Manejo endoscópico de la enfermedad por reflujo gastroesofágico (ERGE) / Endoscopic management of gastroesophageal reflux disease (GERD)

La enfermedad por reflujo gastroesofágico (ERGE) se manifiesta cuando el quimo gástrico refluye al esófago y pasa de ser fisiológico a sintomático y patológico. Es frecuente a nivel mundial y de difícil abordaje diagnóstico debido a la multitud de síntomas y presentaciones, haciendo que su enfoque terapéutico sea complejo. Existen múltiples opciones de tratamiento siendo el farmacológico basado en inhibidores de bomba de protones (IBP) la piedra angular. El manejo quirúrgico está descrito pero reservado a ciertos pacientes específicos. La terapia endoscópica surge como otra opción con indicaciones similares a la cirugía, pero con las ventajas propias de los procedimientos endoscópicos. Se han descrito varias técnicas endoluminales con pobres resultados, que no se han logrado popularizar.

Gastroesophageal reflux disease (GERD) occurs when gastric chyme refluxes back into the esophagus and changes from physiologic to symptomatic and pathologic. It is common worldwide and is difficult to diagnose due to the diversity of symptoms and presentations, making its therapeutic approach complex. Although there are multiple treatment options, proton pump inhibitors (PPIs) have been the mainstay of pharmacological management of GERD. Surgical treatment is described but is used in selected patients. Endoscopic therapy emerges as another option with similar indications as surgery, featuring the advantages of endoscopic procedures. Several endoluminal techniques have been described showing poor results, thus their generalized use has not been achieved.

Manejo endoscópico de la fístula traqueoesofágica recurrente con la aplicación de ácido tricloroacético, en el paciente pediátrico / Endoscopic management of recurrent tracheoesophageal fistula with trichloroacetic acid in pediatric patients

Introducción: La reparación quirúrgica de la fístula traqueoeso-fágica recurrente tiene alto riesgo de complicaciones por lo que se hanutilizado diversas técnicas endoscópicas para evitarlas. Objetivo: Conocer la utilidad de la aplicación endoscópica deácido tricloroacético para el tratamiento de la fístula traqueoesofágicarecurrente. Material y método: Estudio observacional, descriptivo y retros-pectivo, tipo de serie de casos en un hospital pediátrico de tercer nivel.Se revisaron los expedientes de pacientes con fístula traqueoesofágicarecurrente de 2015 a 2021. En todos los pacientes durante este periodose realizó cepillado y aplicación de ácido tricloroacético. Resultado: El tiempo medio de aparición de la fístula traqueoesofá-gica recurrente fue de 4,8 meses (rango 1-19,2). Dos con fístula pequeña(menor a 4 mm), tres con fístula mediana (4 mm) y dos con fístula grande(mayor a 4 mm). El número medio de sesiones para cerrar la fístula fue2,2 veces (rango 1-4). El intervalo medio entre procedimientos fue 22días (rango 14-30). El tiempo medio de seguimiento desde la confir-mación de cierre de la fistula fue de 33 meses (rango 9-72), periodo detiempo donde no se observó recurrencia del cuadro. Conclusión: El manejo endoscópico de la fístula traqueoesofágica recurrente con la aplicación de ácido tricloroacético es un procedimientoseguro y efectivo. La técnica de cepillado y aplicación de ácido triclo-roacético mejora la efectividad de éxito. La fístula mayor de 4 mm dediámetro requiere mayor número de procedimientos; sin embargo, serequiere mayor número de pacientes y mayor tiempo de seguimientopara poder aseverar esta opinión.(AU)

Introduction: Surgical repair of recurrent tracheoesophageal fistulahas a high risk of complications. Therefore, various endoscopic tech-niques have been used to avoid complications. Objective: To understand the usefulness of trichloroacetic acid en-doscopic application for the treatment of recurrent tracheoesophageal fistula. Materials and methods: An observational, descriptive, retrospec-tive, case-series-based study was carried out in a tertiary pediatric hos-pital. Records of patients with recurrent tracheoesophageal fistula from2015 to 2021 were reviewed. All patients within this period underwentbrushing and trichloroacetic acid application. Results: Mean time of recurrent tracheoesophageal fistula occur-rence was 4.8 months (range: 1-19.2). Two patients had a small fistula(less than 4 mm), three patients had a medium fistula (4 mm), and twopatients had a large fistula (more than 4 mm). Mean sessions for fistulaclosure were 2.2 (range: 1-4). Mean time between procedures was 22days (range: 14-30). Mean follow-up since fistula closure confirmationwas 33 months (range: 9-72), during which no recurrences were noted. Conclusion: Endoscopic management of recurrent transesophagealfistula with trichloroacetic acid is a safe and effective procedure. Brush-ing and trichloroacetic acid combined improve success rates. Fistulasover 4 mm in diameter require more procedures. However, a largerpatient cohort and a longer follow-up period are needed to confirm this.(AU)

