Herramientas para el tamizaje de aneurisma de aorta abdominal / Tools for abdominal aortic aneurysm screening

Introducción. El aneurisma de la aorta abdominal (AAA) es la dilatación de la aorta abdominal mayor de 1,5 veces el diámetro esperado. Su prevalencia es variable, con tasas reportadas de hasta el 12,5 %. Se considera como causa de muerte de más de 10.000 personas al año en los Estados Unidos. El objetivo de esta revisión de la literatura fue describir los factores de riesgo y las herramientas de tamizaje de AAA. Métodos. Se realizó una búsqueda de la literatura utilizando dos ecuaciones en bases de datos electrónicas, empleando términos seleccionados de "Medical Subject Heading" (MeSH) y "Descriptores en Ciencias de la Salud" (DeCS). Se evaluó la calidad de los estudios con la herramienta STROBE (Strengthening the Reporting of Observational Studies in Epidemiology). Resultados. Se recolectaron 40 artículos y a partir de ellos se construyó el texto de revisión, identificando en estos, los factores de riesgo asociados al desarrollo de AAA, tales como sexo masculino, tabaquismo, hipertensión arterial, antecedente familiar y obesidad, entre otros. La diabetes mellitus parece actuar como factor protector. Dentro de los instrumentos de tamizaje, el ultrasonido abdominal es uno de los más usados. Conclusión. El AAA es una patología multifactorial. En la actualidad la ultrasonografía de aorta es el método de elección para el tamizaje, permitiendo la detección precoz. El tamizaje de AAA con métodos no invasivos, como el ultrasonido, es útil sobre todo en zonas con prevalencia alta de la patología y en pacientes con determinados factores de riesgo.

Introduction. Abdominal aortic aneurysm (AAA) is a dilation of the abdominal aorta greater than 1.5 times the expected diameter. Its prevalence is variable, with reported rates of up to 12.5%. It is considered the cause of death of more than 10,000 people a year in the United States. The objective of this literature review was to describe risk factors and screening tools for AAA. Methods. A literature search was conducted using two equations in electronic databases, using terms selected from "Medical Subject Heading" (MeSH) and "Descriptors in Health Sciences" (DeCS). The quality of the studies was evaluated with the STROBE (Strengthening the Reporting of Observational Studies in Epidemiology) tool. Results. Forty articles were collected and from them the review text was constructed, identifying the risk factors associated with the development of AAA, such as male sex, smoking, high blood pressure, family history and obesity, among others. Diabetes mellitus seems to act as a protective factor. Among the screening instruments, abdominal ultrasound is one of the most used. Conclusion. AAA is a multifactorial pathology. Currently, aortic ultrasonography is the method of choice for screening, allowing early detection. Screening for AAA with non-invasive methods, such as ultrasound, is useful especially in areas with a high prevalence of this pathology and in patients with certain risk factors.

Mortalidad perioperatoria en Tolima, perspectivas del cuarto indicador de The Lancet Commission on Global Surgery: Un análisis preliminar de la cohorte prospectiva del estudio Colombian Surgical Outcomes Study (ColSOS) / Perioperative mortality in Tolima and perspectives of the fourth indicator of The Lancet Commission on Global Surgery: A preliminary analysis of the prospective cohort of the Colombian Surgical Outcomes Study (ColSOS)

