Canulación biliar difícil: precorte precoz tipo fistulotomía para evitar la pancreatitis post CPRE. Un análisis retrospectivo de dos años / Difficult biliary cannulation: early precut fistulotomy to avoid post ERCP pancreatitis. A retrospective analysis for two years

Antecedentes: La canulación biliar difícil es un factor de riesgo para la pancreatitis post-CPRE. En estos casos el precorte es la técnica más usada. Objetivo: Demostrar que el precorte tipo fistulotomía es seguro y eficaz. Materiales y métodos: Se revisaron los datos de mayo de 2016 a mayo de 2018. Se definió canulación difícil como: litiasis impactada, canulación inadvertida del conducto pancreático en tres ocasiones e incapacidad para lograr la canulación en 3 minutos. Las medidas de resultados fueron la canulación biliar exitosa y la pancreatitis post-CPRE. Resultados: Se realizó precorte tipo fistulotomía en 96 casos (67 mujeres, 29 hombres). La tasa de éxito de la canulación biliar fue del 95,8% (92/96). Ochenta pacientes tenían factores de riesgo para pancreatitis post CPRE: 29 tuvieron un solo factor de riesgo, 26 tuvieron dos, 19 tuvieron tres y 6 tuvieron cuatro. Factores de riesgo ampulares de canulación difícil: calculo impactado 9 casos, abultamiento de la papila en 10 casos, ubicación inferior del orificio papilar en 38 casos, localización parcial del poro papilar en 23 y estenosis del orificio papilar en 16 casos. Diez pacientes tuvieron divertículo periampular, 7 pacientes tuvieron conducto biliar normal. Ninguno de los pacientes experimentó pancreatitis. Tres pacientes tuvieron sangrado precoz, una paciente presento sangrado tardío. Un paciente (2%) tuvo fiebre y fue hospitalizado. Conclusiones: En casos de canulación biliar difícil el precorte tipo fistulotomía es seguro y eficaz.

Background: Difficult biliary cannulation is a risk factor for post-ERCP pancreatitis. In these cases, precutting is the most used technique. Objective: To demonstrate that precut fistulotomy is safe and effective. Materials and methods: Data from May 2016 to May 2018 were reviewed. Difficult cannulation was defined as: impacted lithiasis, inadvertent cannulation of the pancreatic duct on three occasions and inability to achieve deep biliary cannulation in 3 minutes. The outcome measures were successful biliary cannulation and post-ERCP Pancreatitis. Results: Precut fistulotomy was performed in 96 cases (67 women, 29 men). The success rate of biliary cannulation was 95.8% (92/96). Eighty patients had risk factors for post-ERCP pancreatitis: 29 had 1 risk factor, 26 had 2 risk factors, 19 had 3 risk factors, and 6 had four risk factors. Ampullary risk factors of difficult cannulation: impacted stone in the papilla: 9 cases, papilla bulging: 10 cases, lower location of the hole papillary 38 cases, partial location of the papillary pore 23 and papillary orifice stenosis 16 cases. Ten patients had periampullary diverticulum, 7 patients had normal bile duct. None of the patients experienced Pancreatitis. Three patients had early bleeding, one patient had late bleeding. One patient (2%) had a fever and was hospitalized. Conclusions: In cases of difficult biliary cannulation, the precut fistulotomy is safe and effective.

[Difficult biliary cannulation: early precut fistulotomy to avoid post ERCP pancreatitis. A retrospective analysis for two years]. / Canulación biliar difícil: precorte precoz tipo fistulotomía para evitar la pancreatitis post CPRE. Un análisis retrospectivo de dos años.

