Esophageal candidiasis in patients from a specialty hospital / Candidiasis esofágica en pacientes de un hospital de especialidades

Background: Esophageal candidiasis (EC) is the most common cause of infectious esophagitis. So far, its main risk factor has been HIV infection; in recent years, EC has been favoured by the increasing of diabetes mellitus, wide-spread use of acid-lowering agents, broad-spectrum antibiotics, and inhaled steroids. In Mexico EC has been poorly studied. Objectives: To determine the clinical and epidemiological characteristics of EC, and to identify its etiological agents as well as its antifungal susceptibility. Methods: Patients who revealed the presence of scattered white spots through an upper gastrointestinal system endoscopy, in a period of one year, in a tertiary care hospital, were included. Samples from patches were collected for microscopic examination, culture, and susceptibility tests. Results: Out of 1763 patients studied, 23 had scattered white spots, and most of them presented Kodsi grade I; 13 were men; half of the patients were between the ages 20 to 40; main comorbidity was liver cirrhosis; use of omeprazole was significant. 22 isolates were obtained from 17 patients. The most frequent species were C. albicans (14) and C. parapsilosis (3). In five cases we found a two-species association v. g. Candida famata with Trichosporon mucoides. Half of the isolates showed resistance to one or several antifungal drugs. Conclusions: EC frequency in this study was similar to other studies' results. Obtained isolates showed high resistance to azolic compounds and to caspofungin, which is relevant information to take a therapeutic decision.

Introducción: la candidiasis esofágica (CE) es la causa más común de esofagitis infecciosa. Su principal factor de riesgo ha sido la infección por VIH. En México ha sido poco estudiada. Objetivos: determinar las características clínico-epidemiológicas de la CE e identificar sus agentes etiológicos y su sensibilidad a antifúngicos. Métodos: se incluyeron pacientes a quienes se les detectaron placas blanquecinas durante una endoscopía esofágica, en un periodo de un año, en un hospital de tercer nivel de atención. Se tomó muestra de las placas para examen microscópico, cultivo, y estudios de sensibilidad. Resultados: de 1763 pacientes estudiados, 23 presentaron placas blanquecinas; 13 fueron hombres; la mitad tenía de 20 a 40 años de edad; la principal comorbilidad fue cirrosis hepática; el uso de omeprazol fue significativo. Se obtuvieron 22 aislados de 17 pacientes; predominaron Candida albicans (14) y Candida parapsilosis (3). En cinco casos se encontró asociación de dos especies v. g. Candida famata con Trichosporon mucoides. La mitad de los aislados mostró resistencia a antimicóticos. Conclusiones: la frecuencia de CE fue similar a la de otras casuísticas. Los aislados obtenidos mostraron resistencia elevada a compuestos azólicos y a caspofungina, información relevante para tomar una decisión terapéutica.

Feasibility of the peroral endoscopic myotomy (POEM) procedure with a new small-caliber endoscope (thin-POEM) in patients with achalasia.

BACKGROUND: Peroral endoscopic myotomy (POEM) is a recognized technique for patients with achalasia. We aimed to evaluate the feasibility of using a small-caliber endoscope (thin-POEM) to perform POEM in patients with achalasia. METHODS: Naïve or previously treated patients were included between February 2016 and April 2018. A small-caliber (5.9 mm) nasoendoscope was used, with a modified closure method using cyanoacrylate. Strict follow-up was performed. RESULTS: 45 patients were included, aged 45.5 years (interquartile range [IQR] 22 - 69); 53 % (24/45) had type II achalasia. Median total time for thin-POEM was 54 minutes (IQR 37 - 77) and median myotomy length was 13.5 cm (IQR 6 - 20). Results pre-procedure and 3 months post were Eckardt score 10 vs. 1 (P < 0.001), integrated relaxation pressure (IRP) 25.3 vs. 8.5 mmHg (P < 0.001), and timed barium esophagram (TBE) 100 % severely delayed vs. 86 % normal (P < 0.001), respectively. Type III patients had the longest thin-POEM times (median 58 minutes [IQR 52 - 77]). Reflux was confirmed at 3 months clinically in 17 % of patients, endoscopically in 20 %, and on pH monitoring in 53 %. At 6 months and 12 months, 40 % and 33 % of patients remained positive on pH monitoring and were medically managed. CONCLUSIONS: Thin-POEM seems to be a safe, effective, and efficient procedure for POEM in patients with achalasia, with good short-term follow-up results.