Introducción. La mortalidad perioperatoria en el mundo representa 4,2 millones de muertes anuales. El cuarto indicador de The Lancet Commission on Global Surgery permite estandarizar la mortalidad perioperatoria. En Colombia, existen aproximaciones por datos secundarios, limitando el análisis y las intervenciones aplicables a nuestra población. El objetivo de este estudio fue describir la mortalidad perioperatoria a través de datos primarios que permitan sustentar políticas públicas. Métodos. Se hizo el análisis preliminar de un estudio observacional, de cohorte prospectiva, multicéntrico en 6 instituciones del departamento de Tolima. Se incluyeron los pacientes llevados a procedimientos quirúrgicos por una semana, con posterior seguimiento hasta el egreso, fallecimiento o 30 días de hospitalización. La mortalidad perioperatoria fue el desenlace primario. Resultados. Fueron incluidos 378 pacientes, con mediana de 49 años (RIC 32-66), buen estado funcional (ASA I-II 80 %) y baja complejidad quirúrgica (42 %). Las cirugías más comunes fueron por Ortopedia (25,4 %) y Cirugía plástica (23,3 %). El 29,7 % presentaron complicaciones postoperatorias, las más comunes fueron síndrome de dificultad respiratoria agudo e íleo postoperatorio. La mortalidad perioperatoria fue de 1,3 %. Discusión. La mortalidad perioperatoria discrepó de la reportada en otros estudios nacionales, aun cuando los pacientes tenían un bajo perfil de riesgo y baja complejidad de los procedimientos. Sin embargo, coincide con la reportada internacionalmente y nos acerca a la realidad del país. Conclusión. La determinación del cuarto indicador es de vital importancia para mejorar la atención quirúrgica en Colombia. Este es el primer acercamiento con datos primarios que nos permite tener información aplicable a nuestra población

Introduction. Perioperative mortality accounts for 4.2 million deaths annually. The fourth indicator of The Lancet Commission on Global Surgery allows standardizing perioperative mortality. In Colombia, there are approximations based on secondary data, limiting the analysis and interventions applicable to our population. The objective of this study is to describe perioperative mortality through primary data that allow supporting public policies. Methods. A preliminary analysis of an observational, prospective cohort, multicenter study was carried out at six institutions in the District of Tolima. Patients undergoing surgical procedures were included for one week, for subsequent follow-up until discharge, death, or 30 days of hospitalization. Perioperative mortality was the primary outcome and was presented as a proportion. Results. A total of 378 patients were included, with a median age of 49 years (RIC 32-66), low-risk profile (ASA I-II 80%), and low surgical complexity (42%). The most common surgeries were Orthopedic (25.4%) and Plastic Surgery (23.3%). Postoperative complications occurred in 29.7%, the most common were ARDS and postoperative ileus. Perioperative mortality was 1.3%. Discussion. Perioperative mortality differed from that reported in national studies, even when the patients had a low-risk profile and low complexity of the procedures. However, it coincides with that reported internationally and brings us closer to the reality of the country. Conclusion. The determination of the fourth indicator is of vital importance to improving surgical care in Colombia. This is the first approach with primary data that allows us to have applicable information for our population

Retrospective validation of parkland grading scale in a Latin-American high-volume center.

BACKGROUND: Increased complication rates following laparoscopic cholecystectomies have been described, likely related to surgical difficulty, anatomical variations, and gallbladder inflammation severity. Parkland Grading Scale (PGS) stratifies the severity of intraoperative findings to predict operative difficulty and complications. This study aims to validate PGS as a postoperative-outcome predictive tool, comparing its performance with Tokyo Guidelines Grading System (TGGS). METHODS: This is a single-center retrospective cohort study where PGS and TGGS performances were evaluated regarding intraoperative and postoperative outcomes. Both univariate and bivariate analyses were performed on each severity grading scale using STATA-SE 16.0 software. Additionally, we proposed a Logistic Regression Model for each scale. Their association with outcomes was compared between both scales by their Receiver Operating Characteristic Curve. RESULTS: 400 Patients were included. Grade 1 predominance was observed for both PGS and TGGS (47.36% and 25.3%, respectively). A positive association was observed between higher PGS grades and inpatient postoperative care, length of stay, ICU care, and antibiotic requirement. Based on the area under the ROC curve, better performance was observed for PGS over TGGS in the evaluated outcomes. CONCLUSION: PGS performed better than TGGS as a predictive tool for inpatient postoperative care, length of stay, ICU, and antibiotic requirement, especially in severe cases.

