Clinical practice guideline on the use of single-operator cholangioscopy in the diagnosis of indeterminate biliary stricture and the treatment of difficult biliary stones.

BACKGROUND AND AIMS: Single-operator cholangioscopy (SOC) offer a diagnostic and therapeutic alternative with an improved optical resolution over conventional techniques; however, there are no standardized clinical practice guidelines for this technology. This evidence-based guideline from the Colombian Association of Digestive Endoscopy (ACED) intends to support patients, clinicians, and others in decisions about using in adults the SOC compared to endoscopic retrograde cholangiopancreatography (ERCP), to diagnose indeterminate biliary stricture and to manage difficult biliary stones. METHODS: ACED created a multidisciplinary guideline panel balanced to minimize potential bias from conflicts of interest. Universidad de los Andes and the Colombia Grading of Recommendations Assessment, Development and Evaluation (GRADE) Network supported the guideline-development process, updating and performing systematic evidence reviews. The panel prioritized clinical questions and outcomes according to their importance for clinicians and patients. The GRADE approach was used, including GRADE Evidence-to-Decision frameworks. RESULTS: The panel agreed on one recommendation for adult patients with indeterminate biliary strictures and one for adult patients with difficult biliary stones when comparing SOC versus ERCP. CONCLUSION: For adult patients with indeterminate biliary strictures, the panel made a conditional recommendation for SOC with stricture pattern characterization over ERCP with brushing and/or biopsy for sensitivity, specificity, and procedure success rate outcomes. For the adult patients with difficult biliary stones the panel made conditional recommendation for SOC over ERCP with large-balloon dilation of papilla. Additional research is required on economic estimations of SOC and knowledge translation evaluations to implement SOC intervention in local contexts.

[Recurrent acute pancreatitis secondary to sphincter of oddi dysfunction: Case report]. / Pancreatitis aguda recurrente secundaria a disfunción del esfínter de oddi: Reporte de caso.

Sphincter of Oddi Dysfunction (SOD) is a rare pathology that should be considered in the differential diagnosis of patients with biliary pain episodes or recurrent acute pancreatitis and a background of cholecystectomy. Generally, these are patients with multiple consultations where this pathology has considerably affected their quality of life. Diagnosis is based on clinical findings, serological markers and supporting diagnostic tests requested according to the suspected sphincteric component. The most effective treatment is endoscopic sphincterotomy. The use of prosthesis is accepted but debated. We present the case of a male patient in his forties who consulted for multiple episodes of recurrent acute pancreatitis with etiology studies suspecting dysfunction of the pancreatic sphincter of Oddi and who was taken to endoscopic management with improvement of his clinical picture.

Pancreatitis aguda recurrente secundaria a disfunción del esfínter de oddi: Reporte de caso

La disfunción del esfínter de Oddi (DEO) es una patología poco frecuente que debe ser considerada en el diagnóstico diferencial de pacientes con episodios de dolor biliar o pancreatitis aguda recurrente y antecedente de colecistectomía. Generalmente son pacientes con múltiples consultas, en los cuales la patología ha afectado considerablemente su calidad de vida. El diagnóstico se sustenta en la clínica, los marcadores serológicos y los medios diagnósticos de soporte, que se solicitan según el componente esfinteriano sospechado. El tratamiento con mayor eficacia es la esfinterotomía endoscópica. El uso de prótesis es aceptado, pero discutido. Se presenta el caso de un paciente masculino en la cuarta década de la vida que consultó por múltiples episodios de pancreatitis aguda recurrente con estudios de etiología que sospecharon disfunción del esfínter de Oddi pancreático y quien fue llevado a manejo endoscópico, con mejoría de su cuadro clínico.

Sphincter of Oddi Dysfunction (SOD) is a rare pathology that should be considered in the differential diagnosis of patients with biliary pain episodes or recurrent acute pancreatitis and a background of cholecystectomy. Generally, these are patients with multiple consultations where this pathology has considerably affected their quality of life. Diagnosis is based on clinical findings, serological markers and supporting diagnostic tests requested according to the suspected sphincteric component. The most effective treatment is endoscopic sphincterotomy. The use of prosthesis is accepted but debated. We present the case of a male patient in his forties who consulted for multiple episodes of recurrent acute pancreatitis with etiology studies suspecting dysfunction of the pancreatic sphincter of Oddi and who was taken to endoscopic management with improvement of his clinical picture.

