Colocación de prótesis esofágica para el fracaso del tratamiento endoscópico / Esophageal stent placement for endoscopic treatment failure

Up until approximately 10 years ago, the treatment for acute refractory esophageal variceal bleeding was balloon tamponading. Esophageal fully covered self-expanding stents are considered as effective as balloons and also much safer. They are kept in situ for longer periods, what eases the access to more definitive treatments with a low complication rate. We present 6 cases of patients with cirrhosis and massive bleeding due to esophageal varices refractory to conventional treatment, successfully treated with an esophageal fully covered self-expanding stent. There were no major complications, achieving an effective bleeding control in all cases.(AU)

Stent ureteral Allium®: una nueva alternativa para el tratamiento de estenosis ureterales. Estudio prospectivo de cohortes / Allium® ureteral stent, a new player in the treatment of ureteral stenosis: A prospective cohort study

Introducción y objetivos La estenosis ureteral es una condición crónica que puede provocar la obstrucción del flujo urinario de la unidad renal comprometida, con la consiguiente pérdida de función renal. Los tipos de tratamiento pueden clasificarse en 2categorías principales: endourológicos y reconstructivos. Nuestro objetivo fue investigar la eficacia y seguridad del stent ureteral autoexpandible Allium®, cuyo uso en el tratamiento mínimamente invasivo de la estenosis ureteral se ha extendido en los últimos años. Materiales y métodos El estudio incluyó a 20 pacientes a los que se colocó un stent ureteral autoexpandible entre 2017 y 2021. Se registraron y evaluaron de forma prospectiva sus características clínicas y demográficas, los detalles del tratamiento, las complicaciones perioperatorias y postoperatorias y su tratamiento, y los hallazgos durante el seguimiento. Resultados La etiología incluyó urolitiasis en 16 pacientes (80%), neoplasia en 3 pacientes (15%) y cirugía ginecológica previa en uno (5%). La obstrucción del stent fue la complicación más frecuente en 3 pacientes (15%), seguida de la migración del stent en 2 (10%). Se continúa el seguimiento de 15 pacientes sin obstrucción ni complicaciones relacionadas con el stent. El periodo medio de seguimiento fue de 28±15,7 meses. Conclusiones El stent ureteral constituye una alternativa eficaz y segura para el tratamiento mínimamente invasivo de la estenosis ureteral, con unas tasas de complicaciones aceptables y un manejo sencillo de ellas. (AU)

Introduction and objectives Ureteral stricture is a chronic condition that can result in the obstruction of urinary drainage from the affected renal unit, leading to loss of renal function. reatment methods can be categorized into 2main headings: endourological and reconstructive procedures. We aimed to investigate the efficacy and safety of the self-expandable Allium® ureteral stent, which has been used in the minimally invasive treatment of ureteral stenosis in recent years. Materials and methods Twenty patients who were applied Allium® ureteral stent between 2017-2021 included in the study. The demographic and clinical characteristics of the patients, the details of the treatments applied to the patients, the perioperative and postoperative complications, the treatments applied for the complications and the findings in the follow-up were recorded and evaluated prospectively. Results Etiology included urolithiasis in 16 patients (80%), malignancy in 3 patients (15%), and a previous gynecological operation in one patient (5%). Stent obstruction was found to be the most common complication in 3 patients (15%). Stent migration was the second most common complication in 2 patients (10%). Our follow-up continues with 15 patients without stent-related complications and stent obstruction. The mean follow-up period was 28±15.7 months. Conclusions Allium ureteral stent is an effective and reliable method in the minimally invasive treatment of ureteral stricture with complications seen at acceptable rates and ease of treatment in the management of complications. (AU)

Allium® ureteral stent, a new player in the treatment of ureteral stenosis: a prospective cohort study.

INTRODUCTION AND OBJECTIVES: Ureteral stricture is a chronic condition that can result in the obstruction of urinary drainage from the affected renal unit, leading to loss of renal function. Treatment methods can be categorized into two main headings: endourological and reconstructive procedures. We aimed to investigate the efficacy and safety of the self-expandable Allium® ureteral stent, which has been used in the minimally invasive treatment of ureteral stenosis in recent years. MATERIALS AND METHODS: Twenty patients who were applied Allium® ureteral stent between 2017 and 2021 included in the study. The demographic and clinical characteristics of the patients, the details of the treatments applied to the patients, the perioperative and postoperative complications, the treatments applied for the complications and the findings in the follow-up were recorded and evaluated prospectively. RESULTS: Etiology included urolithiasis in 16 patients (80%), malignancy in 3 patients (15%), and a previous gynecological operation in 1 patient (5%). Stent obstruction was found to be the most common complication in 3 patients (15%). Stent migration was the second most common complication in 2 patients (10%). Our follow-up continues with 15 patients without stent-related complications and stent obstruction. The mean follow-up period was 28 ± 15.7 months. CONCLUSIONS: Allium ureteral stent is an effective and reliable method in the minimally invasive treatment of ureteral stricture with complications seen at acceptable rates and ease of treatment in the management of complications.