BACKGROUND: Difficult biliary cannulation is a risk factor for post-ERCP pancreatitis. In these cases, precutting is the most used technique. OBJECTIVE: To demonstrate that precut fistulotomy is safe and effective. MATERIALS AND METHODS: Data from May 2016 to May 2018 were reviewed. Difficult cannulation was defined as: impacted lithiasis, inadvertent cannulation of the pancreatic duct on three occasions and inability to achieve deep biliary cannulation in 3 minutes. The outcome measures were successful biliary cannulation and post-ERCP Pancreatitis. RESULTS: Precut fistulotomy was performed in 96 cases (67 women, 29 men). The success rate of biliary cannulation was 95.8% (92/96). Eighty patients had risk factors for post-ERCP pancreatitis: 29 had 1 risk factor, 26 had 2 risk factors, 19 had 3 risk factors, and 6 had four risk factors. Ampullary risk factors of difficult cannulation: impacted stone in the papilla: 9 cases, papilla bulging: 10 cases, lower location of the hole papillary 38 cases, partial location of the papillary pore 23 and papillary orifice stenosis 16 cases. Ten patients had periampullary diverticulum, 7 patients had normal bile duct. None of the patients experienced Pancreatitis. Three patients had early bleeding, one patient had late bleeding. One patient (2%) had a fever and was hospitalized. CONCLUSIONS: In cases of difficult biliary cannulation, the precut fistulotomy is safe and effective.

Diagnostic and therapeutic cholangioscopy in biliary diseases: a prospective study in Peru / Uso diagnóstico y terapéutico de la colangioscopía en enfermedades de la vía biliar: un estudio prospectivo en Perú

Introduction: Cholangioscopy is a test that allows the evaluation of the biliary epithelium. It is used for diagnosis and management of biliary diseases. Objectives: Determine the success rate of complete removal of difficult stones with the use of laser lithotripsy through cholangioscopy as well as its complications. Determine the visual impression accuracy of bile duct injuries. Materials and methods: This is a prospective and descriptive study. We included 39 patients between July 2016 and July 2017 with diagnosis of difficult stones in the biliary tract and indeterminate stenosis of the biliary tract that were submitted to cholangioscopy. Results: Success rate of complete removal of difficult stones was 65.3%, there was one complication. Two laser sessions were required in 4 of the 17 patients who obtained complete removal of the stones. The visual impression accuracy of lesions in the bile duct to determine malignancy coincided in all cases with the final diagnosis of the patient. Conclusions: Laser lithotripsy allows a safe and effective treatment of the difficult stones of the bile duct. Precession of visual impression of lesions in the bile duct is very high.

Introducción: La colangioscopía es un examen que permite evaluar la luz biliar, el epitelio biliar y sirve para diagnóstico y manejo de enfermedades de la vía biliar. Objetivos: Determinar la tasa de éxito de remoción completa de cálculos difíciles con el uso de litotripcia con láser a través de la colangioscopía asi como las complicaciones de ésta. Determinar la precisión de impresión visual de lesiones de la vía bilar. Materiales y métodos: Estudio prospectivo, descriptivo. Se incluyeron a 39 pacientes entre Julio 2016 a Julio 2017 con diagnóstico de cálculo difícil en la vía biliar y estenosis indeterminada de la vía biliar que fueron sometidos a colangioscopía. Resultados: La tasa de éxito de remoción completa de cálculos difíciles fue de 65,3% con una complicación. Se requirió de dos sesiones con láser en 4 de los 17 pacientes que obtuvieron remoción completa de cálculos. La precisión de impresión visual de lesiones en la vía biliar para determinar malignidad coincidió en todos los casos con el diagnóstico final del paciente. Conclusiones: La colangioscopía con uso de litotripcia con láser permite un tratamiento seguro y eficaz en los cálculos difíciles de la vía biliar. La precesión de la impresión visual de lesiones en la vía biliar es muy alta.

Diagnostic and therapeutic cholangioscopy in biliary diseases: a prospective study in Peru.