Tratamiento endoscópico del divertículo de Zenker / Endoscopic management of Zenker's diverticulum

Introducción: el divertículo de Zenker es un saco que se produce como resultado del aumento de presión a nivel de la pared posterior de la hipofaringe que lleva a la protrusión de mucosa y submucosa a través de los músculos constrictor inferior de la faringe y cricofaríngeo. Discusión: es característico de los pacientes adultos mayores en la séptima y octava década de la vida, con una discreta predilección por el sexo masculino. El síntoma principal es la disfagia y en casos severos episodios de broncoaspiración. Tiene diferentes opciones de tratamiento, entre las que se encuentran el abordaje quirúrgico y endoscópico, siendo esta última la técnica más recomendada dado sus buenos resultados y menores tasas de complicaciones descritas.

Introduction: Zenker ́s diverticulum is a saccular formation in the posterior wall of the hypopharynx due to increased pressure, leading to mucosal and sub-mucosal herniation between the cricopharyngeus muscle and the inferior pharyngeal constrictor muscle. Discussion: it is primarily seen in elderly individuals in the seventh and eighth decades of life, with a discrete higher predominance in men. Dysphagia is the main symptom and episodes of pulmonary aspiration may present in severe cases. There are several treatment options, among which is endoscopic surgical approach. The latter constitutes the most recommended technique for it has shown good results and lower complication rates.

Manejo endoscópico de la enfermedad por reflujo gastroesofágico (ERGE) / Endoscopic management of gastroesophageal reflux disease (GERD)

La enfermedad por reflujo gastroesofágico (ERGE) se manifiesta cuando el quimo gástrico refluye al esófago y pasa de ser fisiológico a sintomático y patológico. Es frecuente a nivel mundial y de difícil abordaje diagnóstico debido a la multitud de síntomas y presentaciones, haciendo que su enfoque terapéutico sea complejo. Existen múltiples opciones de tratamiento siendo el farmacológico basado en inhibidores de bomba de protones (IBP) la piedra angular. El manejo quirúrgico está descrito pero reservado a ciertos pacientes específicos. La terapia endoscópica surge como otra opción con indicaciones similares a la cirugía, pero con las ventajas propias de los procedimientos endoscópicos. Se han descrito varias técnicas endoluminales con pobres resultados, que no se han logrado popularizar.

Gastroesophageal reflux disease (GERD) occurs when gastric chyme refluxes back into the esophagus and changes from physiologic to symptomatic and pathologic. It is common worldwide and is difficult to diagnose due to the diversity of symptoms and presentations, making its therapeutic approach complex. Although there are multiple treatment options, proton pump inhibitors (PPIs) have been the mainstay of pharmacological management of GERD. Surgical treatment is described but is used in selected patients. Endoscopic therapy emerges as another option with similar indications as surgery, featuring the advantages of endoscopic procedures. Several endoluminal techniques have been described showing poor results, thus their generalized use has not been achieved.

Enteroscopia de doble balón: experiencia inicial en un hospital universitario / Double balloon enteroscopy: Initial experience in a university hospital

Resumen Introducción: el estudio de intestino delgado es un desafío, motivo de avance médico y de interés. La enteroscopia de doble balón (EDB) permite una visualización directa del intestino delgado. Objetivo: describir indicaciones, características del procedimiento, hallazgos, complicaciones y seguimiento de pacientes llevados a EDB en el Hospital de San José de Bogotá, entre noviembre de 2011 y abril de 2019. Metodología: estudio de serie de casos. Se incluyeron pacientes con indicación clínica o por imágenes diagnósticas sugerentes de lesión a nivel de intestino delgado. Se empleó estadística descriptiva. Resultados: se realizaron 45 enteroscopias a 44 pacientes, con una mediana de edad de 58 años. La principal indicación fue hemorragia digestiva potencial de intestino delgado (53,3 %) y diarrea crónica (11,1 %); fueron más frecuentes los procedimientos por vía anterógrada. La mayoría de los resultados fue normal (46,7 %); entre los hallazgos más frecuentes estuvieron los tumores (11,1 %), enfermedad de Crohn (8,9 %) y úlceras/erosiones (6,7 %). El rendimiento diagnóstico fue 53,3 %, la correlación con la videocápsula endoscópica (VCE) fue 37,5 % y con estudios de imagen, 42,9 %. No se presentaron complicaciones. Se hizo seguimiento al 91,1 % de los pacientes con una mediana de 56 meses y se observó la resolución de síntomas en el 78,1 %. La finalidad de la enteroscopia fue diagnóstica en el 84,4 %. Conclusiones: La EDB es útil en la evaluación del intestino delgado con posibilidad terapéutica. Los resultados son similares a los reportados en la literatura mundial. Si se realiza seguimiento, se puede definir la necesidad de repetición del procedimiento, realización de estudios adicionales u observar resolución de los síntomas.