Lesión de la mucosa intestinal asociada a cristales: serie de casos y revisión de la literatura / Intestinal mucosal lesion associated with crystals: Case series and literature review

Resumen La lesión de la mucosa asociada a cristales es un cuadro clínico importante en un subconjunto de pacientes urémicos a los que se les administran resinas de intercambio catiónico como el sulfonato de poliestireno sódico (Kayexalate) y sevelamer para el tratamiento de la hiperpotasemia y la hiperfosfatemia, respectivamente. La necrosis colónica en estos pacientes es rara, pero puede estar asociada a una lesión gastrointestinal mortal, con una tasa de mortalidad del 33%. Los secuestrantes de ácidos biliares son otro tipo de resina que teóricamente son biológicamente inertes. Se presentan dos casos de colitis asociada a cristales. El primer paciente tenía antecedentes de múltiples intervenciones quirúrgicas y patologías del tracto gastrointestinal, y estaba en manejo con colestiramina. Se realizó una sigmoidectomía en la que se encontraron varios focos de cristales. El segundo paciente tenía antecedente de enfermedad renal crónica que requirió el uso de Kayexalate y se presentó al servicio de urgencias con una hemorragia grave del tracto gastrointestinal inferior. Se realizó una colectomía parcial en la que se detectaron cambios morfológicos relacionados con el depósito de cristales. Las resinas pueden producir un amplio espectro de lesiones mortales de la mucosa, por lo que el diagnóstico precoz es fundamental para disminuir la mortalidad y mejorar el pronóstico. Sin embargo, es incierto si el consumo de colestiramina y Kayexalate, así como el depósito de sus cristales en el tracto gastrointestinal son el factor causal de la lesión de las mucosas. Por tanto, la presencia de resinas debería ayudar a establecer el diagnóstico correcto y el tratamiento médico oportuno para evitar resultados nocivos.

Abstract Crystal-associated mucosal injury is a crucial clinical picture in a subset of uremic patients who are given cation exchange resins such as sodium polystyrene sulfonate (Kayexalate) and sevelamer to treat hyperkalemia and hyperphosphatemia, respectively. Colonic necrosis in these patients is rare but may be associated with fatal gastrointestinal injury, with a mortality rate of 33%. Bile acid sequestrants are another type of resin that is theoretically biologically inert. Two cases of colitis associated with crystals are presented. The first patient had a history of multiple surgeries and pathologies of the gastrointestinal tract and was treated with cholestyramine. A sigmoidectomy was performed in which several crystal foci were found. The second patient had a history of chronic kidney disease requiring Kayexalate and attended the emergency department with severe lower GI bleeding. A partial colectomy was performed in which morphological changes related to the deposit of crystals were detected. Resins can cause a broad spectrum of malignant mucosal lesions, so early diagnosis is essential to reduce mortality and improve prognosis. However, it is uncertain whether the consumption of cholestyramine and kayexalate, as well as the deposition of their crystals in the GI tract, are the causative factor of mucosal damage. Therefore, resins should help establish the correct diagnosis and prompt medical treatment to avoid harmful results.

Minimally invasive management of Mirizzi syndrome Va: Case series and narrative review of the literature.

INTRODUCTION: Mirizzi's Syndrome (MS) is a rare pathology, known to be a challenge for the surgeon. In the surgical management, open approach vs laparoscopic is a topic of discussion due to anatomic variations. The aim of this study is to analyze our experience in the laparoscopic management of this condition in Type Va. METHODS: We made a descriptive retrospective study of patients diagnosed with MS type Va and treated by laparoscopic approach from 2014 to 2019, in two high volume centers of Bogotá, Colombia. RESULTS: 1073 patients who presented complications from gallstones were evaluated, of which 16 were diagnosed with MS type Va. 75% were females and 25% males; 80% presented jaundice and 90% abdominal pain; 12 patients showed cholecystoduodenal fistula and 4 cholecystocolic fistula. All patients underwent laparoscopic management, total cholecystectomy and fistula resection with primary closure was possible on a 100% of the patients. Conversion rate was 0%. The follow up was 18 months. CONCLUSION: Laparoscopic management of MS is feasible and safe; the experience of the surgery group and selection of the patients is the key to a successful outcome.

