Lesión de Dieulafoy: reporte de dos casos / Dieulafoy lesion: a report of two cases

Se describen dos casos de lesión de Dieulafoy, la cual es definida como una anormalidad de una arteria grande o arteriola, que conserva su calibre al aproximarse a la mucosa. Esta lesión suele presentarse como sangrado gastrointestinal masivo no doloroso e inestabilidad hemodinámica y puede ser causa de hemorragia gastrointestinal fatal. El diagnóstico definitivo es anatomopatológico aunque con la endoscopia se puede alcanzar una precisión elevada siendo esta última el tratamiento de elección. La enfermedad presentaba una mortalidad cercana al 80% antes de la terapia endoscópica y gracias a esta actualmente se ha reducido al 13%. La experiencia del endoscopista y los recursos disponibles influyen en forma directa con la eficacia en el diagnostico, tratamiento y sobrevida de los pacientes.

Two cases of Dieulafoy lesion, defined as a malformation in a large artery or arteriole that retains its caliber when approaching the mucosa, are described here. This lesion usually causes non-painful massive gastrointestinal bleeding and hemodynamic instability and can cause a fatal gastrointestinal hemorrhage. The definitive diagnosis is pathologic, although a high precision can be achieved by endoscopy, that is the treatment of choice. The disease had a mortality rate near 90% before the endoscopic therapy and, thanks to it, it has currently been reduced to 13%. The endoscopist's experience and the available resources influence directly on the effectiveness of diagnosis, management and survival of patients.

Heterotopía Gástrica Rectal. Reporte de un Caso / Rectal Gastric Heterotopia. A Case Report

La mucosa gástrica heterotópica es una alteración caracterizada por la presencia de mucosa gástrica fuera del estómago siendo la ubicación más frecuente en esófago. La heterotopía gástrica del recto es un hallazgo infrecuente, con sólo 50 casos reportados hasta el momento, descripta por primera vez en 1939. A continuación, describimos un caso de heterotopía gástrica en recto haciendo una breve actualización de las manifestaciones, posibles etiologías y opciones terapéuticas.

Heterotopic gastric mucosa is an anomaly that is characterized by the appearance of gastric mucosa out of the stomach, usually in the esophagus. The gastric heterotopia in rectum is a rare finding -of which only 50 cases reported so far- that was first described in 1939. Below, we describe a case of gastric heterotopia in rectum briefly updating the manifestations, possible causes and therapeutic options.

Esfinterotomía más dilatación con balones de grandes volúmenes versus esfinterotomía en la extracción de litiasis complejas: análisis prospectivo / Sphincterotomy plus large balloon dilation versus sphincterotomy alone for the extraction of complex lithiasis: a prospective analysis

ANTECEDENTES Y PROPÓSITO: la esfinterotomía mediana asociada a dilatación con balones de grandes volúmenes es una alternativa a la esfinterotomía amplia en la remoción de litiasis complejas pero no resulta claro cuál de las dos técnicas es más efectiva. Nosotros comparamos ambos métodos de manera prospectiva. MÉTODO: desde enero de 2012 hasta marzo de 2014 se incluyeron en forma consecutiva 133 pacientes con litiasis complejas. Al grupo A se le realizó esfinterotomía mediana asociada a dilatación con balones de grandes volúmenes y al grupo B esfinterotomía amplia. Se evaluaron las tasas de éxito en la extracción de litiasis, tasa de permeabilidad ductal, la utilización de litotripcia mecánica, dosis, tiempo y dosis por área de la radioscopia y complicaciones vinculadas al procedimiento. RESULTADOS: el grupo A tuvo 44 pacientes y el grupo B 69. La tasa de éxito global en la extracción fue de 86,4% en el grupo A y 70% en el grupo B (p = 0,069). En las litiasis gigantes la efectividad en la extracción fue de 89,3% en el grupo A y 58,6% en el grupo B (p = 0,019). El porcentaje de utilización de litotripcia mecánica fue de 15,9% y 30,4%, respectivamente (p = 0,142). La dosis total de radiación fue de 39,8 mGy vs. 26,2 mGy, respectivamente (p= 0,134). Se presentaron complicaciones en el 6,8% y 5,5% de los procedimientos de cada grupo sin diferencias significativas (p = 0,856). CONCLUSIÓN: la técnica de esfinterotomía con dilatación resulta más efectiva e igualmente segura que la esfinterotomía convencional en el manejo de la coledocolitiasis gigante