Abstract Introduction: The study of the small bowel is a challenging task that has sparked interest and progress in medicine. In this context, double balloon enteroscopy (DBE) has allowed the direct visualization of the small intestine. Objective: To describe indications, procedure characteristics, findings, complications, and follow-up of patients taken to DBE at the Hospital de San José, Bogotá, between November 2011 and April 2019. Methodology: Case series study. Patients with a clinical indication or diagnostic images suggestive of small bowel lesion were included. Descriptive statistics were used. Results: 45 enteroscopies were performed in 44 patients, with a median age of 58 years. The main indication was potential small bowel bleeding (53.3%) and chronic diarrhea (11.1%). Anterograde procedures were more frequent. Most of the results were normal (46.7%); tumors (11.1%), Crohn's disease (8.9%), and ulcers/erosions (6.7%) were among the most frequent findings. The diagnostic yield was 53.3% and the correlation with capsule endoscopy (CE) was 37.5%, and with imaging studies 42.9%. There were no complications. 91.1 % of patients were followed up on after a median of 56 months, with 78.1 % reporting symptom remission. The aim of enteroscopy was diagnostic in 84.4%. Conclusions: DBE is useful in the evaluation of the small intestine with a therapeutic possibility. The results are similar to those reported in the world literature. Follow-up can define the need for repeating the procedure, performing further studies, or symptom resolution.

Disfunción del esfínter de Oddi: un reporte de caso / Sphincter of Oddi dysfunction: Case report

Resumen La disfunción del esfínter de Oddi es un síndrome clínico causado por una enfermedad funcional (discinesia) o estructural (estenosis). La prevalencia estimada de disfunción del esfínter de Oddi en la población en general es del 1 %; aumentando a 20 % para pacientes con dolor persistente posterior a colecistectomía y a 70 % en pacientes con pancreatitis aguda recurrente idiopática. Se caracteriza clínicamente por la presencia de dolor abdominal, similar al cólico biliar o dolor tipo pancreático en ausencia de patología biliar orgánica; así como en pacientes con pancreatitis recurrente idiopática asociada con elevación de enzimas pancreáticas o hepáticas, y dilatación del conducto biliar o pancreático. El tratamiento para la disfunción del esfínter de Oddi tipo I se basa en la realización de esfinterotomía endoscópica, pero existe controversia en el manejo de la disfunción del esfínter de Oddi tipo II y III. En este artículo se presenta el caso clínico de una paciente de 67 años con antecedente de colecistectomía por laparotomía. Después del procedimiento quirúrgico refirió un dolor abdominal de predominio en el hipocondrio derecho tipo cólico asociado con emesis de características biliares. En el reporte de colangiorresonancia se encontró una ligera dilatación de la vía biliar intrahepática y gammagrafía con ácido iminodiacético hepatobiliar (HIDA) diagnóstica de disfunción del esfínter de Oddi. Se realizó una esfinterotomía endoscópica. En el seguimiento, dos años después, la paciente se encontraba asintomática con la disfunción del esfínter de Oddi resuelta.

Abstract Sphincter of Oddi dysfunction is a clinical syndrome caused by functional (dyskinesia) or structural (stenosis) disease. The estimated prevalence of this condition in the general population is 1%, reaching 20% in patients with persistent pain after cholecystectomy and 70% in patients with idiopathic recurrent acute pancreatitis. It is clinically characterized by the presence of abdominal pain, similar to biliary colic or pancreatic pain in the absence of organic biliary disease. It is also observed in patients with idiopathic recurrent pancreatitis, associated with elevated pancreatic or hepatic enzymes, and bile duct and/or pancreatic duct dilatation. Treatment for sphincter of Oddi dysfunction type I is based on endoscopic sphincterotomy, but there is controversy regarding the management of sphincter of Oddi dysfunction types II and III. This article presents the clinical case of a 67-year-old female patient with a history of cholecystectomy by laparotomy. After the surgical procedure, she reported abdominal pain predominantly in the right hypochondrium, colicky, associated with emesis of biliary characteristics. Cholangioresonance report revealed mild intrahepatic bile duct dilatation, and scintigraphy with HIDA scan showed sphincter of Oddi dysfunction. Endoscopic sphincterotomy was performed. The patient was asymptomatic and the sphincter of Oddi dysfunction had resolved at two-year follow-up.

