In search of the grail: A race for acid suppression. / La búsqueda del Grial: una carrera por la supresión ácida.

Proton pump inhibitors are the reference standards for the treatment of acid-related diseases. Acid suppression in gastroesophageal reflux disease is associated with a high rate of mucosal cicatrization, but symptom response differs among endoscopic phenotypes. Extraesophageal manifestations have a good clinical response in patients that present with abnormal acid exposure (diagnostic test) in the esophagus. Proton pump inhibitors have shown their effectiveness for reducing symptom intensity in nighttime reflux and sleep disorders, improving quality of life and work productivity. That can sometimes be achieved through dose modifications by splitting or increasing the dose, or through galenic formulation. Proton pump inhibitors are not exempt from controversial aspects related to associated adverse events. Technological development is directed at improving proton pump inhibitor performance through increasing the half-life, maximum concentration, and area under the curve of the plasma concentrations through galenic formulation, as well as creating safer and more tolerable drugs. The present review is focused on the mechanisms of action, pharmacokinetic properties, and technological advances for increasing the pharmacologic performance of a proton pump inhibitor.

Systematic alphanumeric-coded endoscopy versus chromoendoscopy for the detection of precancerous gastric lesions and early gastric cancer in subjects at average risk for gastric cancer. / Aplicación de la endoscopia sistemática alfanumérica codificada más cromoendoscopia para la detección de lesiones precancerosas gástricas y cáncer gástrico temprano en sujetos con riesgo promedio de cáncer gástrico.

INTRODUCTION AND AIMS: Gastric cancer is one of the main causes of cancer worldwide, but there is currently no global screening strategy for the disease. Endoscopy is the screening method of choice in some Asian countries, but no standardized technique has been recognized. Systematic alphanumeric-coded endoscopy can increase gastric lesion detection. The aim of the present article was to compare the usefulness of systematic alphanumeric-coded endoscopy with conventional endoscopy for the detection of premalignant lesions and early gastric cancer in subjects at average risk for gastric cancer. MATERIALS AND METHODS: A cross-sectional, comparative, prospective, randomized study was conducted on patients at average risk for gastric cancer (40-50 years of age, no history of H. pylori infection, intestinal metaplasia, gastric atrophy, or gastrointestinal surgery). Before undergoing endoscopy, the patients had gastric preparation (200mg of oral acetylcysteine or 50mg of oral dimethicone). Conventional chromoendoscopy was performed with indigo carmine dye for contrast enhancement. RESULTS: Fifty consecutive cases (mean age 44.4 ± 3.34 years, 60% women, BMI 27.6 ± 5.82 kg/m2) were evaluated. Endoscopic imaging quality was satisfactory in all the cases, with no differences between methods (p = 0.817). The detection rate of premalignant lesions and early gastric cancer was 14% (6 cases of intestinal metaplasia and one case of gastric adenocarcinoma). Sensitivity, specificity, positive predictive value, negative predictive value, and diagnostic accuracy were 100, 95, 80, 100 and 96%, respectively, for systematic alphanumeric-coded endoscopy, and 100, 45, 20, 100, and 52%, respectively, for conventional endoscopy. Lesion detection through systematic alphanumeric-coded endoscopy was superior to that of conventional endoscopy (p = 0.003; OR = 12). CONCLUSION: Both techniques were effective, but systematic alphanumeric-coded endoscopy significantly reduced the false positive rate.

Efficacy of narrow-band imaging for detecting intestinal metaplasia in adult patients with symptoms of dyspepsia. / La eficacia de la imagen de banda estrecha para la detección de metaplasia intestinal en pacientes adultos con síntomas de dispepsia.