Tratamiento endovascular de fístula carotídea yugular por catéter de diálisis con stent cubierto autoexpandible / Endovascular treatment with autoexpandible stentgraft for jugular-carotid fistula after dialysis catheter misplacement

Paciente masculino de 59 años con antecedentes de obesidad, hipertensión arterial y enfermedad renal crónica que presentó fracaso renal agudo de su riñón trasplantado, que requirió la colocación de un catéter transitorio. Durante la colocación de un catéter 12 Fr guiado por ecografía, inadvertidamente se realizó una fístula carotídea yugular (FYC). Después de que fallara la compresión guiada por ultrasonido, se desplegó en la carótida primitiva un stent autoexpandible cubierto con exclusión defi nitiva de la fístula. Estos resultan una opción segura y factible para el tratamiento de la fístula yugular carotídea en zonas de exposición quirúrgica complicada y pacientes de alto riesgo.(AU)

A 59-year-old male patient with a history of obesity, high blood pressure, and chronic kidney disease who presented acute renal failure of his transplanted kidney, requiring temporary catheter placement. During the placement of a 12 Fr catheter guided by ultrasound, a jugular-carotid fi stula (JCF) was inadvertently created. After ultrasound-guided compression failed, a covered self-expanding stent was deployed in the common carotid with defi nitive exclusion of the fi stula. These are a safe and feasible option for the treatment of carotid jugular fi stula in areas with complicated surgical exposure and for high-risk patients.(AU)

La técnica de superposición de cúspides en TAVI con dispositivo autoexpandible optimiza la profundidad del implante y reduce la necesidad de marcapasos permanente / Cusp-overlapping TAVI technique with a self-expanding device optimizes implantation depth and reduces permanent pacemaker requirement

Introducción y objetivos: Una profundidad más alta del implante percutáneo de una válvula aórtica autoexpandible minimiza el daño en el sistema de conducción y puede reducir las tasas de marcapasos permanente a 30 días. El objetivo es determinar la seguridad y la eficacia de modificar la técnica de implante clásica para el reemplazo percutáneo de la válvula aórtica a una técnica de proyección de superposición de cúspides (PSC) para lograr una profundidad más alta del implante y reducir la necesidad de marcapasos permanente. Métodos: Desde marzo de 2017 se incluyó a 226 pacientes consecutivos: 113 tratados con técnica de implante PSC frente a 113 casos consecutivos previos con implante clásico. La profundidad del implante se evaluó mediante 3 métodos en todos los pacientes (cúspide no coronaria a válvula cardiaca percutánea (VCP); media de cúspide no coronaria y cúspide coronaria izquierda a VCP y el borde más profundo de cúspide coronaria izquierda y cúspide no coronaria a VCP). Resultados: El grupo de PSC presentó una profundidad del implante menor que el del grupo de implante clásico (4,8±2,2 frente a 5,7±3,1 mm; p=0,011; 5,8±3,1 frente a 6,5±2,4 mm; p=0,095; 7,1±2,8 frente a 7,4±3,2 mm; p=0,392). A los 30 días de seguimiento, 40 pacientes (17,7%) requirieron el implante de marcapasos permanente, menos en el grupo de PSC (el 12,4 frente al 23%; p=0,036). La técnica de implante PSC protegió contra el evento principal (OR=0,45; IC95%, 0,21-0,97; p=0,043), con parecidos éxito del procedimiento y complicaciones. Conclusiones: La técnica de implante PSC es una simple modificación en el protocolo que proporciona una profundidad del implante más alta de la prótesis valvular autoexpandible con menores alteraciones de la conducción y tasas de marcapasos permanente (AU)

Introduction and objectives: This study aimed to determine the safety and efficacy of modifying the classic implantation technique for aortic transcatheter heart valve (THV) implantation to a cusp-overlap-projection (COP) technique to achieve a higher implantation depth and to reduce the burden of new permanent pacemaker implantation (PPMI) at 30 days. Aortic self-expanding THV carries an elevated risk for PPMI. A higher implantation depth minimizes the damage in the conduction system and may reduce PPMI rates. Methods: From March 2017, 226 patients were consecutively included: 113 patients were treated using the COP implantation technique compared with the previous 113 consecutive patients treated using the classic technique. In all patients, implantation depth was assessed by 3 methods (noncoronary cusp to the THV, mean of the noncoronary cusp and the left coronary cusp to the THV, and the deepest edge from the left coronary cusp and the noncoronary cusp to the THV). Results: The COP group had a lower implantation depth than the group treated with the classic technique (4.8 mm± 2.2 vs 5.7 mm± 3.1; P=.011; 5.8 mm± 3.1 vs 6.5 mm± 2.4; P=.095; 7.1 mm± 2.8 vs 7.4 mm±3.2; P=.392). Forty patients (17.7%) required a new PPMI after the 30-day follow-up but this requirement was significantly lower in the COP group (12.4% vs 23%, P=.036). The COP implantation technique consistently protected against the main event (OR, 0.45; 95%CI, 0.21-0.97; P=.043), with similar procedural success rates and complications. Conclusions: The COP implantation technique is a simple modification of the implantation protocol and provides a higher implantation depth of self-expanding-THV with lower conduction disturbances and PPMI rates (AU)

Cusp-overlapping TAVI technique with a self-expanding device optimizes implantation depth and reduces permanent pacemaker requirement.