Per-oral Endoscopic Myotomy (POEM): A safe and effective treatment for achalasia in geriatric patients / Miotomía endoscópica a través de la boca (POEM): una alternativa endoscópica segura y efectiva para el tratamiento de la acalasia en pacientes geriátricos

Background: Esophageal achalasia is a primary motor disorder of the esophagus characterized by impair relaxation of the lower esophageal sphincter and absent of esophageal peristalsis. Per-oral endoscopic myotomy is an alternative treatment to surgical Heller myotomy in patients over 65 years old. The aim of this paper was to describe the results of peroral endoscopic myotomy (POEM) or the treatment of achalasia in geriatric patients. Methods: We included patients over 65 years old with POEM, from retrospective cohort review, in which POEM was performed with a standardized technique in our department. Results: 12 patients were included, the procedure was successful in 98% of patients, minor adverse events occurred without mortality. Conclusions: POEM is a safe and effective technique for the treatment of achalasia, the results of the study are similar to those reported in the literature.

Introducción: La acalasia es un trastorno motor primario del esófago caracterizado por falla en la relajación del esfínter esofágico inferior y ausencia de peristalsis esofágica sin una causa identificable de obstrucción en el esófago distal. La miotomía endoscópica a través de la boca es un tratamiento alternativo a la cardiomiotomía de Heller laparoscópica en pacientes mayores de 65 años. El objetivo de este trabajo fue describir los resultados la miotomía endoscópica a través de la boca (POEM), en pacientes mayores de 65 años. Métodos: Estudio retrospectivo con diagnóstico manométrico de acalasia, de pacientes mayores de 65 años de edad. Resultados: Se incluyeron 12 pacientes, se consideró tratamiento exitoso cuando el paciente alcanza un índice de Eckardt < 3. El procedimiento fue exitoso en el 98% de los pacientes, se presentaron eventos adversos menores en la mayoría de los pacientes. Conclusiones: La miotomía endoscópica a través de la boca es una técnica segura y efectiva para el tratamiento de acalasia en adultos mayores, los resultados del estudio son similares a los reportados en la literatura.

The Per Oral Endoscopic Myotomy (POEM) technique: how many preclinical procedures are needed to master it?

BACKGROUND AND STUDY AIM: Per oral endoscopic myotomy (POEM) is a complex technique used in achalasia. Preclinical training is essential but little is known about the number of procedures needed. The aim of this study was to determine the number of procedures required to master POEM in an animal model. PATIENTS AND METHODS: This prospective comparative study was conducted in two swine models at a single institution in Mexico City between November 2012 and October 2014: Group 1 (G1) = 30 ex vivo and Group 2 (G2) = 20 live swine models. POEM was mastered after finishing the five steps without complications. Time, characteristics, and complications were recorded. Velocity of tunnelization and myotomy (VTM) was determined. Ex vivo analysis was done in G1 immediately after finishing POEM and at day 30 in G2. RESULTS: A total of 50 POEM were done in both groups (G1 = 30, G2 = 20). The mean times were 90.17 min (G1) and 89.50 min (G2) (P = 0.92). Myotomy was faster in G2 (21.10 vs 27.97 min; P = 0.009) with a slightly slower tunnelization (40.35 vs 41.13 min; P = 0.86). Myotomy was longer in G2 (9.25 vs 8.83 cm; P = 0.26). VTM between the groups was similar (G1 = 0.159 vs G2 = 0.157 cm/min; P = 0.925). Complications were: mucosotomy (G1 = 18 %, G2 = 8 %; P = 0.430), mediastinal perforation (G1 = 12 %, G2 = 8 %; P = 1.0), and perforation at the gastroesophageal junction (GEJ) level (G1 = 16 %, G2 = 4 %; P = 0.149). Seven models in G2 presented minor bleeding and there was one death not attributed to the procedure. Mastery was obtained after 26 cases. CONCLUSIONS: We suggest that centers interested in learning POEM consider 26 procedures in animal models to master it before performing it in patients with achalasia.

[Causes of non-cardiac chest pain: multidisciplinary perspective]. / Causas de dolor torácico no cardiaco.