Endoscopic retrograde cholangiopancreatography results three days after a failed pre-cut.

INTRODUCTION: deep cannulation of the common bile duct is essential in endoscopic retrograde cholangiopancreatography (ERCP). However, cannulation is not possible in approximately 20 % of the cases with the usual techniques. Pre-cutting is an alternative that allows cannulation in difficult cases although its success is not guaranteed. Repeating the ERCP within three days of a failed pre-cut is an acceptable option. OBJECTIVE: to determine if an ERCP performed three days after a failed pre-cut papillotomy allows the bile duct to be cannulated without increasing complication rates. PATIENTS AND METHODS: patients who underwent an ERCP plus pre-cut were included, in whom the common bile duct could not be cannulated and who also underwent a new ERCP three days after the initial pre-cut. The primary objective was a successful biliary cannulation in the second ERCP and the secondary objective were the complications of the initial pre-cut. RESULTS: forty patients with an average age of 65 years were identified and 57 % were male. The indications for ERCP were choledocholithiasis in 95 %, biliary fistula in 2.5 % and pancreatic neoplasia in 2.5 %. The ERCP was repeated three days later in 92.5 % of the cases and the biliary cannulation was successful in 78.3 %. CONCLUSIONS: a new ERCP performed within three days of a failed pre-cut is justifiable since it has a significant success rate. Bile duct cannulation is achieved in three out of four patients, with an acceptable percentage of complications.

Colangiopancreatografía retrógrada endoscópica (CPRE) transgástrica asistida por laparoscopia en un paciente con derivación gástrica en Y de Roux. Reporte de un caso y revisión de la literatura / Laparoscopic-assisted transgastric retrograde endoscopic cholangiopancreatography in a patient with a Roux-en-Y gastric bypass: Case report and literature review

Resumen La obesidad es un problema de salud pública. La cirugía bariátrica juega un papel importante en el manejo de estos pacientes. Con la llegada de estas técnicas quirúrgicas, los procedimientos endoscópicos digestivos y en especial la colangiopancreatografía retrógrada endoscópica (CPRE) se convierten en un desafío constante. Se describe un caso de CPRE transgástrica asistida por laparoscopia para el manejo de cálculos de la vía biliar principal en un paciente con antecedente de derivación gástrica en Y de Roux (BPGYR).

Abstract Obesity is a public health problem. Bariatric surgery plays an important role in the management of these patients. With the advent of bariatric surgical techniques, endoscopic digestive procedures, especially endoscopic retrograde cholangiopancreatography (ERCP), have become constant challenges. We describe a case of laparoscopic-assisted transgastric retrograde endoscopic cholangiopancreatography (ERCP) to treat calculi in the main bile duct of a patient with a history of a Roux-en-Y gastric bypass.

[ERCP success after 72 hours of pre-cut]. / éxito de CPRE 72 horas después de precorte.

INTRODUCTION: Despite the advances of bile duct catheterization, its success is still not guaranteed. Few studies have been published regarding a second ERCP attempt, however those reports enhance the catheterization success Objective: To determine whether an ERCP performed 72 hours after a first precut papillotomy enhances the bile duct catheterization. MATERIAL AND METHODS: A cohort study was performed including all patients that had ERCP with precut papilotomy without catheterization of the bile duct and 72 hours later were programmed to a new ERCP between September 2015 and September 2016. These patients did not have any distinctive characteristic such as age, gender or anatomy that were associated with the failure to catheterize the bile duct, compared to the general population. RESULT: 16 patients were included with a mean age of 61,3 years (SD: 10,6), bile duct catheterization was successful in 14 cases. No complications presented after precut papilotomy. Both failures went to surgery. CONCLUSIONS: Our experience about an 87% successful bile duct catheterization, 72 hours after precut papillotomy allows us to suggest it as an alternative before considering surgery.