INTRODUCTION: Cholangioscopy is a test that allows the evaluation of the biliary epithelium. It is used for diagnosis and management of biliary diseases. OBJECTIVES: Determine the success rate of complete removal of difficult stones with the use of laser lithotripsy through cholangioscopy as well as its complications. Determine the visual impression accuracy of bile duct injuries. MATERIALS AND METHODS: This is a prospective and descriptive study. We included 39 patients between July 2016 and July 2017 with diagnosis of difficult stones in the biliary tract and indeterminate stenosis of the biliary tract that were submitted to cholangioscopy. RESULTS: Success rate of complete removal of difficult stones was 65.3%, there was one complication. Two laser sessions were required in 4 of the 17 patients who obtained complete removal of the stones. The visual impression accuracy of lesions in the bile duct to determine malignancy coincided in all cases with the final diagnosis of the patient. CONCLUSIONS: Laser lithotripsy allows a safe and effective treatment of the difficult stones of the bile duct. Precession of visual impression of lesions in the bile duct is very high.

[New technique for safe removal of impacted foreign bodies in the upper gastrointestinal tract using reusable variceal "cap" (cup, cap or cylinder)]. / Una nueva técnica para la remoción segura de cuerpos extraños impactados en el tubo digestivo alto: uso del "cap" (copa, capuchón o cilindro)reusable del ligador variceal.

OBJECTIVES: The ingestion of a foreign body is one of the most common endoscopic emergencies. Foreign bodies in the upper gastrointestinal tract should be extracted as soon as possible to avoid serious complications such as perforation o bleeding. However, removals of foreign bodies with sharp edges are very difficult and can develop complications during their removal. Various devices have therefore been developed to prevent mucosal injury from the sharp edges during endoscopic extraction. MATERIALS AND METHODS: We report a new technique for the successful foreign body extraction of upper digestive tract using the cap from six shooter variceal banding reused. RESULTS: We present 17 cases (9 males and 8 females). The types of foreign bodies removed were: chicken bones (n:7), fish bones (n:3), denture prosthesis (n:2), food bolus (n:2), long pin (n:1), golden thumb tack (n: 1) and press-through package (n:1). There were no complications. CONCLUSIONS: This new technique is safe and effective. Highlights its advantages: enhanced sight pharyngo esophageal junction, foreign bodies disimpact at that level, food bolus suck, avoid sharp object damage mucosal or scope and decrease time removal.

Una nueva técnica para la remoción segura de cuerpos extraños impactados en el tubo digestivo alto: uso del "CAP" (copa, capuchon o cilindro) reusable del ligador variceral / New technique for safe removal of impacted foreign bodies in the upper gastrointestinal tract using reusable variceal CAP (Cup, Cap or Cylinder)

OBJETIVOS: La ingesta de cuerpos extraños es una de las mas comunes emergencias endoscopicas. Deben ser extraidos tan pronto como sea posible para evitar complicaciones graves como perforacion o hemorragia. Sin embargo, la remoción de los objetos puntiagudos es dificil y pueden ocurrir complicaciones durante su extracción. Por lo que varios accesorios son usados para prevenir la injuria de la mucosa. MATERIALES Y MÉTODOS: Describimos una nueva tecnica para la extracción exitosa de cuerpos extraños del tracto digestivo superior usando el ¨cap¨ (copa, capuchón o cilindro plástico) reusado de un ligador variceal. RESULTADOS: Se presentan 17 casos ( 9 hombres y 8 mujeres). Los tipos de cuerpos extraños removidos fueron huesos de pollo (n:7), espinas de pescado (n:3), prótesis dental parcial (n:2), bolo alimenticio (n:2), alfiler (n:1), chinche dorado (n:1) y una tableta con su empaque (n:1). No se presentaron complicaciones. CONCLUSIONES: Esta nueva técnica es segura y efectiva. Ventajas: mejorar la visión en unión faringo- esofagica, desimpactar los cuerpos extraños a ese nivel, evitar que los objetos puntiagudos dañen la mucosa o el endoscopio, aspirar bolos de alimentos y disminuir el tiempo de la extracción.