BACKGROUND: Non-cardiac chest pain (NCCP) is defined by recurrent episodes of substernal chest pain non related to ischemic heart disease, it's origin being in many cases the gastrointestinal tract; however, it may be associated to psychosomatic disorder. OBJECTIVES: To investigate the main causes of NCCP and to evaluate associated psychiatric comorbidity. METHODS: Patients with NCCP referred by a cardiologist were assessed underwent an upper endoscopy, ambulatory pH monitoring and stationary esophageal manometry. NCCP was considered gastro esophageal reflux disease (GERD) positive when the endoscopy and/or ambulatory pH monitoring were abnormal. When all results were normal, the symptom was considered as a functional chest pain (FCP). Patients were assessed by the Psychiatry service and diagnosed in accordance to the Diagnostic and Statistics Manual of Mental Diseases, fourth edition (DSM-IV). Several other test were applied for the assessment of anxiety and depression. RESULTS: Thirty-four patients were included (25 women and nine men; average age: 46.2 +/- 11.56 years). Three patients were eliminated because of refusal of the psychiatric evaluation. In 21 (68%) patients, NCCP was GERD-positive and in 10 (32%) to FCP. The most common symptoms associated to chest pain were: heartburn in 23 (74%), regurgitation in 21 (68%) and dysphagia in 15 (48%) patients. Upper endoscopy was abnormal in four cases; ambulatory pH monitoring was abnormal in 21 (67.7%) patients. The frequency of psychiatric disorders related to NCCP was 52%, in 10 patients with GERD-positive (48%) and six patients with FCP (60%). Mayor depression was the most common diagnoses identified among both groups. CONCLUSION: The high frequency of GERD and psychiatric disorders found in NCCP supports the multidisciplinary approach to NCCP.

[Double-balloon enteroscopy: experience in the Hospital de Especialidades del Centro Médico Nacional Siglo XXI IMSS, Mexico City]. / Enteroscopia de doble balón: experiencia en el hospital de Especialidades del Centro Médico Nacional Siglo XXI, IMSS, Ciudad de México.

UNLABELLED: The methods used for the study of the small bowel are not ideal. Double-balloon enteroscopy is a new alternative with therapeutic potential. OBJECTIVE: Evaluate the utility, efficacy and safety of double-balloon enteroscopy in Mexico. MATERIAL AND METHODS: Adult patients seen in the Hospital de Especialidades Centro Médico Nacional Siglo XXI, Mexico City who were being studied for: chronic diarrhea, obscure gastrointestinal hemorrhage, weight-loss and chronic anemia were included in the study. Anterograde (oral) and retrograde (anal) approaches were used and study time, findings and complications were evaluated. RESULTS: Thirty-one enteroscopies were performed, 15 were anterograde, 8 retrograde and 8 were performed via both routes, in 23 patients studied between February and October, 2004; 10 of them were women and 13 men with ages ranging from 25 to 80 years. Fourteen patients were sedated and 9 patients were anesthetized. Study time varied form 55 to 90 minutes. With the anterograde route the ileum was reached in 56.6% of cases, 39.1% the jejunum and only in one patient (4.3%) the whole intestine was explored. With the retrograde route in 62.5% of cases the jejunum was explored and 37.5% the ileum. Four patients with obscure gastrointestinal bleeding and 1 patient with chronic anemia had vascular ecstasies, and in 40% of patients there was no identifiable cause. In 2 patients with intestinal stenosis biopsies revealed intestinal lymphoma in one and ischemic injury in another one. The adverse effects were mild and transitoru. CONCLUSIONS: Double-balloon enteroscopy is a safe diagnostic and therapeutic method that is useful in cases of obscure hemorrhage, chronic anemia; small bowel pathology was found in 64.7% of cases.

Enteroscopia de doble balón: experiencia en el Hospital de Especialidades del Centro Médico Nacional Siglo XXI IMSS, Ciudad de México / Double-balloon enteroscopy: experience in the Specialty Hospital National Medical Center Siglo XXI IMSS, Mexico City