INTRODUCTION AND OBJECTIVES: This study aimed to determine the safety and efficacy of modifying the classic implantation technique for aortic transcatheter heart valve (THV) implantation to a cusp-overlap-projection (COP) technique to achieve a higher implantation depth and to reduce the burden of new permanent pacemaker implantation (PPMI) at 30 days. Aortic self-expanding THV carries an elevated risk for PPMI. A higher implantation depth minimizes the damage in the conduction system and may reduce PPMI rates. METHODS: From March 2017, 226 patients were consecutively included: 113 patients were treated using the COP implantation technique compared with the previous 113 consecutive patients treated using the classic technique. In all patients, implantation depth was assessed by 3 methods (noncoronary cusp to the THV, mean of the noncoronary cusp and the left coronary cusp to the THV, and the deepest edge from the left coronary cusp and the noncoronary cusp to the THV). RESULTS: The COP group had a lower implantation depth than the group treated with the classic technique (4.8 mm± 2.2 vs 5.7 mm± 3.1; P=.011; 5.8 mm± 3.1 vs 6.5 mm± 2.4; P=.095; 7.1 mm± 2.8 vs 7.4 mm±3.2; P=.392). Forty patients (17.7%) required a new PPMI after the 30-day follow-up but this requirement was significantly lower in the COP group (12.4% vs 23%, P=.036). The COP implantation technique consistently protected against the main event (OR, 0.45; 95%CI, 0.21-0.97; P=.043), with similar procedural success rates and complications. CONCLUSIONS: The COP implantation technique is a simple modification of the implantation protocol and provides a higher implantation depth of self-expanding-THV with lower conduction disturbances and PPMI rates.

Experience in the management of neoplastic gastric outlet obstruction in patients at the Hospital Universitario San Ignacio in Bogotá, Colombia.

INTRODUCTION: Malignant gastric outlet obstruction is a condition that alters patient quality of life, conditioning progressive malnutrition. However, self-expanding metal stents (SEMSs) and surgical gastrojejunostomy (SGJ) are palliative options in patients with unresectable disease. AIM: To characterize patients diagnosed with malignant gastric outlet obstruction requiring SEMS placement or SGJ. MATERIALS AND METHODS: Sequential non-probability convenience sampling was conducted and included 68 patients, 40 of whom had SEMS placement and 28 of whom underwent SGJ. RESULTS: Patients sought medical consultations for the symptoms of vomiting, abdominal pain, weight loss, and upper gastrointestinal bleeding. Ninety-five percent of the patients in the SEMS group and 64.3% in the SGJ group presented with metastasis. Technical and clinical success, patency duration, and number of patients with no complications were greater in the SGJ group. Mean survival in days was 88 (SD ±â€¯21) in the SEMS group versus 501 (SD ±â€¯122) in the SGJ group. The log-rank test detected a statistically significant difference between subgroups (p = 0.00). CONCLUSION: SGJ has greater technical and clinical success rates but SEMS placement continues to be utilized in distal gastric cancer, especially in cases in which surgery is not an option.

Paliación endoscópica con stent duodenal en cáncer gástrico estadio IV complicado con estenosis gastroduodenal / Endoscopic stenting for palliation of Stage IV gastric cancer with malignant gastric outlet obstruction. A clinical case / Paliação endoscópica com stent duodenal em câncer gástrico estágio IV complicado por estenose gastroduodenal. Caso clínico

Resumen: Introducción: el cáncer gástrico es la quinta neoplasia en frecuencia a nivel mundial. Su diagnóstico suele ser tardío. La estenosis gastroduodenal es una complicación frecuente, que condiciona el pronóstico y el tratamiento. Contamos con varias modalidades en cuanto a la paliación de esta complicación. Destacamos el tratamiento quirúrgico mediante derivación digestiva (gastroenteroanastomosis), y el tratamiento endoscópico, mediante colocación de un stent o prótesis metalica autoexpandible (PMA). El objetivo es exponer el caso clínico de una paciente portadora de un cáncer gástrico avanzado complicado con estenosis gastroduodenal en la cual se optó por la colocación de una PMA. La bibliografía comparativa entre ambas técnicas es controvertida. Existen estudios importantes que recomiendan la técnica quirúrgica frente a la endoscópica, y viceversa. Con este fin se han realizado múltiples trabajos. Los posibles beneficios de la paliación endoscópica son: menor estadía hospitalaria, rápido reintegro a la vía oral. El caso clínico expuesto por el contrario no se benefició de la menor estadía hospitalaria, en parte, por ser necesaria su internación por comorbilidades médicas. No presentó complicaciones posteriores relacionadas al procedimiento. Conclusiones: la elección de la técnica a utilizar deberá ser individualizada, teniendo en cuenta el paciente, sus comorbilidades, recursos técnicos, experiencia del personal, y recursos económicos. Se necesitan más estudios para demostrar beneficio de la técnica paliativa más adecuada.