Divertículos duodenales periampulares y el fallo técnico-terapéutico durante colangiopancreatografía retrógrada endoscópica (CPRE) / Periampullary duodenal diverticula and technical-therapeutic failure during endoscopic retrograde cholangiopancreatography (ERCP)

Resumen Introducción y objetivos: los divertículos duodenales periampulares (DDP) son infrecuentes y su hallazgo es incidental. Además, se clasifican en tres tipos según Boix por la cercanía a la ampolla mayor. El objetivo de este estudio fue realizar una descripción de nuestra experiencia con esta anomalía anatómica y demostrar la forma en que esto afecta la tasa de éxito técnica y terapéutica del procedimiento. Material y métodos: se realizó un estudio de corte transversal, con recolección de datos de forma retrospectiva en un período de 5 años de pacientes con divertículos periampulares duodenales. Se evaluó el fracaso terapéutico, complicaciones y dificultad de canulación de la vía biliar. Resultados: se evaluó un total de 214 pacientes, con una relación mujer-hombre de 2,15:1. La distribución de los sujetos por tipo de DDP fue: tipo 1 (29,9 %), tipo 2 (51,9 %) y tipo 3 (18,2 %). La indicación más frecuente de CPRE fue los cálculos del conducto biliar común en un 53,3 %. El DDP tipo 1 presentó mayor dificultad de canulación (11,6 %) y falla terapéutica (28,12 %). Conclusión: la presencia de DDP durante la CPRE se asocia con una mayor falla técnica (falla en la canulación) y falla terapéutica (persistencia de la obstrucción biliar). Además, estas fallas aumentan considerablemente cuando se trata de una papila intradiverticular tipo 1 de la clasificación según Boix. Por lo anterior, se sugiere que los procedimientos endoscópicos biliares en estas condiciones sean realizados por endoscopistas con gran experiencia con el fin de minimizar la probabilidad de falla técnica y terapéutica, y las complicaciones asociadas.

Abstract Introduction and objectives: Periampullary duodenal diverticula are infrequent, and their finding is incidental. They are classified into three types according to Boix due to their proximity to the larger blister. This study aims to describe the experience with this anatomical abnormality and to demonstrate how this affects the technical and therapeutic success rate of the procedure. Materials y Methods: A cross-sectional study was conducted, with retrospective data collection over a 5-year period of patients with periampullary duodenal diverticula. Therapeutic failure, complications, and difficulty of cannulation of the bile duct were evaluated. Results: A total of 214 patients were evaluated, with a female-male ratio of 2.15: 1. The distribution of the subjects by type of PDD was: type 1 (29.9%), type 2 (51.9%), and type 3 (18.2%). The most frequent indication for ERCP was common bile duct stones in 53.3%. Type 1 PDD presented greater difficulty in cannulation (11.6%) and therapeutic failure (28.12%). Conclusion: The presence of PDD during ERCP is associated with greater technical failure (failure in cannulation) and therapeutic failure (persistence of biliary obstruction). In addition, this failures increases considerably when it is a type 1 intradiverticular papilla of the Boix classification. Therefore, it is suggested that biliary endoscopic procedures in these conditions are performed by highly experienced endoscopists to minimize the probability of technical and therapeutic failure and associated complications.

Terapia asistida con vacío y estoma flotante (floating stoma): una nueva forma de tratar un absceso periostomal / Vacuum assisted therapy and floating stoma: S new way to treat a periostomal abscess

Resumen Introducción: Los estomas flotantes se definen como un estoma que no está fijado a la piel de la pared abdominal, esta técnica se ha descrito en cirugía para fístulas entero-atmosféricas y de control de daños. Caso Clínico: Presentamos un reporte de caso de manejo de absceso paraostomal en paciente con antecedente de laparotomía por abdomen agudo, por lo que se decide uso de terapia de presión negativa asociada a estoma flotante, demostrando su utilidad en este tipo complejo de pacientes.

Introduction: Floating stomata are defined as a stoma that is not attached to the skin of the abdominal wall, this technique is described in surgery for entero-atmospheric fistulas and damage control. Clinical Case: We present a case report of the management of paraostomal abscess in a patient with a history of laparotomy due to acute abdomen, it was decided to use negative pressure therapy associated with a floating stoma, demonstrating its usefulness in this complex type of patient.

Minimally invasive management of Mirizzi syndrome Va: Case series and narrative review of the literature. / Manejo mínimamente invasivo del síndrome de Mirizzi Va: Reporte de casos y revisión narrativa de la literatura.