BACKGROUND AND PURPOSE: Mid-size sphincterotomy associated with large balloon dilation is an alternative to wide sphincterotomy to remove complex lithiases. However, which of the two techniques is most effective remains unclear. Hence, we conducted this study to compare both methods prospectively. Method: Since January 2012 until March 2014, 133 consecutive patients with complex stones were included. Group A underwent mid-size sphincterotomy associated with large balloon dilation and group B underwent wide sphincterotomy alone. Success rates were assessed for: Extraction of stones, ductal patency rate, the use of mechanical lithotripsy, dose, time and dose per radioscopy area as well as procedure-related complications. Results: Group A comprised 44 patients and group B comprised 69 patients. Overall success rate for extraction was 86.4% in group A and 70% in group B (p = 0.069). In giant lithiasis, effective extraction was 89.3% in group A and 58.6% in group B (p = 0.019). Use of mechanical lithotripsy was 15.9% and 30.4%, respectively (p = 0.142). Total radiotherapy dose was 39.8 mGy vs. 26.2 mGy, respectively (p = 0.134). Complications occurred in 6.8% and 5.5% of the procedures in each group, without significant differences among them (p = 0.856). Conclusion: Sphincterotomy plus large balloon dilation is more effective and equally safe than conventional sphincterotomy for the management of giant main bile duct lithiasis

Tumores hiliares biliares: ¿drenaje endoscópico o percutáneo? Análisis prospectivo / Hilar bile duct tumors: endoscopic or percutaneous drainage? A prospective analysis

ANTECEDENTES Y OBJETIVO: existen dos técnicas válidas para el drenaje de los tumores hiliares: el abordaje endoscópico y el percutáneo. Nuestro objetivo primario fue reportar la efectividad y las complicaciones de estos procedimientos. MÉTODOS: análisis prospectivo observacional referido al manejo endoscópico y/o percutáneo de todos los tumores hiliares intervenidos en un hospital de tercer nivel desde octubre de 2011 a octubre de 2014. El grupo A representó a los pacientes abordados endoscópicamente, y el grupo B incluyó aquellos con drenaje percutáneo. Se analizaron las siguientes variables: tasa de drenaje biliar efectivo, tiempo de sobrevida y complicaciones. RESULTADOS: el grupo A tuvo 40 pacientes y el grupo B 22. La tasa de éxito global en lograr un drenaje biliar efectivo fue del 85% en el grupo A y del 90,9% en el grupo B (p = 0,78). En cinco pacientes se requirió un abordaje combinado. La efectividad del grupo A en el drenaje de pacientes con tumores tipo Bismuth IV fue del 58,3%, mientras que el grupo B alcanzó el 81,8% (p = 0,44). La sobrevida media de los pacientes no presentó diferencias estadísticas entre ambos grupos. En el grupo A la tasa de complicaciones alcanzó un 11,5% mientras que en el B fue de 2,94% (p = 0,41). CONCLUSIONES: el drenaje biliar endoscópico y el percutáneo son métodos efectivos en el tratamiento paliativo de los tumores hiliares. Sin embargo, en estenosis tipo Bismuth IV, el drenaje percutáneo resultó más efectivo y seguro

BACKGROUND AND OBJECTIVE: Both the endoscopic and the percutaneous approach are widely accepted for the drainage of hilar tumors. Our primary objective was to report on the effectiveness and complications of these procedures. METHODS: Prospective observational analysis of the endoscopic and/or percutaneous management of all hilar tumors treated at a referral hospital from October 2011 until October 2014. Group A included patients treated endoscopically and group B included patients treated with percutaneous drainage. The following variables were assessed: Effective biliary drainage rate, survival time and complications. RESULTS: Group A comprised 40 patients and group B, 22 patients. Overall success rate in achieving effective biliary drainage was 85% in group A and 90.9% in group B (p = 0.78). Five patients required a combined approach. In group A, the rate of effective drainage in patients with Bismuth IV-type tumors was 58.3%, while it was 81.8% in patients in group B (p = 0.44). There was no difference in mean survival between both groups. For group A, complication rate was 11.5%, whereas it was 2.94% for group B (p = 0.41). CONCLUSIONS: Endoscopic and percutaneous biliary drainage are both effective methods for the palliative treatment of patients with hilar tumors. However, for Bismuth IV-type strictures, percutaneous drainage proved to be safer and more effective

[Sphincterotomy plus large balloon dilation versus sphincterotomy alone for the extraction of complex lithiasis: A prospective analysis]. / Esfinterotomía más dilatación con balones de grandes volúmenes versusesfinterotomía en la extracción de litiasis complejas: análisis prospective.