Abstract: Introduction: gastric cancer is the fifth neoplasm in terms of global incidence and its diagnosis often comes late. Gastric outlet obstruction is a frequent complication that influences prognosis and treatment. Among the various modalities available for palliation of this complication, we stand out two: surgical treatment by means of a digestive derivation: gastrojejunostomy and endoscopic treatment, by placing a stent or a steel mesh self-expanding endoprosthesis (EMP). The study aims to present the clinical case of a patient carrier of advanced gastric cancer with gastric outlet obstruction, who was treated by placing a self-expandable metallic stent. Comparative bibliography of both techniques is controversial. A number of important studies recomend the surgical technique instead of endoscopic treatment, and viceversa. For this reason, several studies have been conducted. The potential benefits of endoscopic palliation are the following: shorter hospital stay, fast return to oral intake. However the clinical case presented did not benefit from a shorter hospital stay, since it required longer hospitalization, partly due to medical comorbilities. There were no complications after the procedure. Conclusions: the specific technique to treat the condition needs to be chosen for each individual case, considering the particular patient and his or her comorbilities, technical resources, the experience of the medical staff and economic resources. More studies are necessary to prove the benefits of the most appropriate palliative technique.

Resumo: Introdução: o câncer gástrico é a quinta neoplasia em frequência no mundo. Seu diagnóstico costuma ser tardio. A estenose gastroduodenal é uma complicação frequente, que determina o prognóstico e o tratamento. Existem várias modalidades quanto à paliação desta complicação entre os quais destacamos o tratamento cirúrgico por derivação digestiva: gastro enteroanastomose e o tratamento endoscópico, com colocação de Stent ou Prótese Metálica Autoexpansível (PMA). O objetivo deste trabalho é apresentar o caso clínico de um paciente com câncer gástrico avançado complicado por estenose gastroduodenal em que se optou pela colocação de PMA. A bibliografia comparativa entre as duas técnicas é controversa. Existem estudos importantes que preconizam a técnica cirúrgica em detrimento da endoscópica e vice-versa. Para isso, vários trabalhos foram realizados. Os possíveis benefícios da paliação endoscópica são: menor tempo de internação, rápida reintrodução à via oral. Neste caso o paciente não se beneficiou do menor tempo de internação, em parte, porque a internação foi necessária por comorbidades médicas. Não foram observadas complicações subsequentes relacionadas ao procedimento. Conclusões: a escolha da técnica a ser utilizada deve ser individualizada, levando em consideração o paciente, suas comorbidades, os recursos técnicos, a experiência da equipe e os recursos econômicos. Mais estudos são necessários para demonstrar o benefício da técnica paliativa mais adequada.

Stents metálicos autoexpandibles para el manejo endoscópico de las fístulas esofagogástricas / Self-expanding metal stents for endoscopic management of esophageal and gastric fistulas

Resumen Objetivos: mostrar la eficacia y seguridad de los stents metálicos autoexpandibles para el manejo endoscópico de las fístulas esofágicas. Materiales y métodos: se evalúo una serie de casos de manera retrospectiva entre el 2007 y el 2017, en los que se manejaron a 11 pacientes con un stent metálico autoexpandible para el manejo de fístula esofágica, en quienes se realizó el diagnóstico por clínica, endoscopia digestiva alta o estudios radiológicos en la unidad de gastroenterología del Hospital Universitario San Ignacio (HUSI) de Bogotá D. C., Colombia. Resultados: el principal síntoma inicial fue la disnea en 27,3 % de los casos, seguido por tos en un 18,2 %. El hallazgo más frecuentemente encontrado durante el seguimiento fue el derrame pleural en el 36,4 %, se realizó el diagnóstico de fístula en el 45,5 % con esofagograma y el tipo de lesión más reportada fue la fuga en la anastomosis esofagoentérica, con un 45,5 %, seguida de la esofagopleural, con un 36,4 %; y estos pacientes fueron manejados con un stent metálico autoexpandible. En el 100 % hubo éxito técnico y la resolución del defecto se evidenció en el 72,7 % de los casos. La única complicación reportada fue el desplazamiento del stent en el 27,3 %, y en un paciente se requirió el cambio del stent en 3 oportunidades. El promedio de estancia hospitalaria fue de 41,5 días. Conclusiones: el manejo endoscópico de las fístulas esofagogástricas con stents metálicos autoexpandibles es efectivo y seguro, con una baja tasa de complicaciones.

Abstract Objective: To demonstrate the efficacy and safety of self-expanding metal stents for endoscopic management of esophageal fistulas. Materials and methods: Retrospective case series between 2007 and 2017. A total of 11 patients were treated with self-expanding metal stents for esophageal fistula management, after being diagnosed based on symptoms, upper endoscopy, and/or radiological studies in the gastroenterology unit of the Hospital Universitario San Ignacio (HUSI) in Bogotá D.C, Colombia. Results: The most common initial symptom was dyspnea in 27.3% of cases, followed by cough in 18.2%. The most frequent finding during follow-up was pleural effusion in 36.4% of the cases, of which 45.5% received a diagnosis of fistula through esophagogram. The most reported lesion was esophagoenteric anastomotic leak with 45.5%, followed by esophagopleural injury with 36.4%; these patients were those who received self-expanding metal stent management. Technical success was achieved in 100% of the cases, and the defect was resolved in in 72.7% of them. The only complication reported was stent migration in 27.3%, requiring 3 changes in 1 patient. The average hospital stay was 41.5 days. Conclusions: Endoscopic management of esophagogastric fistulas with self-expanding metal stents is effective and safe, with a low complication rate.