INTRODUCTION: Mirizzi's Syndrome (MS) is a rare pathology, known to be a challenge for the surgeon. In the surgical management, open approach vs laparoscopic is a topic of discussion due to anatomic variations. The aim of this study is to analyze our experience in the laparoscopic management of this condition in Type Va. METHODS: We made a descriptive retrospective study of patients diagnosed with MS type Va and treated by laparoscopic approach from 2014 to 2019, in two high volume centers of Bogotá, Colombia. RESULTS: 1073 patients who presented complications from gallstones were evaluated, of which 16 were diagnosed with MS type Va. 75% were females and 25% males; 80% presented jaundice and 90% abdominal pain; 12 patients showed cholecystoduodenal fistula and 4 cholecystocolic fistula. All patients underwent laparoscopic management, total cholecystectomy and fistula resection with primary closure was possible on a 100% of the patients. Conversion rate was 0%. The follow up was 18 months. CONCLUSION: Laparoscopic management of MS is feasible and safe; the experience of the surgery group and selection of the patients is the key to a successful outcome.

Endoscopy mitigation strategy with telemedicine and low-cost device use for COVID-19 prevention: A fourth-level Colombian center experience.

BACKGROUND AND STUDY AIMS: The COVID-19 outbreak has reorganized surgical team conditions regarding endoscopy. The number of interventions has been reduced, the number of healthcare professionals must be limited, and both the patients and physicians are more protected than ever. PATIENTS AND METHODS: In the highest peak of contagion in Colombia, endoscopy, colonoscopy, and esophagogastroduodenoscopy were performed using a low-cost disposable device. A total of 1388 procedures were performed. Every patient was assessed for symptoms via a telephone call, at the health center, and after the procedure, following specific attention routes. RESULTS: After procedure follow-up, no positive cases of COVID-19 were noted. CONCLUSION: The methodology reduced the risk of infection during the COVID-19 pandemic.

Divertículo de Meckel en asociación a onfalocele y tetralogía de Fallot: reporte de caso y revisión de la literatura / Meckel's diverticulum in association with omphalocele and tetralogy of Fallot: Case report and literature review

El onfalocele o exónfalos se definen como un defecto congénito de la pared abdominal, que consiste en la herniación de las vísceras abdominales a través del anillo umbilical. Esta entidad rara vez se asocia a la comunicación del divertículo de Meckel con el saco del onfalocele. Teniendo en cuenta la escasa prevalencia de dicha entidad, compartimos el reporte de caso de un paciente recién nacido, con diagnóstico de onfalocele menor, en quien se sospechaba ruptura del saco, sin embargo, de manera intraoperatoria se encontró que la aparente ruptura del saco, correspondía a la comunicación con un divertículo de Meckel. El caso además se asoció con hallazgos ecocardiográficos de tetralogía de Fallot

Omphalocele or exomphalos are defined as a congenital defect of the abdominal wall, which consists of the herniation of the abdominal viscera through the umbilical ring. This entity is rarely associated with the communication of Meckel's diverticulum with the omphalocele sac. Considering the low prevalence of this entity, we report the case of a newborn with a diagnosis of minor omphalocele, in whom rupture of the sac was suspected; however, intraoperatively it was found that the apparent rupture of the sac corresponded to a communication with a Meckel's diverticulum. The case was also associated with echocardiographic findings of tetralogy of Fallot

Manejo del aneurisma roto de aorta abdominal: un reto para el cirujano general / Management of ruptured abdominal aortic aneurysm: a challenge for the general surgeon