Éxito de CPRE 72 horas después de precorte / ERCP success after 72 hours of pre-cut

Introducción A pesar de los avances en las técnicas para canalizar la vía biliar no se puede asegurar su éxito. Se han publicado pocos estudios que soporten un segundo intento de CPRE que, sin embargo, reportan un aumento en la tasa de canalización. Objetivo: Determinar si una CPRE 72 horas después de realizarse una papilotomía por precorte permite la canalización de la vía biliar. Materiales y métodos: Se realizó un estudio de cohorte descriptiva, se incluyeron todos los pacientes llevados a CPRE más papilotomía por precorte sin lograr el ingreso a la vía biliar y que 72 horas después fueron programados para una nueva CPRE entre septiembre de 2015 y septiembre de 2016.Los pacientes en quienes no se logró canalizar la via biliar a pesar de la papilotomia por precorte no tenían ninguna característica de edad, género o anatómica que se asocie con fracaso en la canalización respecto a la población general. Se analizó el porcentaje de éxito en la canalización a las 72 horas y las complicaciones asociadas a la papilotomía por precorte en el procedimiento inicial. Resultados: Ingresaron al estudio 16 pacientes, con edad promedio de 61.3 años (DE: 10.6), se logró canalizar la vía biliar en 14 de los casos que se llevaron a una CPRE 72 horas después de una papilotomía por precorte. No se presentaron complicaciones después de la papilotomía por precorte. En los dos pacientes no canalizados se indicó cirugía: Conclusiones: La experiencia reportada en este estudio sobre el éxito de canalización de la vía biliar 72 horas después de la realización de una papilotomía por precorte en un 87% sin complicaciones nos permite sugerirla como una alternativa de manejo antes de una exploración quirúrgica.

Introduction: Despite the advances of bile duct catheterization, its success is still not guaranteed. Few studies have been published regarding a second ERCP attempt, however those reports enhance the catheterization success Objective: To determine whether an ERCP performed 72 hours after a first precut papillotomy enhances the bile duct catheterization. Material and methods: A cohort study was performed including all patients that had ERCP with precut papilotomy without catheterization of the bile duct and 72 hours later were programmed to a new ERCP between September 2015 and September 2016. These patients did not have any distinctive characteristic such as age, gender or anatomy that were associated with the failure to catheterize the bile duct, compared to the general population. Result: 16 patients were included with a mean age of 61,3 years (SD: 10,6), bile duct catheterization was successful in 14 cases. No complications presented after precut papilotomy. Both failures went to surgery. Conclusions: Our experience about an 87% successful bile duct catheterization, 72 hours after precut papillotomy allows us to suggest it as an alternative before considering surgery

Manejo del divertículo de Zenker con endoscopia avanzada / Advanced endoscopic management of Zenker´s diverticulum

El divertículo de Zenker es un saco que protruye a través de los músculos constrictor inferior de la faringe y cricofaríngeo (triángulo de Killian); es una alteración que ocasiona disfagia como síntoma principal y se puede manejar con el endoscopio flexible con buenos resultados. Objetivo. Describir la experiencia preliminar en el manejo endoscópico del divertículo de Zenker en el Hospital de San José. Métodos. Se trata de una serie de casos llevada a cabo desde diciembre de 2014 hasta abril de 2016 en el Hospital de San José, en la cual se utilizó el endoscopio flexible para la diverticulotomía en pacientes ambulatorios. Resultados. Se intervinieron seis pacientes, en los cuales se llevaron a cabo nueve procedimientos. El diagnóstico se hizo mediante esofagogastroduodenoscopia y esofagograma. La edad promedio fue de 65 años y cuatro pacientes eran hombres. En todos se practicó el procedimiento bajo anestesia general, usando endoscopio flexible, sonda orogástrica y capuchón. No se usaron antibióticos profilácticos y todos los pacientes se atendieron en forma ambulatora. Conclusión. La diverticulotomía endoscópica con equipo de endoscopia flexible es una técnica que ha sido adoptada por los gastroenterólogos intervencionistas debido a su seguridad y buenos resultados. Por lo anterior, esta técnica se debe tener en cuenta en los pacientes con esta enfermedad

Zenker's diverticulum is a sac that protrudes through the inferior constrictor muscles of the pharynx and cricopharyngeus (Killian triangle), a condition that causes dysphagia as the main symptom and can be managed by flexible endoscopy with good results. Objective: To describe the preliminary experience in the endoscopic management of Zenker's diverticulum at Hospital San José, Bogotá, Colombia. Methods: This is a case series conducted from December 2014 to April 2016 utilizing the flexible endoscope for divericulectomy as an outpatient procedure. Results: Nine procedures were performed in six patients. Diagnosis was made by esophagogastroduodenoscopy and barium swallow. Average age was 65 years, and four patients were men. All the procedure were carried out under general anesthesia using flexible endoscope, orogastric tube and cap. We do not use prophylactic antibiotics and all were outpatients. Conclusion: Endoscopic equipment diverticulectomy with flexible endoscopy is a technique that has been adopted by the interventional gastroenterologists because of its safety and good results. Therefore, this technique should be considered in patients with this pathology