Reemplazo valvular aórtico transcatéter (RVAT): manejo perioperatorio y consideraciones anestésicas / Transcathether aortic valve replacement (TAVR): perioperative management and anesthetic considerations

The trans-catheter aortic valve replacement (TAVR) is becoming more frequent and, therefore, there is need for a proper perioperative management. The new devices have reduced the complications and therefore increased the indications of this technique, even in patients with low surgical risk. It is necessary to know the procedure and the types of valves available, the most frequent access is transfemoral and the devices are usually separated in ballon-expandable and self-expanding valves. There is recent evidence that would indicate some benefits of using sedation as the anesthetic technique, however, the choice should be based on each individual patient, the center and the experience of each anesthesiologist in charge. Although TAVR is much safer today, there are multiple complications reported, such as vascular lesions, paravalvular leakage, neurological complications, among others. An adequate knowledge and monitoring of them will allow us to reduce them in the perioperative period.

Cada vez es más frecuente el reemplazo valvular aórtico trans-catéter (RVAT) y, por ende, la necesidad de su adecuado manejo perioperatorio. Los nuevos dispositivos han disminuido sus complicaciones y, por lo tanto, aumentado su indicación, incluso en pacientes de bajo riesgo quirúrgico. Es necesario conocer la forma en que se realiza el procedimiento, tipos de válvulas disponibles, accesos más frecuentes y los tipos de dispositivos. Existe evidencia reciente que indicaría algunos beneficios de utilizar sedación como técnica anestésica, sin embargo, la elección se debe basar en cada paciente en particular, el centro y la experiencia de cada anestesiólogo a cargo. Si bien el RVAT hoy es mucho más seguro, existen complicaciones, entre las que se encuentran lesiones vasculares, leak paravalvular, complicaciones neurológicas, tamponamiento, entre otras. Un adecuado conocimiento y monitorización de ellas nos permitirá reducirlas en el perioperatorio.

Predictors of self-expanding metallic stent dysfunction in malignant gastric outlet obstruction. / Predictores de disfunción del stent metálico autoexplandible en la obstrucción de salida gástrica maligna.

INTRODUCTION AND OBJECTIVES: Self-expanding metallic stents (SEMS) are the ideal treatment for malignant gastric outlet obstruction (MGOO) in patients with a short life expectancy, but stent dysfunction is frequent. The primary aim of our study was to identify the predictive factors of SEMS dysfunction in MGOO and the secondary aim was to determine the technical success, clinical success, and nutritional impact after SEMS placement. MATERIAL AND METHODS: A retrospective, longitudinal study was conducted at the gastrointestinal endoscopy department of the Instituto Nacional de Cancerología in Mexico City. Patients diagnosed with MGOO that underwent SEMS placement within the time frame of January 2015 to May 2018 were included. We utilized the gastric outlet obstruction scoring system (GOOSS) to determine clinical success and SEMS dysfunction. RESULTS: The study included 43 patients, technical success was 97.7% (n=42), and clinical success was 88.3% (n=38). SEMS dysfunction presented in 30.2% (n=13) of the patients, occurring in<6 months after placement in 53.8% (n=7) of them. In the univariate analysis, the histologic subtype, diffuse gastric adenocarcinoma (p=0.02) and the use of uncovered SEMS (p=0.02) were the variables associated with dysfunction. Albumin levels and body mass index did not increase after SEMS placement. Medical follow-up was a mean 5.8 months (1-24 months). CONCLUSIONS: SEMS demonstrated adequate technical and clinical efficacy in the treatment of MGOO. SEMS dysfunction was frequent and diffuse type gastric cancer and uncovered SEMS appeared to be dysfunction predictors.

Experience in the management of neoplastic gastric outlet obstruction in patients at the Hospital Universitario San Ignacio in Bogotá, Colombia. / Experiencia del manejo de la obstrucción al tracto de salida gástrico de origen neoplásico en pacientes del Hospital Universitario San Ignacio (HUSI) en Bogotá, Colombia.

INTRODUCTION: Malignant gastric outlet obstruction is a condition that alters patient quality of life, conditioning progressive malnutrition. However, self-expanding metal stents (SEMSs) and surgical gastrojejunostomy (SGJ) are palliative options in patients with unresectable disease. AIMS: To characterize patients diagnosed with malignant gastric outlet obstruction requiring SEMS placement or SGJ. MATERIALS AND METHODS: Sequential non-probability convenience sampling was conducted and included 68 patients, 40 of whom had SEMS placement and 28 of whom underwent SGJ. RESULTS: Patients sought medical consultations for the symptoms of vomiting, abdominal pain, weight loss, and upper gastrointestinal bleeding. Ninety-five percent of the patients in the SEMS group and 64.3% in the SGJ group presented with metastasis. Technical and clinical success, patency duration, and number of patients with no complications were greater in the SGJ group. Mean survival in days was 88 (SD ± 21) in the SEMS group versus 501 (SD ± 122) in the SGJ group. The log-rank test detected a statistically significant difference between subgroups (p = 0.00). CONCLUSION: SGJ has greater technical and clinical success rates but SEMS placement continues to be utilized in distal gastric cancer, especially in cases in which surgery is not an option.

Initial experience in Mexico with the Evolut™ R valve with direct aortic Access.

