[Recommendations based on the management of patients with Crohn disease in the Peruvian context. Position paper of the Association for the Study of the Intestine (ASPEIN)]. / Recomendaciones basadas en el manejo de pacientes con diagnóstico de enfermedad de Crohn en el contexto peruano. Documento de posición de la Asociación Peruana para el Estudio del Intestino (ASPEIN).

Crohn's disease is a chronic inflammatory disease of the gastrointestinal tract whose etiology is unknown, which can transmurally affect any segment of the intestine and/or the perineal region. Worldwide, the incidence of inflammatory bowel disease has increased in recent decades, and the same upward trend can be seen in South America. At national level, there are no official data, however, the increase in the number of publications in the last 20 years confirms this upward trend. Crohn's disease is a forgotten disease and does not have implemented clinical guidelines based on evidence that contribute to clinicians in decision making. In this sense, the Peruvian Association for the Study of the Intestine considers the preparation of this document relevant and timely. clinical contextualized for Peru.

Efficacy and Safety of Endoscopic Submucosal Dissection for Superficial Gastric Neoplasms: A Latin American Cohort Study.

BACKGROUND/AIMS: Endoscopic submucosal dissection (ESD) is the preferred technique for treating early gastric cancer (EGC). However, very few studies have been conducted in South America. This study aimed to assess the efficacy and safety of ESD for EGC. METHODS: We analyzed data from a prospective cohort from 2013 to 2020. A total of 152 superficial gastric neoplasms that fulfilled the absolute or expanded criteria for ESD were included. Outcomes were en bloc, R0, and curative resection rates, incidence of adverse events, and length of procedure. RESULTS: The age of the enrolled patients was 68.4±11.3 years. The number of included patients based on the absolute and expanded indications was 150 and 2, respectively. En bloc, R0, and curative resections were achieved in 98.0%, 96.1%, and 89.5% of the cases, respectively. Bleeding and perforation were reported in 5.9% and 6.6% of the cases, respectively. Histopathological examination revealed lowgrade dysplasia, high-grade dysplasia, well-differentiated adenocarcinoma, and poorly differentiated adenocarcinoma in 13, 20, 117, and 2 cases, respectively. CONCLUSION: Our study shows that ESD performed by properly trained endoscopists in reference centers is safe and effective, with comparable therapeutic outcomes to those reported in the Eastern series.

Peroral endoscopic myotomy in a pediatric patient with refractory achalasia: a case report and review of the literature.

A 15-year-old male patient presented with dysphagia, regurgitation, weight loss and retrosternal pain. The diagnosis of achalasia was made 4 years before. The esophagogram revealed severe esophagus dilatation and the classic "bird-beak" termination. A Heller myotomy plus fundoplication and endoscopic balloon dilatation were conducted four months previously. Nevertheless, the symptoms persisted and the last high-resolution manometry study still showed achalasia type II. The patient underwent a peroral endoscopic esophageal myotomy (POEM). POEM is a feasible and safe procedure for experienced and properly-equipped health care delivery centers and could be used as a rescue treatment in refractory achalasia. We present the youngest patient with achalasia in our region who had a successful response to rescue POEM.

Peroral endoscopic myotomy in a pediatric patient with refractory achalasia: a case report and review of the literature

A 15-year-old male patient presented with dysphagia, regurgitation, weight loss and retrosternal pain. The diagnosis of achalasia was made 4 years before. The esophagogram revealed severe esophagus dilatation and the classic "bird-beak" termination. A Heller myotomy plus fundoplication and endoscopic balloon dilatation were conducted four months previously. Nevertheless, the symptoms persisted and the last high-resolution manometry study still showed achalasia type II. The patient underwent a peroral endoscopic esophageal myotomy (POEM). POEM is a feasible and safe procedure for experienced and properly- equipped health care delivery centers and could be used as a rescue treatment in refractory achalasia. We present the youngest patient with achalasia in our region who had a successful response to rescue POEM.

Un paciente varón de 15 años, con el diagnóstico de acalasia realizado 4 años antes, acudió a evaluación por presentar disfagia, regurgitación, pérdida de peso y dolor restroesternal. El esofagograma baritado evidenció una dilatación severa del esófago y la terminación clásica en "pico de pájaro". El paciente había sido sometido a una miotomía de Heller más fundoplicatura y posteriormente a una dilatación esofágica con balón 4 meses atrás. Sin embargo, los síntomas persistían y la última manometría de alta resolución reveló acalasia tipo II. Finalmente, se realizó una miotomía endoscópica por vía oral (POEM); el cual es un procedimiento seguro y accesible en centros experimentados y debidamente equipados, pudiendo ser una adecuada opción de tratamiento en casos de acalasia refractaria. Presentamos el caso del paciente más joven en nuestra región con acalasia con una respuesta exitosa a un POEM de rescate.

[Massive digestive hemorrhage from secondary fistulas of great vessels to the digestive tract]. / Hemorragia digestiva masiva por fístulas secundarias de grandes vasos al tracto digestivo.

The formation of a fistula between large caliber arteries and the digestive tract is an uncommon complication of reconstructive surgery of the large vessels secondary to the use of vascular prostheses, which manifest themselves with massive hemorrhages with high mortality. We report two cases of aorto-enteric fistula and carotid-esophageal fistula that share common characteristics such as the clinical manifestation of massive and fatal gastrointestinal bleeding in patients with a history of vascular prosthesis placement.