Utilidad de la cistouretrografía miccional intraoperatoria como indicador de éxito del tratamiento endoscópico del reflujo vesicoureteral / Usefulness of intraoperative voiding cystourethrogram as an indicator of success in the endoscopic treatment of vesicoureteral reflux

Objetivo: La cistouretrografía miccional seriada (CUMS) ha sido hasta ahora el gold standard en el diagnóstico del reflujo vesicoureteral (RVU). La finalidad de la CUMS intraoperatoria durante el tratamientoendoscópico es detectar aquellos pacientes subsidiarios de inyectar más material biosintético por persistencia del RVU. En este estudio hemos querido evaluar la utilidad de esta prueba como predictor de éxito deltratamiento. Material y métodos: Estudio analítico retrospectivo mediante la revisión de historias clínicas de pacientes, medidos en unidades ureterales, intervenidos de RVU de forma endoscópica entre los años 2000 y2019. Se comparó la persistencia de RVU en la CUMS intraoperatoria tras el tratamiento con el resultado de la CUMS a los 3 meses. Resultados: De un total de 167 unidades ureterales intervenidas, se observó persistencia del reflujo inmediatamente tras la intervención en 17 casos (10% de la muestra). Solo 3 asociaban otras malformacionesurológicas. En la CUMS a los 3 meses se observó reflujo en el 38% de la muestra (64 casos). Al comparar los resultados, obtenemos para la CUMS intraoperatoria una especificidad del 92,6% y una sensibilidad del 15,6%. Conclusiones: Dada la baja sensibilidad (15,6%) de la CUMS intraoperatoria para detectar los casos en los que persiste el reflujo a medio plazo y, teniendo en cuenta los riesgos asociados a la radiación que supone en una población especialmente sensible como es la pediátrica, se desestima su utilidad como indicador de éxito del tratamientoendoscópico.(AU)

Objective: Up until now, serial voiding cystourethrogram (SVCU) has been regarded as the gold standard technique in the diagnosis ofvesicoureteral reflux (VUR). The aim of intraoperative SVCU during endoscopic treatment is to detect those patients eligible to receive morebiosynthetic material as a result of persistent VUR. The objective of this study was to assess the usefulness of SVCU as a predictor of treatment success. Materials and methods: An analytical, retrospective study of patient medical records was carried out. Patients included had undergoneendoscopic VUR surgery from 2000 to 2019, and they were measured in ureteral units. VUR persistence at intraoperative SVCU followingtreatment was compared with SVCU results after 3 months. Results: Of a total of 167 ureteral units undergoing surgery, persistent reflux immediately after surgery was observed in 17 cases (10%of the sample). Only 3 cases had other urological malformations. In the SVCU carried out after 3 months, reflux was found in 38% of thesample (64 cases). When comparing the results, intraoperative SVCU demonstrated a specificity of 92.6%, and a sensitivity of 15.6%. Conclusions: Given the low sensitivity (15.6%) of intraoperative SVCU to detect cases of persistent reflux in the midterm, and considering the risks associated with radiation in the pediatric population which is extremely sensitive to it, intraoperative SVCU should be ruled outas a useful indicator of endoscopic treatment success.(AU)

Vólvulo gástrico en una paciente nonagenaria: intervención endoscópica y laparoscópica. Reporte de caso / Gastric volvulus in a nonagenarian patient: endoscopic and laparoscopic intervention. Case report

Resumen El vólvulo gástrico es una entidad rara que puede presentarse de manera aguda o crónica y se acompaña de síntomas inespecíficos. Es fundamental su rápida identificación, ya que tiene alta mortalidad y el tratamiento oportuno de esta patología determina el pronóstico del paciente. A continuación, presentamos el caso de una paciente femenina de 89 años, que consulta por cuadro clínico de dolor torácico atípico, con documentación en radiografía de tórax de vólvulo gástrico organoaxial, en quien se realiza inicialmente devolvulación endoscópica con éxito. Sin embargo, en las imágenes de control se evidencia recurrencia del vólvulo, por lo cual se realizó manejo quirúrgico con hiatoplastia y funduplicatura tipo Toupet, además de gastrostomía percutánea de fijación, procedimiento realizado sin complicaciones, con los que se logró la devolvulación completa sin recurrencia.