OBJECTIVES: The ingestion of a foreign body is one of the most common endoscopic emergencies. Foreign bodies in the upper gastrointestinal tract should de extracted as soon as possible to avoid serious complications such as perforation o bleeding. However, removals of foreign bodies with sharp edges are very difficult and can develop complications during their removal. Various devices have therefore been developed to prevent mucosal injury from the sharp edges during endoscopic extraction. MATERIALS AND METHODS: We report a new technique for the sucesfull foreign body extraction of upper digestive tract using the "cap" from six shooter variceral banding reused. RESULTS: We presented 17 cases (9 males and 8 females). The types of foreign bodies removed were: chicken bones (n:7), fish bones (n:3), denture prosthesis (n:2), food bolus (n:2), long pin (n:1), golden thumb tack (n: 1) and press-through package (n:1). There were no complications. CONCLUSIONS: This new technique is safe and effective. Highlights its advantages: enhanced sight pharyngo esophageal junction, foreign bodies disimpact at that level, food bolus sick, avoid sharp object damage mucosal or scope and decrease time removal.

Experiencia con la colangiografía retrógrada endoscópica como procedimiento diagnóstico y terapéutico / Experience with the endoscopic retrograde cholangiopancreatography as a diagnostic and therapeutic procedure

La colangiopancreatografía retrógrada endoscópica (CPRE) es el procedimiento de elección actual en la patología biliopancreática principalmente en casos de obstrucción biliar y colangitis debido a que hace posible el diagnóstico y tratamiento en un alto porcentaje de ellos. También juega un rol importante en el diagnóstico de las estenosis benignas o malignas de las vías biliares, pudiendo dar manejo definitivo y/o temporal en ellas. Objetivo. El presente estudio evalúa la patología biliopancreática más frecuente diagnosticada por CPRE, el porcentaje de tratamiento endoscópico de las litiasis y estenosis, así como las complicaciones posprocedimiento en un Hospital Nacional de referencia. Material y métodos. Se evaluó a 508 pacientes de un total de 932 informes de CPRE realizadas en el periodo 2002- 2003 con sus historias clínicas con documentación completa pre y pos-CPRE. Resultados. La CPRE aplicada a población adulta mayor a 25 años (80,9 por ciento), fue realizada en una proporción 4/1 a predominio del sexo femenino; se documentó litiasis como patología más frecuente de la vía biliar (41,14 por ciento), seguida de estenosis de la vía biliar (11,81 por ciento), contando con otras causas en un menor número de casos. Se realizó papiloesfinterotomía endoscópica (PEE) en 282 casos de nuestra población de estudio correspondiendo a hallazgos de litiasis, odditis, colangitis, y estenosis (benignas o malignas); reportando la extracción total de cálculos en el 59,33 por ciento, colocación de stents en un 26,53 por ciento de las estenosis malignas. Del total de procedimientos el 6,30 por ciento tuvo complicaciones, pancreatitis en 6,10 por ciento, y hemorragia en 0,20 por ciento. Del 53,51 por ciento de pacientes sometidos a PEE, el 6,38 por ciento tuvo complicaciones, siendo la más frecuente pancreatitis 6,03 por ciento y hemorragia en el 0,35 por ciento. Conclusiones. La patología de mayor diagnóstico fue litiasis en la vía biliar, siendo el manejo...

[Endoscopic treatment of early gastric cancer: from Endoscopic Mucosal Resection (EMR) to Endoscopic Submucosal Dissection (ESD)]. / Tratamiento endoscópico del cáncer gástrico precoz: de la Resección Mucosa Endoscópica (RME) a la Disección Submucosa Endoscópica (DSE).