BACKGROUND AND PURPOSE: Mid-size sphincterotomy associated with large balloon dilation is an alternative to wide sphincterotomy to remove complex lithiases. However, which of the two techniques is most effective remains unclear. Hence, we conducted this study to compare both methods prospectively. METHOD: Since January 2012 until March 2014, 133 consecutive patients with complex stones were included. Group A underwent mid-size sphincterotomy associated with large balloon dilation and group B underwent wide sphincterotomy alone. Success rates were assessed for: Extraction of stones, ductal patency rate, the use of mechanical lithotripsy, dose, time and dose per radioscopy area as well as procedure-related complications. RESULTS: Group A comprised 44 patients and group B comprised 69 patients. Overall success rate for extraction was 86.4% in group A and 70% in group B (p = 0.069). In giant lithiasis, effective extraction was 89.3% in group A and 58.6% in group B (p = 0.019). Use of mechanical lithotripsy was 15.9% and 30.4%, respectively (p = 0.142). Total radiotherapy dose was 39.8 mGy vs. 26.2 mGy, respectively (p = 0.134). Complications occurred in 6.8% and 5.5% of the procedures in each group, without significant differences among them (p = 0.856). CONCLUSION: Sphincterotomy plus large balloon dilation is more effective and equally safe than conventional sphincterotomy for the management of giant main bile duct lithiasis.

[Hilar bile duct tumors: Endoscopic or percutaneous drainage? A prospective analysis]. / Tumores hiliares biliares: ¿drenaje endoscópico o percutáneo?Análisis prospective.

BACKGROUND AND OBJECTIVE: Both the endoscopic and the percutaneous approach are widely accepted for the drainage of hilar tumors. Our primary objective was to report on the effectiveness and complications of these procedures. METHODS: Prospective observational analysis of the endoscopic and/or percutaneous management of all hilar tumors treated at a referral hospital from October 2011 until October 2014. Group A included patients treated endoscopically and group B included patients treated with percutaneous drainage. The following variables were assessed: Effective biliary drainage rate, survival time and complications. RESULTS: Group A comprised 40 patients and group B, 22 patients. Overall success rate in achieving effective biliary drainage was 85% in group A and 90.9% in group B (p = 0.78). Five patients required a combined approach. In group A, the rate of effective drainage in patients with Bismuth IV-type tumors was 58.3%, while it was 81.8% in patients in group B (p = 0.44). There was no difference in mean survival between both groups. For group A, complication rate was 11.5%, whereas it was 2.94% for group B (p = 0.41). CONCLUSIONS: Endoscopic and percutaneous biliary drainage are both effective methods for the palliative treatment of patients with hilar tumors. However, for Bismuth IV-type strictures, percutaneous drainage proved to be safer and more effective.

[Quality and competence in endoscopic cholangiography. Towards certainty]. / Calidad y competencia en colangiografía endoscópica. Rumbo a lo seguro.

INTRODUCTION: The American Society of Gastroenterology (ASGE) and the American College of Gastroenterolog (ACG) have established indicators to recognize high-quality studies in endoscopic retrograde cholagiopancreatography (ERCP). The indicators were: a) Pre-procedure: adequate indication, informed consent, assessment of the degree of difficulty of the procedure and antibiotic prophylaxis. b) Intraprocedure: cannulation, choledocholithiasis extraction and stents placement rates. c) Postprocedure: full documentation and complications rates. METHODS: Between October 2010 and October 2012 we performed a retrospective, descriptive, observational and self-evaluative study to assess the compliance with ERCP quality indicators proposed by the ASGE. RESULTS: Preprocedural indicators were evaluated in 734 studies. Cannulation, choledocolithiasis extraction and stents placement under the hiliar bifurcation rates were 96.2%, 95.4% and 100%, respectively. The complication rate was 5.6% and the mortality was 0.27%. The severity of complications was evaluated according to the classification of Masci (30 mild, 7 moderate and 4 severe). CONCLUSIONS: Quality is a basic tool that allows the comparison between our actions and the indicators already predetermined as suitable. The appropriate indication is an indicator to improve. We believe that 12% of registered normal studies could be due to a difficult accessibility to magnetic resonance cholangiography in our health system. Achievement of the internationally validated indicators place us as a high-quality endoscopic cholagiography unit and as a training center with appropriate expertise.