Abstract Gastric volvulus is a rare condition that can occur acutely or chronically and is accompanied by nonspecific symptoms. Its rapid identification is critical since it has high mortality rate and timely treatment determines the patient's prognosis. The following is the case of an 89-year-old female patient who presented with atypical chest pain, with organoaxial gastric volvulus on chest X-ray, in whom endoscopic devolvulation was initially performed successfully. However, control imaging scans revealed recurrence. Therefore, surgical management included hiatoplasty and Toupet fundoplication, as well as percutaneous fixation gastrostomy, a procedure that was completed without complications and resulted in complete devolvulation without recurrence.

Desarrollo de la técnica de disección submucosa endoscópica en cáncer gástrico incipiente: primeros cincuenta casos de un cirujano / Development of endoscopic submucosal dissection for early gastric cancer: fifty first cases of a surgeon

Resumen Introducción: El cáncer gástrico es un problema de salud en Chile y su mal pronóstico global se explica por un diagnóstico en etapas avanzadas. El cáncer gástrico incipiente (CGI) se asocia a buen pronóstico oncológico y la disección submucosa endoscópica (DSE) como alternativa de tratamiento ha demostrado ser comparable al estándar quirúrgico. Objetivo: Describir la experiencia y resultados de un cirujano en pacientes con CGI sometidos a DSE. Materiales y Método: Estudio retrospectivo que incluyó a los pacientes sometidos a DSE por CGI entre mayo de 2015 y marzo de 2019. Se tabuló información demográfica, datos perioperatorios y del seguimiento obtenidos del registro institucional. Se utilizó estadística descriptiva. Resultados: Se realizaron 52 DSE por CGI en el período analizado. La resección en bloque se logró en un 96% de los casos. La morbilidad alcanzó el 2%, no se registró mortalidad postoperatoria. 98% de las resecciones en bloque fueron consideradas R0 y un 86% de ellas cumplieron estándares de curación. La mediana de seguimiento es de 19 meses y la sobrevida específica por cáncer gástrico y libre de recurrencia alcanza el 100%. Discusión: La DSE es una técnica con potencial curativo en pacientes con CGI, presentando mejores resultados en términos de morbimortalidad, calidad de vida y es comparable a la cirugía en el pronóstico oncológico. Los resultados presentados son concordantes con la literatura y apoyan la implementación de la técnica para el tratamiento del CGI.

Introduction: Gastric cancer is a serious health problem in Chile and its poor prognosis is explained by usual diagnosis in advanced stages. Early gastric cancer (EGC) is associated with good oncological prognosis and endoscopic submucosal dissection (ESD) as its treatment has shown to be comparable to the surgical standard. Aim: Describe the experience and results of a surgeon in patients with EGC undergoing ESD. Materials and Method: Retrospective study including patients undergoing ESD for EGC between May 2015 and March 2019. Demographic information, perioperative and follow-up data obtained from the institutional registry were tabulated. Descriptive statistics was used. Results: 52 ESD were performed per EGC in the analyzed period. En bloc resection was achieved in 96% of cases. Morbidity reached 2% and no postoperative mortality was recorded. 98% of the en bloc resections were considered R0 and 86% of them met healing standards. The median follow-up is 19 months and the specific survival due to gastric cancer and recurrence-free rates reach 100%. Discussion: ESD is a technique with curative potential in patients with EGC, presenting better results in terms of morbidity and mortality, quality of life and is comparable to surgery in the oncological prognosis. The results presented are consistent with the literature and support the implementation of the technique for the treatment of EGC.

Frequency and clinical characteristics of early gastric cancer in comparison to advanced gastric cancer in a health area of Spain. / Frecuencia y aspectos clínicos del cáncer gástrico precoz en relación con el avanzado en un área sanitaria de España.

INTRODUCTION: Gastric cancer (GC) incidence is currently decreasing; however, survival is still low. Early GC (EGC) has better prognosis and it could be cured by endoscopic methods. PATIENTS AND METHODS: Observational study of a retrospective cohort of all patients with GC during a five-year period in a health area of Spain. EGC diagnosis was defined as mucosal or submucosal (T1) cancers regardless of lymph node involvement, whereas the advanced GC were T2-T4. RESULTS: 209 patients were included, and 26 (12%) of them were EGC. There was no difference between EGC and advanced GC in age, sex, HP infection, precancerous lesions or histological type. Other characteristics of EGC were different from advanced GC: location (antrum and incisura in 76% vs 38%, p=0.01), alarm symptoms (69% vs 90%, p<0.01), curative treatment (100% vs 30%, p<0.01), performance status (PS 0-1: 92% vs 75%, p=0.03) and survival (85% vs 20%, p<0.001). Among patients who received curative treatment, 98% (79/81) underwent surgery and 2% (2/81) were treated by mucosectomy. Seven (27%) patients with EGC could have benefited from treatment by endoscopic submucosal resection. DISCUSSION: EGC frequency was low (12% of GCs) in our health area. EGC had a high percentage of alarm symptoms, and was located in the distal third of the stomach (antrum and incisura) and had better prognosis compared to advanced GC. Strategies to increase detection and endoscopic treatment of EGC should be implemented.