Background: Aortic stenosis (AS) is one of the most frequent valvulopathies in elderly patients. The treatment for AS is heart surgery; however, many patients do not benefit from this treatment because they are considered to be at high surgical or inoperable risk. Transcatheter aortic valve implantation (TAVI) was developed for these patients. Objective: To disseminate the feasibility and safety of other access routes for the implantation of transcatheter aortic valves and that it can also be performed in the hemodynamic laboratory. In addition to the rapid growth in technology and knowledge, there is a lot of experience with TAVI already. Methodology: One of the limitations is the diameter of the femoral, subclavian, and axillary vascular accesses. This is why other approaches such as the direct aortic approach are sought after, despite the invasive nature of mini-thoracotomy and aortotomy is technically feasible, familiar, and easy to learn for cardiac surgeons. Results: In addition, it has been associated with favorable outcomes and a lower rate of complications (bleeding and risk of myocardial injury) and shorter length of stay in the intensive care unit compared to surgery or transapical access. Conclusions: Our center successfully implanted the self-expandable aortic valve Evolut™ through direct aortic for presenting a dissection in transverse aorta with possibilities of embolization.

Antecedentes: La estenosis aórtica es una de las valvulopatías más frecuentes en el paciente mayor. Su tratamiento es la cirugía de corazón, sin embargo, muchos pacientes no se benefician de este tratamiento por considerarse de alto riesgo quirúrgico o inoperables. Para estos últimos pacientes se desarrolló el implante de válvula aórtica transcatéter (TAVI). Objetivo: Dar a conocer la factibilidad y seguridad de otras vías de acceso para la implantación de válvulas aórticas transcatéter y que además se puede realizar en el laboratorio de hemodinámica. Además de un rápido crecimiento en tecnología y conocimientos, actualmente ya se tiene mucha experiencia con TAVI. Metodología: Una de las limitantes es el diámetro de los accesos vasculares femorales, subclavio y axilar. Es por esto por lo que se buscan otros accesos como el aórtico directo, a pesar del carácter invasivo de la minitoracotomía y aortotomía es técnicamente factible, familiar y fácil de aprender para los cirujanos cardíacos. Resultado: Se ha asociado con resultados favorables y una menor tasa de complicaciones (sangrado, riesgo de lesión miocárdica) y menor duración de la estancia en la Unidad de Cuidados Intensivos en comparación con la cirugía o el acceso transapical. Conclusión: Nuestro centro implantó con éxito la válvula aórtica autoexpandible Evolut™ vía aórtica directa por presentar una disección en la aorta transversa con posibilidades de embolización.

Experiencia inicial en México con la prótesis aórtica transcatéter Evolut™ R por abordaje aórtico directo.

Background: Aortic stenosis is one of the most frequent valvulopathies in the elderly patient. The treatment for aortic stenosis is heart surgery, however many patients do not benefit from this treatment because they are considered to be at high surgical or inoperable risk. Transcatheter aortic valve (TAVI) was developed for these patients. Objective: To make known the feasibility and safety of other access routes for the implantation of transcatheter aortic valves and that it can also be performed in the hemodynamic laboratory. In addition to rapid growth in technology and know-how, TAVI is already very experienced. Methodology: One of the limitations is the diameter of the femoral, subclavian, and axillary vascular accesses. This is why other approaches such as the direct aortic approach are sought, despite the invasive nature of mini-thoracotomy and aortotomy is technically feasible, familiar and easy to learn for cardiac surgeons. Results: In addition, it has been associated with favorable outcomes and a lower rate of complications (bleeding, risk of myocardial injury) and shorter length of stay in the Intensive Care Unit compared to surgery or transapical access. Conclusion: Our center successfully implanted the self-expandable aortic valve Evolut™ via direct aortic for presenting a dissection in transverse aorta with possibilities of embolization.

Antecedentes: La estenosis aórtica es una de las valvulopatías más frecuentes en el paciente mayor. Su tratamiento es la cirugía de corazón, sin embargo, muchos pacientes no se benefician de este tratamiento por considerarse de alto riesgo quirúrgico o inoperables. Para estos últimos pacientes se desarrolló el implante de válvula aórtica transcatéter (TAVI). Objetivo: Dar a conocer la factibilidad y seguridad de otras vías de acceso para la implantación de válvulas aórticas transcatéter y que además se puede realizar en el laboratorio de hemodinámica. Además de un rápido crecimiento en tecnología y conocimientos, actualmente ya se tiene mucha experiencia con TAVI. Metodología: Una de las limitantes es el diámetro de los accesos vasculares femorales, subclavio y axilar. Es por esto por lo que se buscan otros accesos como el aórtico directo, a pesar del carácter invasivo de la minitoracotomía y aortotomía es técnicamente factible, familiar y fácil de aprender para los cirujanos cardíacos. Resultado: Se ha asociado con resultados favorables y una menor tasa de complicaciones (sangrado, riesgo de lesión miocárdica) y menor duración de la estancia en la Unidad de Cuidados Intensivos en comparación con la cirugía o el acceso transapical. Conclusión: Nuestro centro implantó con éxito la válvula aórtica autoexpandible Evolut™ vía aórtica directa por presentar una disección en la aorta transversa con posibilidades de embolización.

Stent performance in obstructive left colon cancer. Unicentric and cross-sectional study. / Rendimiento del stent en el manejo de la obstrucción intestinal por cáncer de colon izquierdo. Estudio ambispectivo y unicéntrico.