Los métodos actuales de enteroscopia son incapaces de una exploración controlada de todo el intestino delgado, tomar biopsias u ofrecer tratamientos. Por estas razones se creó en Japón el enteroscopio de doble balón. Mediante este sistema se puede avanzar y rectificar las asas del intestino delgado, mejorando la visibilidad realizando una inserción más profunda. El propósito de este estudio fue evaluar la utilidad y seguridad de la enteroscopia de doble balón en el diagnóstico de patologías del intestino delgado en una población mexicana determinada. Métodos: Se captaron pacientes en el Hospital del Centro Médico Nacional Siglo XXI, ambos sexos, en estudio por hemorragia gastrointestinal de origen oscuro, diarrea crónica, anemia, dolor abdominal crónico o pérdida de peso en estudio. Resultados: Se incluyeron 23 pacientes: 10 mujeres y 13 hombres de entre 25 y 80 años, en el período de Febrero a Octubre del 2004, realizando un total de 31 enteroscopias con abordajes distintos: 15 anterógrados y en 8 pacientes ambas vías en distintos tiempos. Se empleó sedación en 14 pacientes con midazolam y en 9 con anestesiólogo utilizando fentanilo y propofol. El tiempo invertido para cada procedimiento fue de 55 a 90 minutos. Mediante fluoroscopia fue posible determinar la posición y alcance del enteroscopio: por vía anterógrada en 1 caso se exploró completamente el intestino delgado (4.3%), en 56.5% se alcanzó el ileon y en 39.1% hasta yeyuno. Por vía retrógrada un 62.5% hasta yeyuno y un 37.5% hasta ileon. En 4 pacientes con hemorragia oscura y en 1 de anemia crónica se demostraron malformaciones vasculares tipo de angiodisplasias y telangiectasias, y en 4 casos (40%) no se logró identificarla causa de sangrado; además se observó un caso de úlcera yeyunal, úlcera en sigmoides y divertículos en colon. En 4 pacientes con diarrea crónica se observaron cambios granulares de la mucosa intestinal.

Current enteroscopy and controlated exploration methods of the entire small bowel are unable for distal biopsy samples and for offering therapeutic methods. For that reason the double balloon enteroscopy system has been developed in Japan. This system is capable to advance and rectify the bowel loops to improve deeply access to the small intestine.The aim of this study is to evaluate the usefulness and safety of the double-balloon method in diagnosis of small intestine disorders in mexican population. Methods: We enrolled patients in the National Medical Center XXI Century Hospital in Mexico City. lndications for the procedure were study for obscure gastrointestinal bleeding, chronic diarrhea, chronic anemia, chronic abdominal pain and unexplained weight loss. Results: For 23 patients (10 woman and 13 men) 31 enteroscopies were performed between February 2004 and October 2004. The age range 25 to 80 years (average 65). For each study patients underwent sedation with midazolam IV in 14 cases and 9 cases required anesthesia with fentanyl and propofol. The time for each study was between 55 to 90 minutes. We used fluoroscopy for locating the enteroscope and evaluating its progress at the different intestinal segments. Double balloon enteroscopy was carried out from oral approach only in 15 patients and from anal and oral approach at different times in 8 patients. In one case it was possible to evaluate the entire small bowel in the same procedure from oral approach (4.3%) and in 56.5% and 39.1% we reached ileum and jejunum. For anal approach the jejunum and ileum was reached in 62.5% and 37.5%. Bleeding sources recognized were angiodysplasia in 4 patients in study for obscure gastrointestinal bleeding and one with chronic anemia; other lesions found included jejunal ulcer, sigmoid ulcer and multiple colonic diverticula with recent bleeding. In 4 cases (40%) we couldn't find the cause of bleeding.

La enseñanza de la endoscopia en México / Teaching endoscopy in Mexico

En los últimos 20 años han ocurrido grandes cambios en la gastroenterología, de los más importantes son los que se presentan en la endoscopia, principalmente en el aspecto terapéutico; estos cambios han motivado un gran interés en el aprendizaje de la endoscopia y, en forma secundaria, se ha provocado una explosión en el número de "Centros de Enseñanza" con nuevos profesores, alumnos y graduados en endoscopia gastrointestinal. Esto último ha ocurrido en muchas partes del mundo y México no ha sido la excepción, desafortunadamente esta explosión en el número de alumnos no ha sido apoyada por la calidad de éstos, tenemos la impresión de que ahora somos más, tanto maestros como alumnos, aunque proporcionalmente, la calidad es menor, en comparación con lo que ocurría hace 10-15 años; se analizan algunos aspectos que han motivado este fenómeno.

Utilidad de la litotripsia extracorpórea en el tratamiento de la colédocolitiasis difícil / Shock wave extracorporeal lithotripsy in giant or difficult bile duct stones

La litotripsia con ondas de choque extracorpóreas, es un recurso poco disponible que ha demostrado ser un elemento útil en el manejo de la colédocolitiasis difícil, cuando se combina con métodos endoscópicos, sus resultados son satisfactorios, con porcentajes de éxito global del 70 al 80 por ciento y con una baja morbilidad y mortalidad.