[Advances in surgical endoscopy: initial experience in endoscopic colonic submucosal dissection (ESD) in Costa Rica]. / Avances en cirugía endoscópica: experiencia inicial de disección endoscópicade la submucosa (DES) de colon en Costa Rica.

OBJECTIVES: To report the first case in Costa Rica of a colon tumor removed by endoscopic submucosal dissection (ESD). PATIENT AND METHOD: We describe the case of a 70-year-old man with a multilobulated 25 millimeters tumor located in the cecum, near the ileocecal valve, detected during a routine colonoscopic check-up. The biopsy revealed a tubular adenoma with high grade dysplasia and the patient underwent an endoscopic submucosal en-bloc dissection of the lesion. RESULTS: The procedure was successfully performed without complications such as bleeding or perforation. The operative time was 117 minutes. The histopathological analysis of the en-bloc specimen confirmed the diagnosis of high grade dysplasia with negative vertical and horizontal margins. CONCLUSION: Colon ESD is an attractive and safe treatment option for the removal of premalignant lesions and some types of early colon cancer.

Serum pepsinogen levels, Helicobacter pylori CagA Status, and cytokine gene polymorphisms associated with gastric premalignant lesions in Costa Rica.

The detection of gastric premalignant lesions, atrophic gastritis, corpus atrophic gastritis, and intestinal metaplasia, using several potential markers was examined in Costa Rica. Depending on the lesion investigated, from a total of 223 dyspeptic patients, 58 (26.0%), 31 (13.9%), or 23 (10.3%) were histologically diagnosed with atrophic gastritis, corpus atrophic gastritis, or intestinal metaplasia, respectively. Sera were used for the measurement of pepsinogen (PG) and Helicobacter pylori CagA antibody (CagA-ab) levels by ELISA, and human genomic DNAs were used for the genotyping of interleukin (IL)-1beta (-511 and +3954), IL-10 (-1082 and -592), and IL-1RN intron 2 by PCR and RFLP. Multivariate analysis was done adjusting for sex, age, and H. pylori seropositivity. Low PG levels (L-PG; PG I < or = 70 microg/L + PG I/II < or = 3), very low PG levels (VL-PG; PG I < or = 30 microg/L + PG I/II < or = 2), and CagA-ab were individually associated with all premalignant lesions whereas IL-1beta +3954T-carrier and IL-1RN homozygous 2 allele were associated with intestinal metaplasia. VL-PG, for corpus atrophic gastritis detection, was the single marker with the highest combination of test characteristics, sensitivity (77.4%), specificity (80.7%), positive predictive value (39.3%), negative predictive value (95.7%), and seropositivity rate (27.4%), expected to improve after periodic measurements. Combined examinations of VL-PG and CagA-ab improved the specificity (92.7%) and positive predictive value (62.2%), with similar sensitivity (74.2%) and negative predictive value (95.7%). In conclusion, corpus atrophic gastritis detection with periodic measurements of serum PG, alone or in combination with CagA-ab status, to identify high gastric cancer risk, seems to be the method best suited for mass screening in Costa Rica.

Helicobacter pylori CagA status associated with gastric cancer incidence rate variability in Costa Rican regions.

BACKGROUND: We evaluated several risk factors for gastric cancer in Costa Rican regions having contrasting gastric cancer incidence rates, despite the small dimensions of the country. METHODS: A total of 180 dyspeptic patients were classified into two groups according to the gastric cancer incidence (GCI) rate in their Costa Rican region: group A, with a high GCI rate (n = 91) and group B, with a low GCI rate (n = 89). Helicobacter pylori infection was detected by rapid urease test, Gram staining, and histological observation. Antral and corpus specimens were obtained to assess the grade of inflammation, topography of gastritis, gastric atrophy, and intestinal metaplasia by histological examination. Serum CagA antibody was measured by an antigen-specific enzyme-linked immunosorbent assay. RESULTS: There was no significant difference in H. pylori prevalence between groups A (73%) and B (63%); however, serum CagA antibody was more frequently detected in group A (79%) than in group B (54%) [P = 0.02; odds ratio (OR), 2.68]. Among patients under 60 years of age, serum CagA antibody was even more frequently detected in group A (81%) than in group B (49%) (P < 0.01; OR, 4.50). The prevalence of corpus-predominant gastritis, atrophic gastritis, and moderate/severe grades of neutrophilic infiltration was higher in serum CagA antibody-positive patients than in CagA antibody-negative patients (P = 0.003, 0.04, and 0.002, respectively). CONCLUSIONS: Infection with H. pylori possessing the cagA gene is associated with the development of severe gastric damage such as gastric atrophy, leading to gastric cancer, and probably influences the differences in GCI between Costa Rican regions.