OBJECTIVE: To evaluate the efficacy, safety and clinical and oncological results of colonic stents in the initial therapeutic strategy of obstructive left colon cancer. METHODS: Descriptive and ambispective study (2008-2018) of patients with clinical and radiological diagnosis of neoplastic obstruction of the left colon in whom a colonic stent was indicated, analyzing the following groups: palliative stent, stent as bridge to surgery and urgent surgery in case of stent failure or complications. RESULTS: The study included 208 patients. The technical and clinical success rates were 82.2% and 74.5%, respectively, with associated perforation in 4.3% of the sample. In 32.2%, the stent was placed as bridge to surgery, while 28.4% required urgent surgical intervention. The stent was placed with palliative intent in 39.4%. The proportion of laparoscopic surgery, oncological resection, primary anastomosis and lymph nodes resected were higher in patients undergoing elective surgery than in urgent surgery, with shorter postoperative stay and less severe postoperative morbidity and mortality. Stage II-III patients with oncological tumor resection who underwent elective surgery had increased survival compared to those who underwent urgent surgery (P=0.001). CONCLUSIONS: Initial treatment of neoplastic obstruction of the left colon with a stent is an effective strategy in elective surgery and avoids permanent colostomy in palliative patients, although complications or stent failure lead to urgent surgery in almost one-third of patients.

Experiencia inicial en México con la prótesis aórtica transcatéter Evolut R por abordaje aórtico directo / Initial experience in Mexico with the EvolutTM R valve with direct aortic access

Resumen Antecedentes: La estenosis aórtica es una de las valvulopatías más frecuentes en el paciente mayor. Su tratamiento es la cirugía de corazón, sin embargo, muchos pacientes no se benefician de este tratamiento por considerarse de alto riesgo quirúrgico o inoperables. Para estos últimos pacientes se desarrolló el implante de válvula aórtica transcatéter (TAVI). Objetivo: Dar a conocer la factibilidad y seguridad de otras vías de acceso para la implantación de válvulas aórticas transcatéter y que además se puede realizar en el laboratorio de hemodinámica. Además de un rápido crecimiento en tecnología y conocimientos, actualmente ya se tiene mucha experiencia con TAVI. Metodología: Una de las limitantes es el diámetro de los accesos vasculares femorales, subclavio y axilar. Es por esto por lo que se buscan otros accesos como el aórtico directo, a pesar del carácter invasivo de la minitoracotomía y aortotomía es técnicamente factible, familiar y fácil de aprender para los cirujanos cardíacos. Resultado: Se ha asociado con resultados favorables y una menor tasa de complicaciones (sangrado, riesgo de lesión miocárdica) y menor duración de la estancia en la Unidad de Cuidados Intensivos en comparación con la cirugía o el acceso transapical. Conclusión: Nuestro centro implantó con éxito la válvula aórtica autoexpandible Evolut vía aórtica directa por presentar una disección en la aorta transversa con posibilidades de embolización.

Abstract Background: Aortic stenosis is one of the most frequent valvulopathies in the elderly patient. The treatment for aortic stenosis is heart surgery, however many patients do not benefit from this treatment because they are considered to be at high surgical or inoperable risk. Transcatheter aortic valve (TAVI) was developed for these patients. Objective: To make known the feasibility and safety of other access routes for the implantation of transcatheter aortic valves and that it can also be performed in the hemodynamic laboratory. In addition to rapid growth in technology and know-how, TAVI is already very experienced. Methodology: One of the limitations is the diameter of the femoral, subclavian, and axillary vascular accesses. This is why other approaches such as the direct aortic approach are sought, despite the invasive nature of mini-thoracotomy and aortotomy is technically feasible, familiar and easy to learn for cardiac surgeons. Results: In addition, it has been associated with favorable outcomes and a lower rate of complications (bleeding, risk of myocardial injury) and shorter length of stay in the Intensive Care Unit compared to surgery or transapical access. Conclusion: Our center successfully implanted the self-expandable aortic valve Evolut via direct aortic for presenting a dissection in transverse aorta with possibilities of embolization.

Short- and long-term clinical outcomes of self-expandable metal stents inserted for colorectal obstruction and efficacy of different insertion techniques.

OBJECTIVES: (1) To evaluate the short- and long-term clinical outcomes of patients after colorectal stent placement and (2) to assess the safety and efficacy of the stents for the resolution of colorectal obstruction according to the insertion technique. METHODS: Retrospective cohort study which included 177 patients with colonic obstruction who underwent insertion of a stent. RESULTS: A total of 196 stents were implanted in 177 patients. Overall, the most common cause of obstruction was colorectal cancer (89.3%). Ninety-two stents (47%) were placed by radiologic technique and 104 (53%) by endoscopy under fluoroscopic guidance. Technical success rates were 95% in both groups. Clinical success rates were 77% in the radiological group and 81% in the endoscopic group (p>0.05). The rate of complications was higher in the radiologic group compared with the endoscopic group (38% vs 20%, respectively; p=0.006). Among patients with colorectal cancer (158), 65 stents were placed for palliation but 30% eventually required surgery. The multivariate analysis identified three factors associated with poorer long-term survival: tumor stage IV, comorbidity and onset of complications. CONCLUSIONS: Stents may be an alternative to emergency surgery in colorectal obstruction, but the clinical outcome depends on the tumor stage, comorbidity and stent complications. The rate of definitive palliative stent placement was high; although surgery was eventually required in 30%. Our study suggests that the endoscopic method of stent placement is safer than the radiologic method.