The role of endoprostheses in the treatment of leaks after laparoscopic sleeve gastrectomy. Analysis of a Spanish registry. / Papel de las endoprótesis en el tratamiento de las fistulas posgastrectomía vertical laparoscópica. Análisis de un registro nacional.

It has been suggested that endoprostheses are an effective treatment for fistulae after sleeve gastrectomy, but the results published are very variable. To analyze the effectiveness of stents as treatment of leakage after sleeve gastrectomy, the Spanish Society of Obesity Surgery (SECO) and the Obesity Division of the Spanish Association of Surgeons (AEC) set up a National Registry to record treatments of leaks after sleeve gastrectomy. We have analyzed patients with leaks after sleeve gastrectomy and treated with endoprostheses: 19 medical centers reported the use of endoprostheses, where 51 endoprostheses were used in 42 patients (34 women/8 men, mean age: 43.8 years, BMI: 47.6). Global effectiveness was 45%, with a complication rate of 35%. Uni- and multivariate analyses detected no factors influencing the efficacy of treatment. A larger diameter bouggie used to calibrate the stomach was related to a higher incidence of complications. No factors were found related with better stent efficacy. The effectiveness of a second stent was very low when the previous one had not been effective.

Stomach-partitioning gastrojejunostomy versus stent placement for the treatment of malignant gastric outlet obstruction. / Anastomosis gastroyeyunal con separación gástrica parcial frente al tratamiento endoscópico para el tratamiento del síndrome de obstrucción antroduodenal de causa maligna.

INTRODUCTION: Gastric outlet obstruction is a complication of advanced tumors. It causes upper gastrointestinal obstruction, with progressive malnutrition and reduced survival. Currently, gastrojejunostomy or stent placement (SP) are feasible alternatives for the treatment of malignant gastric outlet obstruction. The aim of this study is to compare the efficacy and survival of both techniques. METHODS: Single-center observational and prospective study of 58 patients with gastric outlet obstruction who underwent surgical treatment with stomach-partitioning gastrojejunostomy (SPGJ) or SP with self-expanding intraluminal prostheses between 2007 and 2018. RESULTS: Thirty patients underwent SPGJ and 28 SP. The mean age of the first group was significantly lower (69 vs. 78 years, respectively; P=.001). There were no statistically significant differences in terms of sex, perioperative risk or tumor etiology. Postoperative complications were non-significantly higher in the SPGJ group (P=.156). SP was associated with a shorter hospital stay (P=.02) and faster oral intake (P<.0001). However, SP had significantly higher rates of persistent and recurrent obstruction (P=.048 and .01, respectively), poorer energy targets (P=.009) and shorter survival (9.61 vs. 4.47 months; P=.008). CONCLUSIONS: SPGJ presents greater luminal permeability, better oral intake and greater survival than SP. SP is preferable for non-surgical patients with a limited short-term prognosis.

Technical challenges of endoscopic treatment for vesicoureteral reflux after Cohen reimplantation. / Consideraciones técnicas en el tratamiento endoscópico del reflujo vesicoureteral tras reimplante tipo Cohen.

INTRODUCTION: The range of indications for endoscopic treatment of vesicoureteral reflux opens more and more until including correction of secondary reflux (VUR) after ureteral reimplantation. However these cases suppose a technical challenge due to postoperative changes. The aim of this work is to present our experience on endoscopic treatment for VUR in ureteral units with Cohen reimplantation surgery, with special interest in the technical peculiarities of the procedure. MATERIAL AND METHODS: A retrospective study of cases of secondary VUR after reimplantation surgery treated by subureteral injection. TECHNIQUE: We put the needle perpendicular to submucous tunnel and inject medially to hole forming a wheal on the anterior face that occludes the meatus RESULTS: During the 1993-2016 period 21 injections were performed in 15 ureteral units. The ureteral pathology included primary VUR (4), duplex system with lower pole reflux (4), megaureter (3) and ureterocele (2). Average patient age was 5.7 years old (2-12). Succesful outcome had been got in 10 ureteral units (66.67%), a decrease of VUR grade in 4 (26.67%) and perseverance/no resolution of grade IV VUR in 1 (6.67%) DISCUSSION: The anti-reflux mechanism of reimplantation depends on optimizing the submucosous tunnel. This subgroup of pacients is small and there are few studies, hindering the agreement on the most appropiate technique. CONCLUSION: Endoscopic treatment of secondary reflux after reimplantation surgery is a procedure with certain technical feature, but safe and effective offering an alternative prior to surgical reoperation.