Closure of colonic deep mural injury and perforation with endoclips

INTRODUCTION: colorectal perforations are one of the most feared complications after performing an endoscopic resection. The use of endoclips is considered for the management of these complications. OBJECTIVES: to evaluate the efficacy and safety of the use of endoclips in the management of perforations and deep mural injuries that occur after an endoscopic colorectal resection. METHODS: a prospective cohort of consecutively included patients was used with a diagnosis of perforation or deep mural injury after an endoscopic colorectal resection treated with endoclips in our institution. The rates of perforation and deep mural injury were obtained. The factors associated with an unfavorable evolution after the placement of the endoclips were analyzed. RESULTS: after 342 endoscopic mucosal resections (EMR) and 42 endoscopic submucosal dissections (ESD), there were 25 cases with perforation or deep mural injury. The deep mural injury rate was 3.22 % and 7.14 % in the case of EMR and ESD, respectively. The perforation rate was 1.46 % and 14.29 % in the case of EMR and ESD, respectively. Successful closure with endoclips was achieved in 24 cases (96 %). Only one patient presented an unfavorable evolution (10 %) after successful closure. The factors associated with an unfavorable evolution were the presence of diffuse peritoneal symptoms and a perforation size greater than or equal to 10 mm. CONCLUSION: endoscopic closure with endoclips is effective to avoid surgery in cases of deep mural injury or perforation after an endoscopic resection

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Closure of colonic deep mural injury and perforation with endoclips.

INTRODUCTION: colorectal perforations are one of the most feared complications after performing an endoscopic resection. The use of endoclips is considered for the management of these complications. OBJECTIVES: to evaluate the efficacy and safety of the use of endoclips in the management of perforations and deep mural injuries that occur after an endoscopic colorectal resection. METHODS: a prospective cohort of consecutively included patients was used with a diagnosis of perforation or deep mural injury after an endoscopic colorectal resection treated with endoclips in our institution. The rates of perforation and deep mural injury were obtained. The factors associated with an unfavorable evolution after the placement of the endoclips were analyzed. RESULTS: after 342 endoscopic mucosal resections (EMR) and 42 endoscopic submucosal dissections (ESD), there were 25 cases with perforation or deep mural injury. The deep mural injury rate was 3.22 % and 7.14 % in the case of EMR and ESD, respectively. The perforation rate was 1.46 % and 14.29 % in the case of EMR and ESD, respectively. Successful closure with endoclips was achieved in 24 cases (96 %). Only one patient presented an unfavorable evolution (10 %) after successful closure. The factors associated with an unfavorable evolution were the presence of diffuse peritoneal symptoms and a perforation size greater than or equal to 10 mm. CONCLUSION: endoscopic closure with endoclips is effective to avoid surgery in cases of deep mural injury or perforation after an endoscopic resection.

Hemorragia digestiva masiva por fístulas secundarias de grandes vasos al tracto digestivo / Massive digestive hemorrhage from secondary fistulas of great vessels to the digestive tract

RESUMEN La formación de una fístula entre arterias de gran calibre y el tubo digestivo es una complicación infrecuente de la cirugía reconstructiva de los grandes vasos sanguíneos secundario al uso de prótesis vasculares, los cuales se manifiestan con hemorragias masivas con elevada mortalidad. Presentamos dos casos de fístula aorto-entérico y de fístula carotideo-esofágico que comparten características comunes como la manifestación clínica de hemorragia digestiva masiva y mortal en pacientes con antecedentes de colocación de prótesis vasculares.

ABSTRACT The formation of a fistula between large caliber arteries and the digestive tract is an uncommon complication of reconstructive surgery of the large vessels secondary to the use of vascular prostheses, which manifest themselves with massive hemorrhages with high mortality. We report two cases of aorto-enteric fistula and carotid-esophageal fistula that share common characteristics such as the clinical manifestation of massive and fatal gastrointestinal bleeding in patients with a history of vascular prosthesis placement.

[Clinical practice guideline for the evaluation and management of upper gastrointestinal bleeding for the Peruvian Social Security (EsSalud)]. / Guía de práctica clínica para la evaluación y el manejo de la hemorragia digestiva alta en el Seguro Social del Perú (EsSalud).

OBJECTIVE: To provide evidence-based clinical recommendations for the evaluation and management of patients with upper gastrointestinal bleeding (UGB) in the Peruvian Social Security (EsSalud). MATERIALS AND METHODS: A local guideline development group (local GDG) was established, including specialists in gastroenterology and methodologists. The local GDG formulated 11 clinical questions to be answered by this clinical practice guide (CPG). We searched and selected CPG of UGB published from 2012, which answered the posed questions and obtained a score higher than 60% in domains 1 and 3 of the Appraisal of Guidelines for Research and Evaluation II (AGREE-II) tool. During September 2017, bibliographic searches were conducted in Pubmed, to update 9 clinical questions of the preselected CPGs, and to answer 2 de novo questions. The quality of the evidence was evaluated using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) methodology. In periodic work meetings, the local GDG reviewed the evidence and formulated the recommendations, points of good clinical practice and the flowchart of evaluation and management, using the GRADE methodology Lastly, the CPG was approved with Resolución N° 80-IETSI-ESSALUD-2017. RESULTS: This CPG addressed 11 clinical questions, divided into four themes: risk assessment, initial management, management of non-variceal UGB, and management of variceal UGB. Based on these questions, 10 recommendations (7 strong recommendations and 3 weak recommendations), 24 points of good clinical practice, and 2 flow charts were formulated. CONCLUSION: This article is the summary of the EsSalud' CPG, where the available scientific evidence on evaluation and management of UGB was evaluated.