INTRODUCTION AND OBJECTIVE: Atrophy and intestinal metaplasia are early phenotypic markers in gastric carcinogenesis. White light endoscopy does not allow direct biopsy of intestinal metaplasia due to a lack of contrast of the mucosa. Narrow-band imaging is known to enhance the visibility of intestinal metaplasia, to reduce sampling error, and to increase the diagnostic yield of endoscopy for intestinal metaplasia in Asian patients. The aim of our study was to validate the diagnostic performance of narrow-band imaging using 1.5× electronic zoom endoscopy (with no high magnification) to diagnose intestinal metaplasia in Mexican patients. MATERIALS AND METHODS: A retrospective cohort study was conducted on consecutive patients with dyspeptic symptoms at a private endoscopy center within the time frame of January 2015 to December 2016. RESULTS: A total of 338 patients (63±8.4 years of age, 40% women) were enrolled. The prevalence of H. pylori infection was 10.9% and the incidence of intestinal metaplasia in the gastric antrum and corpus was 23.9 and 5.9%, respectively. Among the patients with intestinal metaplasia, 65.3% had the incomplete type, 42.7% had multifocal disease, and one third had extension to the gastric corpus. Two patients had low-grade dysplasia. The sensitivity of white light endoscopy was 71.2%, with a false negative rate of 9.9%. The sensitivity, specificity, positive predictive value, negative predictive value, and accuracy of narrow-band imaging (with a positive light blue crest) were 85, 98, 86.8, 97.7, and 87.2%, respectively. CONCLUSION: The prevalence of H. pylori infection and intestinal metaplasia in dyspeptic Mexican patients was not high. Through the assessment of the microsurface structure and light blue crest sign, non-optical zoom narrow-band imaging had high predictive values for detecting intestinal metaplasia in patients from a general Western setting.

Post-fundoplication symptoms and complications: Diagnostic approach and treatment. / Síntomas y complicaciones posfunduplicatura: abordaje diagnóstico y tratamiento.

Laparoscopic Nissen fundoplication is currently considered the surgical treatment of choice for gastroesophageal reflux disease (GERD) and its long-term effectiveness is above 90%. Adequate patient selection and the experience of the surgeon are among the predictive factors of good clinical response. However, there can be new, persistent, and recurrent symptoms after the antireflux procedure in up to 30% of the cases. There are numerous causes, but in general, they are due to one or more anatomic abnormalities and esophageal and gastric function alterations. When there are persistent symptoms after the surgical procedure, the surgery should be described as "failed". In the case of a patient that initially manifests symptom control, but the symptoms then reappear, the term "dysfunction" could be used. When symptoms worsen, or when symptoms or clinical situations appear that did not exist before the surgery, this should be considered a "complication". Postoperative dysphagia and dyspeptic symptoms are very frequent and require an integrated approach to determine the best possible treatment. This review details the pathophysiologic aspects, diagnostic approach, and treatment of the symptoms and complications after fundoplication for the management of GERD.

[Endolifter, a new tool for safe and rapid submucosal endoscopic dissection]. / Endolifter, una nueva herramienta para una segura y rápida disección endoscópica submucosa.

BACKGROUND: The effectiveness of endoscopic submucosal dissection (ESD) is similar to that of surgery in the treatment of early lesions. The technique requires a high level of technical skill. Training on biologic models and the mastering of accessories facilitate ESD. AIMS: The aim was to evaluate the usefulness of the Endolifter in facilitating tissue exposure during ESD in an in vivo porcine model performed at the experimental surgery laboratory of the School of Medicine at the Universidad de São Paulo in Brazil. MATERIAL AND METHOD: A study with an experimental design employing an in vivo porcine model was conducted on 5 Yorkshire pigs weighing 20-25kg. ESDs were performed using the Endolifter. Mucosal layer dissection was carried out with a dual knife and IT knife and all the endoscopic procedures were performed by a single expert endoscopist. RESULTS: A total of 25 ESDs were performed, with a technical success rate of 100%. The mean dissection time was 12.34min (range: 10.40-14.50 min) and the mean lesion size was 2.7cm (range: 2.3-3.2cm). There were no episodes of bleeding or perforations during the procedures. CONCLUSIONS: The Endolifter enables rapid and effective ESDs to be carried out. It is an applicable and easy-to-use device that can be manipulated by a single operator.

[Mexican consensus on portal hypertension]. / Consenso Mexicano de Hipertensión Portal.

The aim of the Mexican Consensus on Portal Hypertension was to develop documented guidelines to facilitate clinical practice when dealing with key events of the patient presenting with portal hypertension and variceal bleeding. The panel of experts was made up of Mexican gastroenterologists, hepatologists, and endoscopists, all distinguished professionals. The document analyzes themes of interest in the following modules: preprimary and primary prophylaxis, acute variceal hemorrhage, and secondary prophylaxis. The management of variceal bleeding has improved considerably in recent years. Current information indicates that the general management of the cirrhotic patient presenting with variceal bleeding should be carried out by a multidisciplinary team, with such an approach playing a major role in the final outcome. The combination of drug and endoscopic therapies is recommended for initial management; vasoactive drugs should be started as soon as variceal bleeding is suspected and maintained for 5 days. After the patient is stabilized, urgent diagnostic endoscopy should be carried out by a qualified endoscopist, who then performs the corresponding endoscopic variceal treatment. Antibiotic prophylaxis should be regarded as an integral part of treatment, started upon hospital admittance and continued for 5 days. If there is treatment failure, rescue therapies should be carried out immediately, taking into account that interventional radiology therapies are very effective in controlling refractory variceal bleeding. These guidelines have been developed for the purpose of achieving greater clinical efficacy and are based on the best evidence of portal hypertension that is presently available.