[Clinical usefulness of the non-invasive functional study of the lower urinary tract voiding phase as a predictor of resolution after the first endoscopic treatment of vesico-ureteral reflux in children older than 3 years.] / Utilidad del estudio funcional no invasivo de la fase de vaciado del tracto urinario inferior como factor predictor de la resolución tras el primer tratamiento endoscópico del reflujo vesico-ureteral en niños mayores de 3 años.

OBJECTIVES: To determine the usefulnessof voiding diary (VD), uroflowmetry with electromyography(UF-EMG), bladder wall thickness (before micturition)(VWTUS) and residual urine (PVR) (ultrasound measure)in predicting the outcome of the first endoscopic treatment(1ENDT) of vesicoureteral reflux (VUR) in children> 3 years. METHODS: Cross-sectional ambispective study of 48children with vesicoureteral reflux. Those with previousendoscopic treatment, age or neurological abnormalities and a history of urethralor abdominal surgery were excluded. The outcomevariable was the correctness (by isotopic cystography)three months after 1ENDT. Univariate and multivariateanalyses were performed through a Multilayer Perceptronnetwork and a logistic regression model EmpiricalBayesian penalized type LASSO Elastic net. Diagnosticaccuracy were determined. RESULTS: Mean age of the sample was 6.8 +/- 2.28years. The rate of VUR correction after 1ENDT was 77%.The variables selected by both methods were: VD-retentionist(OR 3.90), high PVR (OR 2.69), high VWTUS (OR4.44). Normal UF-EMG was a preventive variable (OR0.38). Diagnostic accuracy (pSp=48.7%), UF+EMG (Se=27.3%(Se=72.7% (AUC=0.8 cut point 20 ml),VWTUS (Se=81.8% (AUC=0.8 cut point4.6 mm). There were no statistical differences betweenPVR and VWTUS. Combined use of UF+EMG+PVR(Se=90.9%in predicting the persistence of VUR after 1ENDT inchildren > 3 years. After screening with a VD, UF-EMG+ RPM combination could be useful to detect these patientsand propose a treatment that improves bladdervoiding function prior to surgery.

OBJETIVOS: Determinar la utilidad deldiario miccional (DIM), la flujometría asociada a laelectromiografía (UF-EMG) y los parámetros ecográficoscomo son el espesor de la pared vesical premiciconal(EPVECO) y el residuo postmiccional (RPM) en la prediccióndel resultado del primer tratamiento endoscópico(1TEND) del Reflujo Vesico-Ureteral (RVU) en niños > 3años.MATERIAL Y MÉTODOS: Estudio transversal ambispectivode 48 niños con RVU. Criterios de exclusión: 1TENDprevio, edad y cirugía uretral o abdominal previas. Variableresultado: corrección del RVU (cistografía isotópica realizadatres meses después del 1TEND). Se realizaronanálisis univariante y multivariante mediante una red perceptrón multicapa y un modelo de regresión logísticapenalizada tipo Empirical Bayesian LASSO Elastic net.Se consideraron significativas las variables elegidas porambos métodos estadísticos. Se estudió el rendimientodiagnóstico de las pruebas individuales y combinadas. RESULTADOS: Media de edad: 6,8 +/- 2,28 años.Tasa de corrección del RVU traspredictoras de la persistencia del RVU tras 1TENDseleccionadas por ambos métodos: DIM-hábito retencionista(OR 3,90), RPM elevado (OR 2,69), EPVECOaumentado (OR 4,44). La UF-EMG sin alteracionesen el trazado se comportó como variable preventiva(OR 0,38). Rendimiento diagnóstico (p(Se=98% (Se=27,3%RPM (Se=72,7% (AUC=0,8 punto decorte óptimo 20 ml), EPVECO (Se=81,8%(AUC=0,8 punto de corte óptimo 4,6 mm).No existierondiferencias entre el uso del RPM y el EPVECO(p>0,05). Uso conjunto de UF-EMG+RPM (Se=90,9%Es=92%) (pCONCLUSIONES: El estudio funcional no invasivo dela fase de vaciado es útil en la predicción de la persistenciade RVU tras el 1TEND en niños >3 años. Trasel cribado con un diario miccional, la UF-EMG+RPMpodrían ser útiles para detectar a estos pacientes y plantearun tratamiento que mejore el vaciado vesical previoa la cirugía.