Surgery has been the traditional treatment for early gastric cancer, but it is known that the endoscopic treatment offers the same results with a lower mortality rate. The first endoscopic therapy used was the polypectomy in cases of pediculate tumors. However, in depressed or flat tumors, tissue-destructive methods are used together with sclerosant substances, laser or plasma argon; their disadvantage is that the procedure cannot be properly evaluated since the tissue is destroyed. On the other hand, the Endoscopic Mucous Resection (EMR) techniques, such as strip biopsy, the injecting and cutting technique, the transparent capsule or the varices ligation, does permit the evaluation of the results of the endoscopic treatment. Progresses in EMR are due to the use of the chromoscopy and the submucous injection of various substances (normal and hypertonic saline solution, hyaluronic acid, etc.). The problem of the EMR is local relapse, attributed to the resection in lesions fragments of more than 10 mm. To resolve this problem, the Endoscopic Submucous Dissection (ESD) has been developed, using the endoscopic scalpel or its modifications; such as the endoscopic scalpel with the isolated point (IT-Knife). The last ones require more operating time, better skills and have more complications. The efforts to make a better diagnosis and treatment of these lesions continue day by day, by using the magnification endoscopes, the endoscopes with multiple inflexions, etc.

Tratamiento endoscópico del cáncer gástrico precoz: De la Resección Mucosa Endoscópica (RME) a la Disección Submucosa Endoscópica (DSE) / Endoscopic treatment of early gastric cancer: From Endoscopic Mucosal Resection (EMR) to Endoscopic Submucosal Dissection (ESD)

El tratamiento del cáncer gástrico precoz tradicionalmente ha sido la cirugía, pero se sabe que el tratamiento endoscópico, ofrece los mismos resultados con menor morbimortalidad. La primera terapia endoscópica usada fue la polipectomía en casos de tumores pediculados. Pero en tumores deprimidos o planos se utilizan métodos de destrucción tisular usando sustancias esclerosantes, láser o argón plasma. Su desventaja es que no se puede evaluar correctamente el procedimiento, pues destruye el tejido. En cambio, las técnicas de resección mucosa endoscópica (RME) como strip biopsy, la técnica de inyectar y cortar, la cápsula transparente o el ligador de varices, si permiten evaluar los resultados del tratamiento endoscópico. Los avances en la RME se deben al uso de la cromoscopía y a la inyección submucosa de diversas sustancias (solución salina normal, hipertónica, acido hialurónico, etc.). El problema de la RME es la recidiva local, atribuida a la resección en fragmentos de lesiones de más de 10 mm. Para solucionar esto; se ha desarrollado la técnica de la Disección Submucosa Endoscópica (DSE) utilizando el bisturí endoscópico o modificaciones de este como el bisturí endoscópico con la punta aislada (IT-Knife). Estos últimos demandan mayor tiempo operatorio, requieren mayores habilidades y tienen más complicaciones. Los esfuerzos por hacer un mejor diagnóstico y tratamiento de estas lesiones continúan día a día, usándose el endoscopio de magnificación y el endoscopio con múltiples inflexiones, entre otros.

[History of the pancreas and the evolution of concepts and classification of pancreatitis]. / Historia del páncreas y de la evolución en los conceptos y clasificación de pancreatitis.

In this paper we will try to compile briefly the most important historical facts on the pancreas, and how the concepts and classification about its major disorder, pancreatitis, has evolved. In older times, the pancreas was ignored, both as an organ and as a focus of disease. The first description of the pancreas is attributed to Herophilus. It was in the 18th century that the main duct of Wirsung was described as well as its first cannulations to perform studies on pancreatic secretion. In 1889, Fitz established pancreatitis as a nosdogic disease. In 1901, Opie proposed his "common channel" hypothesis. In 1927, Elman described the serum amylase test. In 1963, the first Marseilles Symposium favored a clinic pathologic classification of pancreatitis. In 1984 the second Marseilles Symposium revised that classification. Finally, in 1992, the Atlanta Symposium established a clinically based classification system for acute pancreatitis. In the years to come, we expect further refinements in the classifications, as MRI and innovative technologies become increasingly sophisticated.