Role of self-expanding stents in the treatment of intrathoracic dehiscence after Ivor Lewis esophagectomy. / Papel de las endoprótesis autoexpandibles en el tratamiento de la dehiscencia intratorácica tras el procedimiento de Ivor Lewis.

INTRODUCTION: The role that self-expanding stents play in the treatment of dehiscence after transthoracic esophagectomy is not well defined and controversial. Our aim is to describe the experience in a tertiary care hospital using these devices for treating dehiscence after Ivor Lewis esophagectomy. METHODS: Descriptive observational study of patients who suffered anastomotic dehiscence after a transthoracic esophagectomy, and especially those treated with stents, in the period between 2011-2016 at our hospital. RESULTS: Ten patients (11.8%) presented anastomotic dehiscence. Eight patients received stents, one of them died due to causes unrelated to the device. Stent migration was observed in one case, and the devices were maintained an average of 47.3 days. The stent was not effective only in one patient who suffered early dehiscence due to acute ischemia of the stomach. The two patients who did not receive stents died after reoperation. CONCLUSIONS: Stents are safe and effective devices that did not associate mortality in our series. They are especially indicated in intermediate or late-onset dehiscence and in fragile patients. The use of stents, together with mediastinal and pleural drainage, avoid reoperations with morbidity and mortality. Therefore, stents should be part of the usual therapeutic arsenal for the resolution of most suture dehiscences after Ivor Lewis esophagectomy. Randomized prospective studies would help to more precisely determine the role played by these devices in the treatment of dehiscence after transthoracic esophagectomy.

Self-expanding metallic stent as a bridge to surgery in the treatment of left colon cancer obstruction: Cost-benefit analysis and oncologic results. / Stents metálicos autoexpandibles como puente a la cirugía en el tratamiento del cáncer de colon izquierdo en oclusión. Análisis coste-beneficio y resultados oncológicos.

INTRODUCTION: The use of a self-expanding metallic stent as a bridge to surgery in acute malignant left colonic obstruction has been suggested as an alternative treatment to emergency surgery. The aim of the present study was to compare the morbi-mortality, cost-benefit and long-term oncological outcomes of both therapeutic options. METHODS: This is a prospective, comparative, controlled, non-randomized study (2005-2010) performed in a specialized unit. The study included 82 patients with left colon cancer obstruction treated by stent as a bridge to surgery (n=27) or emergency surgery (n=55) operated with local curative intention. The main outcome measures (postoperative morbi-mortaliy, cost-benefit, stoma rate and long-term oncological outcomes) were compared based on an "intention-to-treat" analysis. RESULTS: There were no significant statistical differences between the two groups in terms of preoperative data and tumor characteristics. The technically successful stenting rate was 88.9% (11.1% perforation during stent placement) and clinical success was 81.4%. No difference was observed in postoperative morbi-mortality rates. The primary anastomosis rate was higher in the bridge to surgery group compared to the emergency surgery group (77.8% vs. 56.4%; P=.05). The mean costs in the emergency surgery group resulted to be €1,391.9 more expensive per patient than in the bridge to surgery group. There was no significant statistical difference in oncological long-term outcomes. CONCLUSIONS: The use of self-expanding metalllic stents as a bridge to surgery is a safe option in the urgent treatment of obstructive left colon cancer, with similar short and long-term results compared to direct surgery, inferior mean costs and a higher rate of primary anastomosis.

Thirty-day Outcome Following CoreValve Evolut R Transcatheter Aortic Valve Implantation: An All-comers Prospective Study.

INTRODUCTION AND OBJECTIVES: There are scarce clinical outcomes data on the new generation recapturable and repositionable CoreValve Evolut R. METHODS: Data on all-comer patients undergoing transcatheter aortic valve implantation (TAVI) with the Evolut R for severe symptomatic aortic stenosis at a single center were prospectively collected between February 2015 and April 2016. Clinical endpoints were independently adjudicated according to the Valve Academic Research Consortium-2 criteria. Primary outcomes consisted of early safety composite endpoints and 30-day device success. The incidence of new permanent pacemaker implantation was recorded. RESULTS: Among the 83 patients undergoing TAVI during this period, 71 (85.5% of the population; median age, 83.0 [interquartile range, 80.0-87.0] years; Society of Thoracic Surgeons scores, 4.8±3.5%) were suitable for Evolut R implantation and were included in the analysis. Repositioning was performed in 26.8% of the procedures. The early safety composite endpoint was observed in 11.3% of patients at 30 days, with 2.8% all-cause mortality. Device success was documented in 90.1% of patients. Paravalvular leakage was less than grade II in 98.4% of patients. The mean transvalvular aortic gradient was reduced from 42.5±14.5mmHg at baseline to 7.7±4.0mmHg at discharge (P<.0001 vs baseline). New permanent pacemaker implantation was required in 23.9% of patients. CONCLUSIONS: The new generation Evolut R is suitable for most patients and shows high device success and acceptable mortality in an unbiased, consecutive, all-comer population at a single center performing TAVI exclusively with Medtronic valves.