Introducción. El aneurisma aórtico abdominal roto, tiene una mortalidad del 80 % al 90 %. Para su reparación existe una técnica abierta y otra endovascular, las cuales tienen diferencias entre sus beneficios y complicaciones. El método de elección en la actualidad para la corrección de esta alteración anatómica es endovascular, sin embargo, no es el más usado, porque no se cuenta todo el tiempo con el equipo humano de cirugía vascular para su realización. Caso clínico. Ingresa a urgencias un paciente en estado de shock de origen desconocido, con dolor abdominal de 24 horas de evolución. Se realiza una tomografía con contraste que demuestra un aneurisma aórtico abdominal infrarrenal roto. Debido a que no se contaba con el equipo de cirugía vascular, es llevado de urgencia a una corrección abierta que duró 153 minutos, con un sangrado intraoperatorio de 1754 cc. Fue dado de alta a los 12 días postoperatorios sin ninguna complicación. Discusión. La reparación endovascular del aneurisma aórtico abdominal roto es la mejor elección, ya que muestra mayores beneficios en comparación con la reparación abierta, sin embargo, no es el más utilizado, porque se necesita de un personal bien entrenado en cirugía endovascular, por lo que, dentro de la formación de los cirujanos generales, se tiene que incluir el aprendizaje de las técnicas abiertas

Introduction. The ruptured abdominal aortic aneurysm has a mortality of 80% to 90%. There is an open and an endovascular techniques for its repair, which have differences between their benefits and complications. The method of choice for the correction of this anatomical alteration is endovascular; however, it is not the most frequently used, mainly because the vascular surgical team is not available all the time to perform it.Clinical case. A patient in a state of shock of unknown origin was admitted to the emergency room, with abdominal pain of 24 hours of evolution. A contrast-enhanced CT scan demonstrated a ruptured infrarenal abdominal aortic aneurysm. Due to the lack of a vascular surgery team, the patient was rushed for an open surgery that lasted 153 minutes, with an intraoperative bleeding of 1754 cc. He was discharged 12 days after surgery without any complications.Discussion. Endovascular repair of ruptured abdominal aortic aneurysm is the best choice, since it shows greater benefits compared to open repair. However, it is not the most widely used because it requires well-trained personnel in endovascular surgery. Therefore, learning of open techniques must be included in the training of general surgeons

Multicenter Evaluation with Eckardt Score of Laparoscopic Management with Heller Myotomy and Dor Fundoplication for Esophageal Achalasia in a Pediatric Population in Colombia.

Background: Esophageal achalasia is a rare, chronic, and progressive neurodegenerative motility disorder that is characterized by a lack of relaxation of the lower esophageal sphincter. Laparoscopic Heller myotomy (LHM) is the ideal in our population. Multiple surgical and medical treatments have been raised. However, there has been a need to expand studies and generate a clear algorithm for an ideal therapeutic algorithm. Methods: Clinical record was retrospectively analyzed of patients who underwent LHM and Dor fundoplication evaluated with Eckardt score, at four Colombian medical centers between February 2008 and December 2018. Results: There were a total of 21 patients (12 males and 9 females, ages 8 months to 16 years). The time from onset of symptoms to surgery was between 5 months and 14 years. One patient had esophageal mucosa perforation, 2 patients were converted to open surgery, and 1 patient had a postoperative fistula. All patients were discharged 3 to 9 days postoperatively, at which time they tolerated normal oral feeding. During follow-up, all the patients had an improvement in nutritional status and a greater functional recovery; 4 had reflux and 1 had reflux-like symptoms. Conclusion: LHM with Dor-type fundoplication maintains the effectiveness of open surgery with low postoperative morbidity and mortality and good functional results according to Eckardt score evaluation.

Colecistogastrostomía guiada por ultrasonografía endoscópica en un paciente con cáncer pancreático: primer caso en Colombia (con video) / Endoscopic ultrasonography-guided cholecystogastrostomy in a patient with pancreatic cancer: the first case in Colombia (with video)