Tratamiento endoscópico de una hendidura laríngea posterior: reporte de un caso y revisión de la literatura / Endoscopic treatment of a laryngeal cleft: case report and literature review

RESUMEN Las hendiduras laríngeas posteriores son anomalías congénitas de la laringe de baja incidencia que comprometen la región interaritenoidea o la lámina cricoidea. En caso de extenderse hasta la tráquea son denominados clefts laringo-tráqueo-esofágicos. Su clínica es inespecífica y debe sospecharse en todo niño con trastorno de deglución y neumonía aspirativa a repetición. A continuación, presentamos un caso de un cleft laríngeo tipo 2 tratado endoscópicamente.

ABSTRACT The posterior laryngeal clefts are congenital anomalies of the larynx of low incidence that comprise the interaritenoid region or the cricoid lamina. In case of extending to the trachea they are called laryngo-tracheo-esophagic clefts. Its clinic is non-specific and should be suspected in any child with swallowing disorder and aspiration pneumonia. We present a case of an endoscopically treated laryngeal cleft type 2.

Manejo percutáneo y endoscópico combinado de las estenosis benignas de la vía biliar / Combined endoscopic and percutaneous management of benign biliary strictures

Antecedentes: las estenosis benignas de la vía biliar (EBVB) tradicionalmente han sido tratadas con derivaciones biliodigestivas. En la actualidad existe una clara tendencia para resolverlas en forma mínimamente invasiva (endoscópica o percutánea o de ambos modos). Objetivo: describir el manejo y los resultados del tratamiento percutáneo y/o endoscópico de las estenosis biliares benignas. Material y métodos: período del estudio: enero de 2009 a junio de 2015. Etología de las EBVB: 8 lesiones quirúrgicas de la vía biliar (LQVB), 5 trasplantes hepáticos (TH), 5 hidatidosis hepáticas (HH), 2 quistes de colédoco (QC). Se realizaron 4 procedimientos promedio por paciente (r. 1-11). Se colocaron 3 stentis (endoprótesis) promedio por paciente (r. 1-5). Seguimiento promedio: 21 meses con una mediana de 13 meses. Resultados: mortalidad relacionada con los procedimientos: 0%. Morbilidad relacionada con los procedimientos: 35% (bacteriemia, colangitis, hemorragia digestiva, síndrome febril, hemoperitoneo leve, sepsis). Diecinueve pacientes (95%) evolucionaron con control satisfactorio de la estenosis; un paciente (5%) presentó recidiva de la estenosis y debió ser tratado nuevamente. Conclusiones: el tratamiento mininvasivo puede lograr resultados satisfactorios en un alto porcentaje de pacientes con estenosis benignas de la vía biliar.

Background: although benign strictures of the bile duct (BSBD) have traditonally been treated by constructon of a surgical biliodigestive anastomosis at present, there is a clear tendency to resolve them in a minimally invasive way (endoscopic or percutaneous or both). Objective: to describe the management and Results of percutaneous and / or endoscopic treatment of BSBD. Materials and methods: study period: January 2009 to June 2015. Etology of BSBD, 8 surgical injury to the bile duct (BDI), 5 liver transplantis (LT), 5 liver hydatidosis (LH), 2 choledochal cystis (CC). As an average, 4 procedures per patent were done (range, 1-11); and 3 stentis were placed (range, 1-5). Average and median follow up were 21 months, and 13 months, respectively. Results: mortality related to the procedure was 0%. Morbidity was 35% (bacteremia, cholangitis, gas-trointestinal bleeding, febrile syndrome, mild hemoperitoneum, and sepsis). 19 patentis (95%) had satisfactory outicome; one patentis (5%) developed a re-stricture that required a new procedure. Conclusions: mininmally invasive treatment can achieve satisfactory Results in a high percentage of patentis with benign stricture of the bile duct.