Polar vectors as a method for evaluating the effectiveness of irritable bowel syndrome treatments: an analysis with pinaverium bromide 100mg plus simethicone 300mg po bid.

BACKGROUND: Irritable Bowel Syndrome (IBS) is a disorder characterized by abdominal pain or discomfort associated with changes in bowel habit. Currently there are no objective outcome measures for evaluating the effectiveness of treatments for this disorder. AIMS: To determine the usefulness of a method of analysis that employs polar vectors to evaluate the effectiveness of IBS treatments. METHODS: Data from a Phase IV clinical study with 1677 active IBS-Rome III patients who received 100mg of pinaverium bromide+300mg of simethicone (PB+S) po bid for a period of four weeks were used for the analysis. Using the Bristol Stool Scale as a reference, the consistency and frequency of each type of bowel movement were recorded weekly in a Bristol Matrix (BM) and the data were expressed as polar vectors. RESULTS: The analysis showed a differential response to the PB+S treatment among the IBS subtypes: in reference to the IBS with constipation subtype, the magnitude of the vector increased from 10.2 to 12.5, reaching maximum improvement at two weeks of treatment (p<0.05, Scheffé). In the IBS with diarrhea and mixed IBS subtypes, the magnitude of the vector decreased from 19 to 14 (p<0.05) and from 16.5 to 13 (p<0.05), respectively, with continuous improvement for a period of four weeks. There was no definable vectorial pattern in the unsubtyped IBS group. CONCLUSIONS: Analysis with polar vectors enables treatment response to be measured in different IBS subtypes. All the groups showed improvement with PB+S, but each one had its own characteristic response in relation to vector magnitude and direction. The proposed method can be implemented in clinical studies to evaluate the efficacy of IBS treatments.

Immunological fecal occult blood test vs. serum ferritin for detection of colorectal neoplasia in high risk asymptomatic population.

INTRODUCTION: Fecal occult blood tests (FOBT) (biochemical or immunological) are based on the fact that most of the polyps or cancers bleed. Anemia due to iron deficiency is a wellknown sign for colorectal cancer (CRC). Ferritin is frequently used to select candidates for colonoscopy. OBJECTIVE: To determine and compare the diagnostic value of immunological fecal occult blood test vs. ferritin for the detection of colorectal neoplasia (cancer or polyps) in high-risk patients. METHODS: A transversal prospective study at National Cancer Institute, Mexico City, in consecutive asymptomatic subjects at high risk for CRC was performed, comparing two tests (immunological against serum ferritin) with colonoscopy plus histopathology. Both tests were performed in a blindly fashion previous to colonoscopy. RESULTS: Fifty patients were included in the study; twenty-eight patients had colorectal neoplasia (21 CRC, 7 adenomas). All immunologic tests for fecaloccult blood were positive in patients with colorectal lesions (sensitivity, 98%). There was no difference between the mean ferritin levels in patients with CRC or adenomas vs. those with negative colonoscopy (p = 0.58). The cutoff point where significant relationship between serum ferritin levels and colon lesions was established was ?46 ng/mL. In anemic patients with serum ferritin levels <46 ng/mL, the test had a sensitivity 53%, specificity 86%, positive predictive value 83%, and negative predictive value of 59% (p = 0.003). CONCLUSIONS: The immunological FOBT is a better diagnostic tool than serum ferritin for screening of colonic neoplasms.

[IT-Knife-2 electroincision as primary treatment of anastomotic strictures]. / Electroincisión con IT-Knife-2 como tratamiento primario de las estenosis posquirúrgicas.