Resumen El tratamiento actual para la obstrucción biliar maligna es la derivación biliar no quirúrgica con propósito paliativo. La cirugía tiene indicaciones específicas en pacientes con patología maligna con propósito curativo. Sin embargo, la obstrucción duodenal y del conducto biliar intra o extrahepático no dilatado hace que esta cirugía y el procedimiento endoscópico guiado por ultrasonografía endoscópica (USE) sean difíciles de realizar. Presentamos nuestra experiencia con el primer caso en Colombia, un país latinoamericano del tercer mundo. Consistió en una colecistogastrostomía guiada por USE, a partir de la utilización de una endoprótesis luminal (Lumen-apposing metal stents, LAMS) (HOT AXIOS stent, Xlumena Inc.; Mountain View, CA, Estados Unidos) de 15 mm × 10 mm, en un paciente masculino con cáncer pancreático inoperable e invasión duodenal con conducto colédoco dilatado. La colecistogastrostomía guiada por USE podría ser considerada como una opción de más importancia para la descompresión biliar que el drenaje percutáneo, ya que es superior en términos de viabilidad técnica, seguridad y eficacia en casos específicos de estenosis ampular e invasión duodenal. Además, puede ser realizada en países del tercer mundo, cuando se cuenta con el entrenamiento y los instrumentos adecuados. La endoprótesis metálica totalmente recubierta, aplicada a luz (HOT AXIOS stent, Xlumena Inc.; Mountain View, CA, Estados Unidos), es ideal para la colecistogastrostomía guiada por USE, a fin de minimizar complicaciones como fugas biliares. Se necesitan estudios comparativos adicionales para validar los beneficios de esta técnica.

Abstract The current treatment of malignant biliary obstruction is non-surgical biliary diversion with palliative intent. The surgery having specific indications in patients with malignant pathology with curative intent. However, duodenal obstruction and non-dilated intra- or extrahepatic bile duct make these surgical and endoscopic procedures guided by EUS difficult. We present our experience with the first case in Colombia, a third-world country in Latin America, of a cholecystogastrostomy guided by endoscopic ultrasound (EUS) in a patient with unresectable pancreatic cancer and duodenal invasion with dilated common bile duct using a luminal stent (LAMS) (HOT AXIOS stent, Xlumena Inc.; Mountain View, CA, USA) 15 mm × 10 mm. EUS-guided cholecystogastrostomy should be considered as an option for biliary decompression of greater importance than percutaneous drainage since it is superior in terms of technical feasibility, safety and efficacy in specific cases of ampullary stenosis and duodenal invasion. In addition, it can be done in third world countries when it has the appropriate training and implements. The fully covered metal stent applied to light (HOT AXIOS stent, Xlumena Inc.; Mountain View, CA, USA) is ideal for EUS guided cholecystogastrostomy to minimize complications such as bile leakage. Additional comparative studies are needed to validate the benefits of this technique.

Endoscopic ultrasound (EUS) guided choledocoduodenostomy in a patient with irresecable pancreas cancer and biliar obstruction using a luminal apposing metal stent (LAMS).

The endoscopic retrograde cholangiopancreatography (ERCP) is the election treatment of biliary obstruction. EUS-guided biliary drainage (EUS-BD) has emerged as an alternative to PTBD with a high technical and clinical success rate, low risk of complications and a better quality of life for the patient. Case presentation we present the first case in Colombia of EUS-guided biliary drainage using luminal apposing metal stent (LAMS) in a patient with unresectable pancreatic adenocarcinoma with biliary obstruction in who ERCP was failed due to neoplastic invasion of the Vater papilla. Discussion Transhepatic biliary drainage has been the most common procedure for treatment of malignant biliary obstruction in cases which ERCP fails due to tumor infiltration of the duodenum or the Vater papilla. During the last decade the development of endoscopic ultrasound (EUS) has implied an alternative for biliary drainage in cases of failed ERCP, demonstrating advantages over Trans hepatic biliary drainage Conclusion Considering that EUS-CD is a safe procedure, with a high rate of technical and clinical success, low risk of complications.

Laparoscopic management of gastric liposarcoma: A case report and review of the literature.

INTRODUCTION: Liposarcoma is one of the most common mesenchymal neoplasms in adults. Predominant locations are the retroperitoneum and limbs, it rarely occurs in the gastrointestinal tract. Gastric liposarcoma is extremely rare, with fewer than 30 cases reported around the world. PRESENTATION OF CASE: Here we present the case of a 70-year-old female patient who was diagnosed with gastric liposarcoma and managed with laparoscopic surgical resection. The patient is currently being followed up and is alive without recurrence 12 months after the operation. DISCUSSION: Gastric liposarcoma approach requires proper diagnosis with computed tomography and endoscopy, in order to develop an adequate surgical plan. Laparoscopic en-bloc resection and gastrointestinal reconstruction is the ideal management in this type of patient. CONCLUSION: Gastric liposarcoma is an extremely rare entity, his management consists of wide en-bloc resection with a gastrointestinal reconstruction.