Septotomía endoscópica del divertículo de Zenker / Endoscopy septotomy in zenker diverticulum

Introducción: La Diverticulotomía o Septotomía endoscópica en el divertículo de Zenker, es una alternativa a otros abordajes terapéuticos. El presente estudio muestra nuestra experiencia de esta técnica endoscópica. Pacientes y Métodos: Análisis retrospectivo, entre el 2009 y 2017 en pacientes con divertículo de Zenker. La septotomía se realizó utilizando videoendoscopio flexible, esfinterótomo aguja, electrobisturi para DSE tipo Hibridknife, mediante una técnica ya estandarizada. Resultados: Se trataron 25 pacientes con edad promedio de 71 años (rango etario de 45 a 84 años). En una paciente su mejoría fue muy poca, por lo que se sometió a intervención quirúrgica, donde tampoco hubo resultados consistentes. Veintiún pacientes mostraron un alivio completo de la disfagia. Tres pacientes que tuvieron recurrencia sintomática fueron tratados con el mismo método endoscópico entre 2 y 4 sesiones evolucionando de forma satisfactoria. Conclusiones: La septotomía endoscópica del divertículo de Zenker es un método eficaz y seguro, por lo tanto representa una alternativa real a la cirugía.

Introduction: Diverticulotomy or Endoscopic septotomy in Zenker's diverticulum is an alternative to others therapeutics approaches. The present study shows our experience of this endoscopic technique. Patients and methods: Retrospective analysis between 2009 and 2017 in patients with Zenker's diverticulum. The procedure was performed using a flexible video endoscope and a needle knife, Erbe hybrid knife probe, using an already standardized technique. Results: Twenty-five patients with an average age of 71 years (age range 45-84 years) were treated. In one patient his improvement was very little, therefore surgical procedure was performed, nevertheless this procedure had not consistent results. Twenty-one patients showed complete relief of dysphagia. Three patients who had symptomatically relapsed were retreated with the same endoscopic method between 2 and 4 sessions with good results. Conclusions: Zenker's endoscopic septotomy of the diverticulum is an effective and safe method; thereby it represents a real alternative to surgical treatment.

Endoscopic electrocauterization for congenital pyriform sinus fistula treatment in paediatrics. Case series. / Electrocauterización endoscópica para el tratamiento de las fístulas congénitas del seno piriforme en pediatría. Serie de casos.

Pyriform sinus fistulas are rare anomalies of the branchial arches. Most of them are located on the left side. They extend from the apex of the pyriform sinus of the hypopharynx to the thyroid gland or adjacent tissues. The diagnosis is suspected in the presence of acute suppurative thyroiditis or recurrent cervical abscesses, and is confirmed by endoscopic visualization of the fistula hole. The traditional treatment consists of excision of the fistulous tract, with or without thyroid lobectomy, by cervical approach. However, less invasive alternatives that obliterate the path of the fistula have been developed, such as endoscopic electrocautery. We describe our experience with 7 patients with this condition, who were treated with endoscopic cauterization using radiofrequency electrocautery, and we evaluate the effectiveness and safety of the treatment performed.

Inyección endoscópica para la corrección del reflujo vesicoureteral / Endoscopic Injection for the Correction of Vesicoureteral Reflux

Resumen:Introducción:la inyección endoscópica subureteral es el método menos invasivo con resultados favorables para el tratamiento del reflujo vesicoureteral.Objetivo:investigar los resultados de la inyección endoscópica y comparar la eficacia de dos agentes de carga diferentes tanto como el Macroplastique y Vantris.Métodos:los datos de los pacientes que se sometieron a inyección endoscópica para el tratamiento del reflujo vesicoureteral en el Hospital Nacional de Niños entre diciembre 2011 y Febrero 2015 fueron retrospectivamente revisados. Se excluyeron pacientes con disfunción miccional persistente, que no tuvieran cistouretrografía miccional posterior al tratamiento endoscópico y expedientes incompletos. La técnica quirúrgica utilizada fue la de STING clásica. El control postoperatorio fue a los 3 meses y se realizó ecografía de vías urinarias; la profilaxis antibiótica se continuó hasta la cistouretrografía miccional control. El éxito del tratamiento se define como la desaparición de reflujo en el cistouretrografía miccional de control.Resultados:en total se revisaron 38 casos, de los cuales 33 cumplían con los criterios de inclusión, el 66,6% correspondía a niñas y el 33,3% a niños; se documentó un 42,4% con reflujo vesicoureteral bilateral (14 casos), luego sigue el lado izquierdo con un 36,36% (12 casos) y el lado derecho con un 21,21% (7 casos). En total se evaluaron 47 unidades ureterales. El Vantris se utilizó en el 63,6% de los casos y el Macroplastique en el 27,4%. La mayoría de los pacientes presentó resolución de su reflujo vesicoureteral posterior al tratamiento (29 casos: 88%); una menor cantidad, persistencia del reflujo (4 casos: 12%), y de estos, 4 pacientes persistieron con reflujo vesicoureteral de menor grado que al momento del diagnóstico. Todos se volvieron a someter a inyección endoscópica antirreflujo, de ellos 3 se curaron y uno persistió con reflujo vesicoureteral, pero de bajo grado y asintomático, por lo que se está manejando de manera conservadora.Conclusiones:la corrección del reflujo vesicoureteral por inyección endoscópica con Macroplastique y Vantris es segura, efectiva y mínimamente invasiva.