[Endoscopic submucosal dissection (esd) for the curative treatment of early gastric cancer: initial experience in Costa Rica]. / Diseccion submucosa endoscopica (dse) para el tratamiento curativo del cancer gastrico precoz: experiencia inicial en Costa Rica.

OBJECTIVES. To report the first case of endoscopic submucosal dissection (ESD) in Costa Rica and to analyze the future impact of this technique for the treatment of early gastric cancer in this country. PATIENTS AND METHODS. We present the case of a 67-year-old woman who underwent an upper endoscopy for mild epigastralgia, resulting in a 12 mm non-ulcerated sessile lesion (0-IIa) located in the antrum at the greater curvature. After biopsy confirmation of a well-differentiated adenocarcinoma limited to the mucosa, the patient underwent an endoscopic submucosal dissection for the en-bloc resection of the lesion. RESULTS. The ESD was successfully performed without intra- or postoperative complications such as bleeding and perforation. Operation time was 65 minutes. Histopathological analysis of the en-bloc specimen confirmed the diagnosis of intramucosal well differentiated adenocarcinoma with negative margins. CONCLUSION. ESD is novel alternative for the curative treatment of early gastric cancer, due to its cost-effectiveness, less invasiveness, which provides a better quality of life for the patient than that of conventional open surgery with same long-term results.

Role of bacterial and genetic factors in gastric cancer in Costa Rica.

AIM: To evaluate several risk factors for gastric cancer (GC) in Costa Rican regions with contrasting GC incidence rate (GCIR). METHODS: According to GCIR, 191 Helicobacter pylori (H pylori)-positive patients were classified into groups A (high GCIR, n = 101) and B (low GCIR, n = 90). Human DNA obtained from biopsy specimens was used in the determination of polymorphisms of the genes coding for interleukin (IL)-1beta and IL-10 by PCR-RFLP, and IL-1RN by PCR. H pylori DNA extractions obtained from clinical isolates of 83 patients were used for PCR-based genotyping of H pylori cagA, vacA and babA2. Human DNA from gastric biopsies of 52 GC patients was utilized for comparative purposes. RESULTS: Cytokine polymorphisms showed no association with GCIR variability. However, gastric atrophy, intestinal metaplasia and strains with different vacA genotypes in the same stomach (mixed strain infection) were more frequently found in group A than in group B, and cagA and vacA s1b were significantly associated with high GCIR (P = 0.026 and 0.041, respectively). IL-1beta+3954_T/C (OR 2.1, 1.0-4.3), IL-1RN*2/L (OR 3.5, 1.7-7.3) and IL-10-592_C/A (OR 3.2, 1.5-6.8) were individually associated with GC, and a combination of these cytokine polymorphisms with H pylori vacA s1b and m1 further increased the risk (OR 7.2, 1.4-36.4). CONCLUSION: Although a proinflammatory cytokine genetic profile showed an increased risk for developing GC, the characteristics of H pylori infection, in particular the status of cagA and vacA genotype distribution seemed to play a major role in GCIR variability in Costa Rica.

Avances en cirugía endoscópica: experiencia inicial de disección endoscópica de la saubmucosa (DES) de colon en Costa Rica / Advances in endoscopic surgery: initial experience of endoscopic submucosal dissection (ESD) in colon in Costa Rica

OBJETIVO. Reportar el primer caso en Costa Rica de disección endoscópica de la submucosa (DES) de un tumor de colon. PACIENTE Y MÉTODO. Se describe el caso de un paciente de 70 años, a quien en una colonoscopia de rutina se le detecta una lesión elevada multilobulada de aproximadamente 25 milímetros localizada en ciego, cerca de la válvula ileocecal. La biopsia reveló un adenoma tubular con displasia de alto grado por lo que el paciente fue sometido a una disección en-bloc de la submucosa de la lesión por vía endoscópica. RESULTADOS. El procedimiento se realizó exitosamente sin complicaciones como sangrado o perforación. El tiempo operatorio fue de 117 minutos. El análisis histopatológico del espécimen en-bloc confirmó el diagnóstico de displasia de alto grado con márgenes verticales y horizontales libres. CONCLUSIÓN. La DES de colon es una atractiva y segura alternativa de tratamiento para resecar de lesiones premalignas y algunos tipos de cáncer temprano de colon.