BACKGROUND: Dysphagia is a common problem after surgical stenosis (5% to 55%) and can be refractory to conventional endoscopic treatment in 22% of cases. It has been proposed that electro-incision is an alternative and effective treatment. OBJECTIVE: To evaluate the effectiveness of electro-incision with the insulation-tipped diathermic Knife-2 (IT-Knife-2) in the treatment of dysphagia produced by surgical anastomotic strictures. METHODS: Longitudinal and case-series study from August 2009 to June 2010. Eight consecutive patients with anastomotic stricture-associated dysphagia and naive to endoscopic treatment were included. We performed three or more radiated cuts in the stricture until passage of the gastroscope was achieved with IT-Knife-2 and electrocautery (ERBE IC 200) with a 70-100 W energy cut-off and 25 W coagulation. We carried out measurements at baseline and 15 days after the intervention, evaluating the dysphagia by the Atkinson grading scale and endoscopic changes. RESULTS: The majority of patients were at clinical stage IV with an Eastern Cooperative Oncology Group score of 1 - 3 and Karnofsky between 40 and 90. At the time of endoscopic diagnosis, patients had dysphagia grade II and III. Strictures in all of the cases were short in length and had a diameter of minor than 5 mm. At 15 days of the intervention, no patient demonstrated dysphagia (p = 0.0013) and the anastomotic diameters was more than 9.5 mm and without evidence of stenosis (p = 0.0001). None of our patients presented postincisional complications. CONCLUSIONS: Electro-incision with IT-Knife-2 is effective as primary treatment for the relief of benign dysphagia associated with postsurgical anastomotic stenosis."

[The value of targeted biopsies with endoscopic magnification and narrow band image vs. chromoendoscopy for the diagnosis of gastric metaplasia]. / Valor de la biopsia dirigida con magnificación endoscópica más imagen de banda estrecha vs. Cromoendoscopia para el diagnóstico de metaplasia gástrica.

INTRODUCTION: Endoscopy is the better test to detect premalignant lesions, but its main problem is the sampling error. OBJECTIVES: To evaluate the diagnostic usefulness of endoscopic biopsies using narrow band imaging (NBI) vs. chromoendoscopy for diagnosing gastric intestinal metaplasia. METHODS: Forty one patients were studied with conventional endoscopy, NBI magnification endoscopy and chromoendoscopy (3% acetic acid, 0.6% indigo carmine) for examination of gastric antrum. Biopsies were taken randomly from the antrum, body and incisura angularis. Additional biopsies were taken from areas with villous or crypt pattern according to NBI and chromoendoscopy examination (targeted biopsies). RESULTS: 240 biopsies were taken, 205 randomized biopsies and 35 targeted biopsies. Intestinal metaplasia was found in 25 randomized biopsies and 9 directed samples (12% vs. 25.7%). The NBI and chromoendoscopy had sensitivity of 70% vs. 77%, specificity of 97% vs. 98%, with diagnostic accuracy of 96% vs. 97%, respectively. Random biopsies and targeted biopsies had a sensitivity of 91% vs. 74%, specificity of 51% vs. 95%, and diagnostic accuracy of 93% vs. 86%, respectively. The intra-observer variability showed a k value of 0.86 (range 0.74 to 0.99). CONCLUSION: Targeted biopsies are more specific than random biopsies to detect gastric intestinal metaplasia. NBI and chromoendoscopy may be used similarly to guide biopsies.

Barrett's esophagus: endoscopic treatments I.

The following on endoscopic treatments of Barrett's esophagus includes commentaries on indications for endoscopic treatments; endo-luminal plication procedures; the cellular modifications induced by the endoscopic ablation therapies; eradication by banding without resection; the evaluation of complete ablation; recurrence after ablation; association of antireflux surgery; radiofrequency ablation; and nondysplastic Barrett's esophagus.

[Endoscopic inanimate biological simulators for training in endoscopic mucosal dissection]. / Entrenamiento en la disección endoscópica de la submucosa "mediante el uso de simuladores biológicos inanimados.

BACKGROUND: Simulators have been used as a training method; they allow training, skill development, standardization of techniques and the performance of a greater number of risk-free procedures. Endoscopic submucosal dissection (ESD) is the standard treatment for early gastric cancer since it allows en bloc resection of larger lesions however requires longer procedure time and has more complications than endoscopic mucosal resection. OBJECTIVE: To evaluate the use of biological inanimate simulators in endoscopic training for the development of skills required for ESD. METHODS: Experimental design using a biological inanimate simulator to evaluate the development of endoscopic skills. Five trained endoscopists with knowledge of the ESD technique, but without previous experience were selected. Technical success, complication rate and procedure time were evaluated. Each participant performed a self-evaluation. RESULTS: 18 lesions of 10-20 mm in diameter were dissected, with a mean area of 2.64 ± 2 cm2 and a mean procedure time of 21.08 ± 14.01 minutes (5.48 - 48.61). Self-evaluation and instructor's evaluation showed a strong positive correlation. There was no correlation between lesion size and procedure time. There was one perforation (5.8%), which was successfully managed with one endoclip. Complications such as bleeding could not be assed. CONCLUSIONS: The use of inanimate biological simulators allows training in complex endoscopic procedures such as ESD with a wide safety margin. Lesion size did not correlate with procedure time. It is necessary to increase the number of procedures to improve the learning curve. This simulator does not allow evaluation of complications other than perforations.