Impact of social media on the continuous education of the general surgeon, a new experience, @Cirbosque: A Latin American example.

Social media has gained widespread recognition for its importance in the medical field. Such platforms play an important role for learning and teaching, because knowledge can be transmitted instantly and massively, and specialists in different world-wide locations can discuss experiences instantaneously. The present article presents our experience of using social media to facilitate surgical learning while encouraging leadership and global mentoring. This retrospective descriptive study was initiated at the time of the creation of our social media handle on Twitter, February 22, 2019. Since that time, we have posted 10,587 academic tweets; the monthly growth rate has been 9% (393 new followers per month). Currently, we have 4,213 followers, 11,241,000 impressions, 121,105 visits, and 121,105 mentions. We have reviewed 59 topics of interest in general surgery and 132 clinical cases in trauma, as well as in hepatobiliary, gastrointestinal, thoracic, and acute-care surgery. We have made 13 image challenges using illustrations of diagnostic and intraoperative images. Although the evidence is uncertain to promote education performed entirely through social media, we show that @Cirbosque has been effective, and the impact of this initiative on Twitter is appreciated by many surgeons worldwide, including renowned teachers in each of the topics addressed. Furthermore, the number of participants in the discussions increased each day, as did all impact indicators according to Twitter Analytics. Thus, we conclude that the educational message of @Cirbosque is having a positive effect and reaching thousands of people worldwide, suggesting that others can develop similar outreach programs in education and communication.

Non surgical management for massive gastric lipomatosis.

BACKGROUND: Gastric lipomatosis (GL) is defined as a lipomatous lesion with diffuse infiltration of the submucosal layer by adipose tissue with multiple lesions and must be differentiated from gastrointestinal lipomas, which are solitary submucosal masses composed of well-differentiated adipose tissue surrounded by a fibrous capsule. GL are uncommon, represents 5 % of gastrointestinal tract lipomas and less than 1∼3 % of all gastric tumors. CASE PRESENTATION: A 65-year-old woman, who underwent non-operatively approach by Gastric lipomatosis. Non-specific gastrointestinal symptoms and endoscopic examination ruled out the possibility of mucosal ulceration or bleeding. Endoscopic ultrasonography and abdominal CT that confirmed gastric lipomatosis. DISCUSSION: Gastric lipomas are usually small, solitary and asymptomatic, and are hence often detected incidentally, surgical management in asymptomatic patients still be a in debate. CONCLUSION: Non operative management in massive gastic lipomatosis is appropiate when the patient is asymptomatic without mucosal ulceration, regardless of the amount of gastric lipomas. Avoiding patient the morbidity of a total gastrectomy.

Endoscopic trans gastric assisted surgery for gastric tumors: Case report and description of a new surgical technique.

BACKGROUND: Minimally invasive intragastric surgery [IGS] was first described by Ohashi in 1995 for early gastric cancer, with 3 trocars placed in the gastric lumen. Prior abdominal surgery is not a contraindication to IGS while the abdominal cavity is not explored, always that exist transilumination. But conversion to laparoscopic and open surgery can be challenging owing to the insufflated stomach and/or small bowel, although gas can be easily released via the gastrostomy. CASE PRESENTATION: A 53-year-old female patient, presented with a sub epithelial gastric antrum lesion confirmed by endoscopic ultrasonography managed with surgical endoscopic percutaneous assisted transgastric technique [EPATS] using a gastrostomy tube and the endoscope. DISCUSSION: We have been developing this operation since 2018. Nevertheless, we think EPATS is worthy to master, as PEIGS can salvage the entire stomach of patients with sub epithelial lesions in the lesser curve and in the esophagogastric junction, who otherwise would have to undergo total or proximal gastrectomy. CONCLUSION: We need to perform more cases for future comparative studies with percutaneous endoscopic intragastric surgery [PEIGS] in terms of parameters as pain, inflammation, complications, stenosis, oncological results and cosmesis.