 days.Objectives: To determine the indication and success of endovascular treatment for the management of gastroin-testinal bleeding in our institutionMaterials and methods: A retrospective and descriptive study.Results: Ten patients (5 females, 5 males) are included, with an average age of 59.8 years; in six cases the bleeding was due to proximal acid-peptic disease, two patients with diverticular disease performed, and two patients bleeding due to gastroduodenal neoplastic disease; all patients required urgent embolization in view of failure or inability to endoscopic management, associated with progressive anemia, active bleeding, schock and requi-rement of more than 3 packed red blood cells; associated with high surgical and anesthetic risk for open surgery. All patients underwent endovascular procedure with selective embolization and the bleeding stop with hemo-dynamic stabilization, two early deaths (<30days) were presented but not associated with the procedure; there were no complications secondary to embolization or percutaneous access, nor was need for further surgery after the procedure to control bleedingConclusion: In our experience the use of endovascular methods to control gastrointestinal bleeding is effective and uncomplicated; reducing morbidity and mortality and the need for major surgery. More studies are needed to determine the number of patients a higher level of evidence

O uso da pinça de biópsia como técnica auxiliar na visualização da papila duodenal maior utilizando-se o esofagogastroduodenoscópio de visão frontal / The use of the forceps biopsy as an auxiliary technique for the visualization of the major duodenal papilla using the foward-viewing upper endoscopy

ABSTRACT BACKGROUND: - Conventional esophagogastroduodenoscopy is the best method for evaluation of the upper gastrointestinal tract, but it has limitations for the identification of the major duodenal papilla, even after the use of the straightening maneuver. Side-viewing duodenoscope is recommended for optimal examination of major duodenal papilla in patients at high risk for lesions in this region. OBJECTIVE: To evaluate the use of the biopsy forceps during conventional esophagogastroduodenoscopy as an additional tool to the straightening maneuver, in the evaluation of the major duodenal papilla. METHODS: A total of 671 patients were studied between 2013 and 2015, with active major duodenal papilla search in three endoscope steps: not straightened, straightened and use of the biopsy forceps after straightening. In all of them it was recorded whether: major duodenal papilla was fully visualized (position A), partially visualized (position B) or not visualized (position C). If major duodenal papilla was not fully visualized, patients continued to the next step. RESULTS: A total of 341 were female (50.8%) with mean age of 49 years. Of the 671 patients, 324 (48.3%) major duodenal papilla was identified in position A, 112 (16.7%) in position B and 235 (35%) in position C. In the 347 patients who underwent the straightening maneuver, position A was found in 186 (53.6%), position B in 51 (14.7%) and position C in 110 (31.7%). Of the 161 remaining patients and after biopsy forceps use, position A was seen in 94 (58.4%), position B in 14 (8.7%) and position C in 53 (32.9%). The overall rate of complete visualization of major duodenal papilla was 90%. CONCLUSION: The use of the biopsy forceps significantly increased the total major duodenal papilla visualization rate by 14%, reaching 604/671 (90%) of the patients (P<0.01) and it can be easily incorporated into the routine endoscopic examination of the upper gastrointestinal tract.

RESUMO CONTEXTO: Esofagogastroduodenoscopia convencional é o melhor método para avaliação do trato gastrointestinal superior, mas apresenta limitações para identificação da papila duodenal maior, mesmo após emprego da manobra de retificação. Exame completo da papila duodenal maior está indicado para pacientes de alto risco para adenocarcinoma da papila duodenal maior. OBJETIVO: Avaliar a utilização da pinça de biópsia durante esofagogastroduodenoscopia convencional como ferramenta adicional à manobra de retificação na avaliação da papila duodenal maior. MÉTODOS: Foram estudados 671 pacientes entre 2013-2015 com busca ativa da papila duodenal maior em três etapas: endoscópio não retificado, endoscópio retificado e uso da pinça de biópsia após retificação. Em todas se registrou: se a papila duodenal maior foi totalmente visualizada (posição A), se parcialmente visualizada (posição B) ou se não visualizada (posição C). Caso a papila duodenal maior não tenha sido completamente visualizada, o paciente foi direcionado para a etapa seguinte. RESULTADOS: Um total de 341 era do sexo feminino (50,8%) com idade média de 49 anos. Dos 671 pacientes, em 324 (48,3%) a papila duodenal maior foi identificada na posição A, 112 (16,7%) em posição B e, 235 (35%) em posição C. Dos 347 pacientes submetidos à manobra de retificação, posição A foi encontrada em 186 (53,6%), posição B em 51 (14,7%) e posição C em 110 (31,7%). Dos 161 pacientes restantes que utilizaram a pinça de biópsia, posição A foi vista em 94 (58,4%), posição B em 14 (8,7%) e posição C em 53 (32,9%). A taxa acumulativa de visualização completa da papila duodenal maior foi de 90%. CONCLUSÃO: O uso da pinça de biópsia aumentou a taxa de visualização completa da papila duodenal maior em 14%, alcançando 604/671 (90%) dos pacientes (P<0,01) avaliados e pode ser facilmente incorporada aos exames endoscópicos de rotina do trato gastrointestinal superior.

Thermal tissue effects of the second-generation argon plasma coagulation on human stomach tissue :An ex vivo study / 西安交通大学学报(医学版)

Objective To explore the thermal effects of the second-generation argon plasma coagulation (VIO APC/APC2) on ex vivo human stomach tissue with different mode ,output power and application time .Methods The thermal effects of VIO APC were studied on fresh surgery-resected human stomach tissues .Different output powers were combined with mode "forced (F )","pulse , effect 1 (P1 )" and "pulse , effect 2 (P2 )";three application time ,the depth and maximum diameter of each injury were recorded .Results The depth of tissue injuries was correlated with output power (P<0 .001) ,energy (P=0 .008) and mode (P=0 .013) .The maximum diameter of injuries was correlated with output power (P<0 .001) ,application duration (P=0 .001) ,energy (P<0 .001) and mode (P=0 .001) .The incidence of harmful damage was only related to mode (P=0 .012) .The depth of tissue injuries was P1> F> P2 (P<0 .05) ,and the maximum diameter of injuries was P2> P1> F (P<0 .05) . Conclusion Different modes of VIO APC can create different thermal effects on the gastric tissues .Compared with F mode ,P1 mode creates deeper injuries while P2 mode creates larger but shallow injuries .All the three modes may cause injuries involving muscularis propria .