Curva de aprendizaje en disección endoscópica de la submucosa en un hospital universitario latinoamericano / Learning curve in the endoscopic submucosal dissection at a Latin American university hospital

Introduction: The endoscopic submucosal dissection (ESD) is a technique used in the treatment of early gastric cancer that was developed in Japan in the early 90's. When compared with mucosectomy it shows clear benefits, as lower local recurrence with the resection of lesions greater than 2 cm, yet with larger number of complications, especially bleeding and perforation. There is little experience with ESD in the West, because of the low incidence of early gastric cancer and the lack of screening programs; ESD reports are scarce in Colombia. Objective: To report the experience with the endoscopic dissection of the gastric submucosa in the period between March 2012 and January 2014 at Hospital de San José, Bogotá, Colombia. Methods: ESD was performed in eight patients (four men and four women) that fulfilled the Vienna criteria for this procedure. Results: Eight ESD were performed, three in the body and five in the antrum, with a mean size of 3.4 cm; complications included bleeding in one patient and perforation in one patient. En bloc resection was achieved in all eight cases with R0 (margins free of tumor) in seven patients. Conclusion: Gastric ESD is a complex technique and infrequent technique in our evironment. The procedure was performed in a safe manner with acceptable complication rates and achieving en bloc resection in all patients.

Introduction: The endoscopic submucosal dissection (ESD) is a technique used in the treatment of early gastric cancer that was developed in Japan in the early 90's. When compared with mucosectomy it shows clear benefits, as lower local recurrence with the resection of lesions greater than 2 cm, yet with larger number of complications, especially bleeding and perforation. There is little experience with ESD in the West, because of the low incidence of early gastric cancer and the lack of screening programs; ESD reports are scarce in Colombia. Objective: To report the experience with the endoscopic dissection of the gastric submucosa in the period between March 2012 and January 2014 at Hospital de San José, Bogotá, Colombia. Methods: ESD was performed in eight patients (four men and four women) that fulfilled the Vienna criteria for this procedure. Results: Eight ESD were performed, three in the body and five in the antrum, with a mean size of 3.4 cm; complications included bleeding in one patient and perforation in one patient. En bloc resection was achieved in all eight cases with R0 (margins free of tumor) in seven patients. Conclusion: Gastric ESD is a complex technique and infrequent technique in our evironment. The procedure was performed in a safe manner with acceptable complication rates and achieving en bloc resection in all patients.

Cirugía Endoscópica Transluminal: ¡es posible! / Transluminal Endoscopic Surgery: is feasible!

Introducción: La cirugía endoscópica transluminal es una técnica de ingreso a través de orifi cios naturales a la cavidad peritoneal y a los órganos allí contenidos, que busca disminuir los efectos adversos y las complicaciones de los procedimientos abiertos, acorde con la tendencia mundial de obtener resultados iguales a través de abordajes menos invasivos. Objetivo: Determinar las complicaciones de la cirugía endoscópica transluminal para la revisión de la cavidad peritoneal y la toma de biopsia hepática en cerdos. Metodología: Estudio experimental en 12 cerdos. Se tomó biopsia hepática transgástrica y se hizo un seguimiento durante 30 días, evaluando complicaciones y mortalidad. Al fi nal se realizó autopsia al animal. Resultados: No se encontró mortalidad intraoperatoria. La mediana de tiempo quirúrgico fue de 84,5 minutos (RIQ 76-99). Se utilizaron para el cierre de la gastrotomía en promedio 7,8 clips (DE 3.5). En la peritoneoscopia se observó el intestino delgado, bazo, hígado y colon en la mayoría de los casos. La calidad de la biopsia hepática fue buena en 10 especímenes. La cicatrización gástrica fue adecuada en el 81.8%. Se encontraron cultivos de líquido peritoneal positivos en 9 casos. Conclusiones: La técnica requiere destreza y la peritoneoscopia es difícil por la falta de apoyo del equipo al maniobrar en retrofl exión. El potencial de la técnica y el enorme benefi cio para los pacientes son razones sufi cientes para continuar avanzando en este tipo de abordajes.