Dilated intercellular spaces in subtypes of gastroesophagic reflux disease.

BACKGROUND: Dilatation of the intercellular spaces by electron microscopy has been considered as an early morphological marker of tissue injury in gastroesophageal reflux disease. The degree of dilatation in Barret's esophagus in currently unknown. OBJECTIVES: To determine the frequency of dilated intervellular spaces in Barrett's esophagus. MATERIAL AND METHODS: Cross-sectional and prospective analysis of consecutive patients with gastroesophageal reflux disease. We selected symptomatic patients > 18 years and both sexes. Patients with recent PPI use (< 14 days), H-2 antagonists, NSAID's or previous upper GI tract surgery were excluded. VARIABLES INCLUDED: Clinical-demographic data, Carlsson-Dent score, conventional endoscopy findings, pH-metry results (in non-erosive) and normal mucosal biopsies at 2 and 5 cm above the squamocolumnar junction. Dilation of intercellular spaces was measured by electron microscopy. STATISTICS: Chi square test with a significance level 0.05 was calculated. The following four groups were compared: a) non-erosive reflux disease (n = 14); b) erosive esophagitis (n = 5); c) Barrett's esophagus (n = 13); and d) healthy controls (n = 5). RESULTS: the dilation of intervellular spaces was increasingly greater form non-erosive revlux to Barrett's esophagus and higher in biopsies taken at 5 cm than at 2 cm of the squamous columnar junction (2.72 +/- 1.35 vs. 1.71 +/- 0.48 microg) (p = 0.001). There was no difference between biopsies at 2 and 5 cm in the order groups. CONCLUSION: dilation of intercellular spaces was greater in Barrett s esophagus than in the other groups and higher at 5 cm from the squamocolumnar junction.

Dilatación de los espacios intercelulares en los subtipos de la enfermedad por reflujo gastroesofágico / No disponible

Introducción: la dilatación de los espacios intercelulares mediantemicroscopia electrónica se considera un marcador morfológicotemprano de daño tisular en la enfermedad por reflujo gastroesofágico.El grado de dilatación en el esófago de Barrett sedesconoce actualmente.Objetivos: determinar la frecuencia y grado de la dilataciónde los espacios intercelulares en el esófago de Barrett.Material y métodos: series de casos consecutivos con análisistransversal y prospectivo de pacientes con reflujo gastroesofágico.Criterios de selección: > 18 años, sintomáticos, ambos sexos. Seexcluyeron aquellos con ingesta de IBP, antagonistas H-2, AINE y cirugíaprevia. Tomamos datos clínicos, cuestionario de Carlsson-Dent, endoscopia, pH-metría (no erosivos), y biopsias de la mucosanormal a 2 y 5 cm por encima de la unión escamo-columnar. La mediciónde la dilatación de los espacios intercelulares fue por microscopiaelectrónica. Estadística: descriptiva. Prueba de Chi-cuadrado connivel de significancia de 0,05. Se compararon 4 grupos: a) enfermedadpor reflujo no erosiva (n = 14); b) esofagitis erosiva (n = 5); c)esófago de Barrett (n = 13); y d) controles sanos (n = 5).Resultados: hubo mayor dilatación de los espacios intercelularesen el esófago de Barrett (5 cm, 2,72 ± 1,3 μm vs. 2 cm, 1,7± 0,48 μm) (p = 0,001). Los otros grupos mostraron menor dilatacióny sin diferencias entre los sitios de toma de biopsias.Conclusión: la dilatación de los espacios intercelulares fuemayor en el esófago de Barrett predominando a los 5 cm de launión escamo-columnar(AU)