OBJECTIVES. To report the first case in Costa Rica of a colon tumor removed by endoscopic submucosal dissection (ESD). PATIENT AND METHOD. We describe the case of a 70-year-old man with a multilobulated 25 millimeters tumor located in the cecum, near the ileocecal valve, detected during a routine colonoscopic check-up. The biopsy revealed a tubular adenoma with high grade dysplasia and the patient underwent an endoscopic submucosal en-bloc dissection of the lesion. RESULTS. The procedure was successfully performed without complications such as bleeding or perforation. The operative time was 117 minutes. The histopathological analysis of the en-bloc specimen confirmed the diagnosis of high grade dysplasia with negative vertical and horizontal margins. CONCLUSION. Colon ESD is an attractive and safe treatment option for the removal of premalignant lesions and some types of early colon cancer.

Diversity of Helicobacter pylori cagA and vacA genes in Costa Rica: its relationship with atrophic gastritis and gastric cancer.

BACKGROUND: Associations between Helicobacter pylori gene diversity and gastric cancer have not been reported on in Costa Rica, despite its being one of the countries with the highest gastric cancer incidence and mortality rates in the world. The aim of this study was to determine the prevalence of H. pylori cagA and vacA genes and investigate whether it could be correlated with atrophic gastritis (AG) and gastric cancer (GC) in Costa Rica. MATERIALS AND METHODS: Genomic DNAs from isolates of 104 patients classified into two groups: non-atrophic gastritis group (n = 68) and atrophic gastritis group (n = 36), were subjected to PCR-based genotyping of cagA and vacA genes and their correlation with clinical outcome was investigated. Total DNA extractions from gastric tissues of 25 H. pylori-infected gastric cancer patients were utilized for comparative purposes. RESULTS: The presence of cagA (75.3%), vacA s1b (75.3%), and vacA m1 (74.2%) was detected, and colonization by strains with different vacA genotypes in the same stomach was found in 9.7% of the patients. Age- and sex-adjusted vacA s1b and vacA m1 were associated with GC while only vacA m1 was significantly associated with AG. A tendency for association between cagA and vacA s1b, and AG was reported. CONCLUSIONS: The prevalence status of the cagA and vacA (s1/m1) genes in Costa Rica seems to fall between that found in European/North American and East Asian countries, and both cagA and vacA seem to have clinical relevance in this country.

Disección submucosa endoscópica (dse) para el tratamiento curativo del cáncer gástrico precoz: experiencia inicial en Costa Rica / Endoscopic submucosal dissection (esd) for the curative treatment of early gastric cancer: initial experience in Costa Rica

OBJETIVO. Reportar el primer caso de disección submucosa endoscópica (DSE) en Costa Rica y analizar el futuro impacto de esta técnica en el abordaje del cáncer gástrico precoz en este país. Pacientes y métodos. Presentamos el caso de una paciente de 67 años, quien tras una endoscopia digestiva alta por leve epigastralgia, se le encuentra una lesión elevada sésil no ulcerada (0-IIa) de aproximadamente 12 milímetros localizada en el antro hacia la curvatura mayor. Posterior al resultado histopatológico de adenocarcinoma bien diferenciado limitado a mucosa, la paciente fue sometida a una disección submucosa en una pieza (en-bloc) de la lesión por vía endoscópica. RESULTADOS. La DSE fue realizada sin ninguna complicación, como sangrado o perforación, intra o postoperatoria. El tiempo operatorio fue de 65 minutos. Con el análisis histopatológico del especimen en-bloc se confirmó el diagnóstico de adenocarcinoma intramucoso con márgenes negativos. CONCLUSIÓN. La DSE promete ser una excelente alternativa para el tratamiento curativo del cáncer gástrico precoz, siendo un método más costo-efectivo, y menos invasivo, ofreciendo una mejor calidad de vida al paciente con iguales resultados a largo plazo que la cirugía convencional a cielo abierto.

OBJECTIVES. To report the first case of endoscopic submucosal dissection (ESD) in Costa Rica and to analyze the future impact of this technique for the treatment of early gastric cancer in this country. PATIENTS AND METHODS. We present the case of a 67-year-old woman who underwent an upper endoscopy for mild epigastralgia, resulting in a 12 mm non-ulcerated sessile lesion (0-IIa) located in the antrum at the greater curvature. After biopsy confirmation of a well-differentiated adenocarcinoma limited to the mucosa, the patient underwent anendoscopic submucosal dissection for the en-bloc resection of the lesion. RESULTS. The ESD was successfully performed without intra- or postoperative complications such as bleeding and perforation. Operation time was 65 minutes. Histopathological analysis of the en-bloc specimen confirmed the diagnosis of intramucosal well differentiated adenocarcinoma with negative margins. CONCLUSION. ESD is novel alternative for the curative treatment of early gastric cancer, due to its cost-effectiveness, less invasiveness, which provides a better quality of life for the patient than that of conventional open surgery with same long-term results.