Introduction: Transluminal endoscopic surgery is a technique that allows access to the peritoneal cavity and the organs contained therein through natural orifi ces, seeking to reduce the adverse effects and complications of open procedures, in line with the global trend of obtaining same results with less invasive approaches. Objective: To determine complications of transluminal endoscopic surgery while exploring the peritoneal cavity and performing a liver biopsy in pigs. Methodology: This is an experimental study done in 12 pigs. Transgastric liver biopsy was taken and animals were followed for 30 days, evaluating complications and mortality. At the end, an autopsy was performed in the animal. Results: No intra-operative mortality was found. The median operative time was 84.5 minutes (IQR 76-99). 7.8 (SD 3.5) clips on average were used for gastrotomy closure. During peritoneoscopy, small intestine, spleen, liver and colon were observed in most cases. Quality of liver biopsy was good in 10 specimens. Gastric healing was adequate in 81.8%. Peritoneal fl uid cultures were positive in 9 cases. Conclusions: This technique requires a skillful operator, since peritoneoscopy is diffi cult because equipment does not support retrofl exion maneuver. Potential of the technique and the huge benefi t to patients are suffi cient reasons for developing this type of approaches.

Primer consenso colombiano sobre la práctica de endoscopia digestiva “Acuerdo en lo fundamental”(Segunda parte. Aspectos éticos) / First Colombian Consensus on the Practice of Endoscopy “Fundamental

Propósito del trabajo: La práctica de la endoscopia digestiva implica conocimientos teóricos, prácticos y éticos. A los dos primeros se les da amplia difusión o importancia en los procesos educativos. A la ética siempre se le menciona, se le asume pero poco se le investiga o indaga. La Asociación Colombiana de Endoscopia Digestiva (ACED) dedica la segunda parte del consenso “Acuerdo sobre lo fundamental” a los aspectos éticos en la práctica de la endoscopia digestiva, abordados desde el análisis de la resolución de dilemas reales que se presentan en los diferentes escenarios que configuran el ejercicio endoscópico. Es esta una forma de apropiar conceptualmente los principios éticos y los valores morales que deben permear el ejercicio profesional de los especialistas que se apoyan en la endoscopia digestiva. Es importante precisar que el resultado final no pretende normatizar las conductas de los médicos; por el contrario, se propone la realización de una reflexión permanente sobre los continuos conflictos que atañen a esta especialidad, los cuales no deberían resolverse por fuera de profundas consideraciones éticas y morales

Purpose: The practice of endoscopy involves theoretical, practical and ethical knowledge. The first two aregiven widespread distribution and great importance in education. Ethics is always mentioned, but is little studiedor investigated. The Colombian Association of Digestive Endoscopy (ACED) devotes the second part ofthe “Fundamental Agreement” consensus to the ethical practice of gastrointestinal endoscopy. We approachthis topic from an analysis of the resolution of real dilemmas that arise in endoscopic scenarios shaping ourpractice. This is the way of conceptually appropriating ethical principles and moral values that should permeatethe practice of specialists who rely on endoscopy. It is important to note that the end result is not intendedto standardize the conduct of doctors. To the contrary, we propose to carry out an ongoing reflection aboutthe continuous conflicts that arise in our specialty which should not be resolved without profound ethical andmoral consideration

Primer consenso colombiano sobre la práctica de endoscopia digestiva "Acuerdo en lo fundamental" (Primera parte: Aspectos formativos) / First colombian consensus on digestive endoscopy

Propósito del trabajo: La práctica de la endoscopia digestiva en Colombia sufrió una modificación cuando la resolución 1043 de 2006 autorizó que especialistas de cirugía general, medicina interna o pediatría pudieran ejercerla si acreditaban entrenamiento de un año en endoscopia otorgado por una institución de educación superior. Esto, junto al desarrollo de relaciones de la endoscopia con diferentes especialidades, generó un escenario desordenado (y para muchos injusto y desigual) donde los requisitos formativos se volvieron diferenciados. En una realidad de tensiones e intereses variados entre especialistas, asociaciones científicas, sistema de salud y prestadores de servicios, se propició este consenso para que, desde acuerdos sobre lo fundamental, se permita hacer recomendaciones sobre unas características formativas unificadas que proporcionen prácticas endoscópicas dirigidas a la calidad, eje central del beneficio para los pacientes. Material y métodos: El consenso es un estudio de investigación social, descriptivo, transversal, de enfoque mixto (cualitativo y cuantitativo), basado en el método Delphy. La información se obtuvo durante el evento "Acuerdo en lo fundamental", citado el 23 de junio de 2012 por la presidencia de la Asociación Colombiana de Endoscopia Digestiva (ACED). Los datos cualitativos se tomaron de las discusiones en 4 mesas redondas en las que los 34 participantes abordaron las 25 preguntas de la encuesta; los cuantitativos, de la votación final, individual, privada y electrónica de la encuesta, definiendo que el 75% o más, constituían consenso. Para el análisis cualitativo, se empleó análisis de discurso orientado desde cinco variables relacionadas con aspectos formativos. Para el cuantitativo, se usó estadística descriptiva básica centrada en porcentajes.