Background: dilatation of the Intercellular spaces by electronmicroscopy has been considered as an early morphological markerof tissue injury in gastroesophageal reflux disease. The degreeof dilatation in Barrett's esophagus in currently unknown.Objectives: to determine the frequency of dilated intercellularspaces in Barrett's esophagus.Material and methods: cross-sectional and prospectiveanalysis of consecutive patients with gastroesophageal reflux disease.We selected symptomatic patients > 18 years and both sexes.Patients with recent PPI use (< 14 days), H-2 antagonists,NSAID’s or previous upper GI tract surgery were excluded. Variablesincluded: clinical-demographic data, Carlsson-Dent score,conventional endoscopy findings, pH-metry results (in non-erosive)and normal mucosal biopsies at 2 and 5 cm above thesquamocolumnar junction. Dilation of intercellular spaces wasmeasured by electron microscopy. Statistics: Chi square test witha significance level 0.05 was calculated. The following four groupswere compared: a) non-erosive reflux disease (n = 14); b) erosiveesophagitis (n = 5); c) Barrett's esophagus (n = 13); and d) healthycontrols (n = 5).Results: the dilation of intercellular spaces was increasinglygreater from non-erosive reflux to Barret´s esophagus and higherin biopsies taken at 5 cm than at 2 cm of the squamous columnarjunction (2.72 ± 1.35 vs. 1.71 ± 0.48 μm) (p = 0.001). Therewas no difference between biopsies at 2 and 5 cm in the othergroups.Conclusion: dilation of intercellular spaces was greater inBarrett's esophagus than in the other groups and higher at 5 cmfrom the squamocolumnar junction(AU)

[A comparative study of 2 methods of preparation for colonoscopic procedure]. / Estudio comparativo de dos esquemas de preparación para procedimiento colonoscópico.

BACKGROUND: Although ingestion of polyethylene glycol solution has become the standard preparation for colonoscopy since 1980, there is investigation of new safe, comfortable and cheap methods. OBJECTIVE: We carried out a prospective study in order to compare the utility and tolerance related to the preparation of the colon for colonoscopy, using a dioctyl sodium sulfosuccinate enema (SD) versus our conventional preparation. METHOD: Group A was prepared the day previous to the study with liquid diet, oral laxative and application of an SD, prior to the endoscopy received another SD. Group B was prepared three days with liquid diet, the day previous to the colonoscopy they ingested oral laxative and used a water enema (W(e)), and they used another W(e) the day of the procedure. The patients' tolerance in each case was compared using a scale assigned as good, fair and poor. The cleaning obtained in the colon was also evaluated in a scale of good, regular and bad, considering three colon segments. RESULTS: Forty-four patients had been studied, 19 men and 25 women; each group with 22 patients. In group A: the preparation tolerance was good in 14 cases (63.6%), fair in seven (31.8%) and poor in one (4.5%); also, the obtained cleaning up to the cecum was good in nine cases (40.9%) and fair in 13 (59%). In group B: the tolerance was good in five cases (22.7%) fair in 12 (54.5%) and poor in five (22.7%); the obtained cleaning in this group up to the cecum was good in two cases (9%), fair in 19 (86.3%) and poor in one (4.5%). CONCLUSIONS: The SD preparation was better tolerated and more effective in order to achieve the cleaning of the colon than the conventional one.

[Gastric leiomyosarcomas and leiomyoblastomas]. / Leiomiosarcomas y leiomioblastomas gástricos.

The authors review the cases with smooth muscle tumors of the stomach (SMTS), excluding the leiomyomas, at the Mexico's General Hospital in a period of 5 years. They found 8 cases in women and 3 in men, with 51.3 years average. The average of evolution of symptoms was 5 months, prevailing: anaemia, digestive bleeding and abdominal pain. Barium radiology and endoscopy guided to the diagnosis. The tumors were located 7 at the fundus, 3 at the body and one at the gastric antrum. The size oscillated between 1.5-28 cm., average 8 cm. Endoscopic specimens were positive in 2/7 cases and cytologic samples were negative in all cases. Eight tumors were leiomyosarcomas (LMS) and 3 were leiomyoblastomas (LMB); the histologic criteria in order to differentiate them was based on the number of mitosis for 50 fields (50 csf), the size and their hypercellularity. A patient died before being operated. Two cases were subjected to emergency surgery, and died after that. In the cases treated with elective surgery the authors performed subtotal gastrectomy with major omentectomy in 4 and surgical resection of the tumor in the remaining 4 patients. The mortality rate for surgery was 27.2%.

[Surgical treatment of achalasia]. / Tratamiento quirúrgico de la acalasia.

Primary achalasia is a motor dysfunction of the esophagus with unknown aetiology. We present our results obtained in 39 patients treated by Heller's Cardiomyotomy. The procedure was successful in 92.3% of the cases and when it is performed in conjunction with an antirreflux technique, it offers excellent results with a very low frequency of gastroesophageal reflux symptoms and complications.