Purpose of the work. The practice of endoscopy in Colombia was modified when Resolution 1043 of 2006 authorized specialists in general surgery, internal medicine and pediatrics to perform endoscopy after completing one year of training in endoscopy at an institution of higher education. This, together with the development of relationships with different specialties within endoscopy, generated a disordered scenario which many considered to be unjust and unequal. Training requirements became differentiated. A world of tensions and interests among specialists, scientists, health care providers and service providers led to this consensus. Starting with fundamental agreements, it makes recommendations for unification of educational features that will allow endoscopic practices which aim for quality and whose central axis is the best interest of our patients. Materials and Methods. This consensus is a descriptive, cross-sectional social research study with a mixed approach (qualitative and quantitative) based on the Delphy method. The information in this study was obtained from the event titled "Acuerdo en lo fundamental" (agreement on fundamental issues) organized on June 23, 2012 by the president of the Colombian Association of Digestive Endoscopy (ACED). Qualitative data were taken from four roundtables discussions in which 34 participants discussed 25 survey questions. The quantitative data were taken from final voting and from an individual, private electronic survey. 75% or greater agreement was defined as consensus. Qualitative analysis employed discourse analysis oriented around five variables related to formative aspects. Basic descriptive statistics centered around percentages were used for quantitative analysis.

Acalasia: en defensa de manejo endoscópico / In defense of endoscopic management of achalasia

La acalasia es una patología esofágica que compromete de manera significativa la calidad de vida de los pacientes. Su fisiopatología no es muy bien comprendida y hasta el momento su etiología no se ha podido establecer. Los tratamientos disponibles, en general, son paliativos y un porcentaje significativo de pacientes, una vez se han agotado todas las opciones endoscópicas y quirúrgicas, deben ser llevados a esofagectomía. La endoscopia terapéutica nos ofrece la dilatación neumática con balón guiada por endoscopia con excelentes resultados. La miotomía de Heller por laparoscopia asociada con fundoplicatura parcial es el tratamiento quirúrgico de elección, y los resultados son comparables a los obtenidos con la endoscopia más dilatación neumática con balón. Sin embargo, la miotomía quirúrgica es una técnica que no está exenta de riesgos, algunos pacientes no la aceptan y otros no son buenos candidatos para la misma. Desde hace algún tiempo y con base en estudios discutibles, se ha popularizado la idea de que la miotomía de Heller por laparoscopia es superior a la endoscopia más dilatación neumática con balón. El desarrollo de la endoscopia terapéutica y el conocimiento cada vez mayor de las capas más profundas del tracto gastrointestinal, ha hecho posible la concepción de la cirugía endoscópica transmural, de tal manera que es posible realizar una miotomía endoscópica submucosa como alternativa de manejo. La endoscopia terapéutica, con los métodos disponibles y las técnicas que se encuentran aún en estudio, seguirá estando dentro de las opciones de manejo de estos pacientes como un tratamiento de primera línea.

Achalasia is an esophageal pathology which significantly compromises patient quality of life. Its pathophysiology is not well understood and its etiology has not yet been established. Available treatments are generally palliative. A significant percentage of patients, once they have exhausted all endoscopic and surgical options, should be referred for esophagectomy. Therapeutic endoscopy offers pneumatic balloon dilation guided by endoscopy with excellent results. Laparoscopic Heller myotomy associated with partial fundoplication is the surgical treatment of choice: its results are comparable to those obtained with endoscopic pneumatic balloon dilatation. However, surgical myotomy is a technique that is not without risks, some patients do not accept it and others are not good candidates for the procedure. For some time now the idea that laparoscopic Heller myotomy is superior to endoscopic pneumatic balloon dilation has been popularized, but this is based on questionable studies. The development of therapeutic endoscopy and the growing awareness of the deeper layers of the gastrointestinal tract have made the concept of transmural endoscopic surgery possible to the point that performing a submucosal endoscopic myotomy is now an alternative for management of Achalasia. Therapeutic endoscopy using available methods and techniques is still under study but will remain a first line treatment option for managing these patients.