Abstract:Introduction:Endoscopic suburetal injection, is the less invasive method with promising results for the treatment vesicoureteral reflux.Objective:To investigate the results of endoscopic injection and compare the efficacy of two agents of different load such as Macroplastique and Vantris.Methods:Data of patients that underwent endoscopic injection for vesicoureteral reflux treatment at Hospital Nacional de Niños between December 2011 and February 2015 were revised retrospectively. Patients with persistent voiding dysfunction, that had no micturatingcystourethrogram after the endoscopic treatment and incomplete records were excluded. The surgical technique used was STING Classic. The postopertative control was after 3 months and an urinary tract ultrasonography was done, a continuous antibiotic prophylaxis was performed until the control voiding cystourethrogram. Treatment success is defined as the disappearance of reflux in the control voiding cystourethrogram control.Results:A total of 38 cases were reviewed, of which 33 met the inclusion criteria, 66.6% were girls and 33.3% were boys, 42.4% were documented with bilateral vesicoureteral reflux (14 Cases), following 36.36% (12 cases) on the left side and on the right side 21.21% (7 cases). In total 47 ureteral units were evaluated. The Vantris was used in 63.6% of cases and Macroplastique in 27.4%. The majority of patients showed resolution of their subsequent vesicoureteral reflux after the treatment (29 cases: 88%), a smaller amount with persistent reflux (4 cases: 12%) of these, 4 patients persisted with vesicoureteral reflux in a lesser degree than at the moment of the diagnosis, all were submited the endoscopic antireflux injection again, of which 3 were cured and one persisted with vesicoureteral reflux, but of low grade and asymptomatic, being managed conservatively.Conclusions:Correction of vesicoureteral reflux by endoscopic injection with Macroplastique and Vantris is safe, effective and minimally invasive.

Fístula biliar postraumática manejada endoscópicamente con colocación de prótesis tipo Cotton Informe de un caso / Posttraumatic biliary fistula treated by endoscopy with a Cotton-Type Prosthesis. A case report

Resumen Antecedentes: La fístula biliar postraumática es el paso anormal del contenido líquido del tracto biliar hacia un órgano, cavidad o cuando se tiene un drenaje artificial hacia la superficie externa del abdomen. Es una secuela postraumática relativamente rara, ocurre en entre 0.5 y 2.6% de los casos de trauma hepático. El manejo endoscópico disminuye considerablemente la estancia hospitalaria y la morbimortalidad de estos pacientes. El objetivo es presentar un caso con fístula biliar postraumática manejado exitosamente con colocación endoscópica de prótesis Cotton 10 FR. Caso clínico: Varón de 28 años que sufrió contusión abdominal contra el volante. Es manejado conservadoramente durante una semana con mejoría leve. Fue sometido a laparotomía exploradora por abdomen agudo con 3000 mL de líquido biliar, se colocó drenaje. Presentó fuga biliar mayor de 500 mL/24 h; se realizó colangiopancreatografía retrógrada endoscópica y se encontró una fístula biliar tipo II; se le colocó prótesis tipo Cotton 10 FR, y 24 horas después el gasto disminuyó a menos de 50 mL/24 h. A los ocho días se retiró el drenaje y tres meses después la prótesis, el paciente no tuvo complicaciones mediatas ni tardías. Conclusión: El tratamiento con colocación de prótesis endoscópica es seguro y eficaz para el manejo de la fístula biliar postraumática.

Abstract Background: Post traumatic biliary fistula is the abnormal passage of liquid from the biliary tract to another organ, cavity or when an artificial drainage to the external surface of the abdomen exists. It is a relatively rare post traumatic sequel, that occurs between 0.5 and 2.6% of the hepatic traumatic cases. Previously, the treatment required a long hospital stay, nowadays the endoscopic management decreased considerably the hospital stay, as well as the morbidity and mortality in these patients. The objective is to describe a case with postraumatic biliary fistula managed with a Cotton 10 FR prosthesis placed endoscopically. Clinical case: 28-year-old male, suffering from abdominal contusion against the steering wheel causing liver lacerations and biliary fistula, which was treated conservatively for a week. . He underwent an exploratory laparotomy for acute abdomen with 3000 mL of bile fluid, afterwars a drain was placed. A biliary leak continued through the drain (greater than 500mL/24 h), an endoscopic retrograde cholangiopancreatography was performed and a biliary type II fistula was found. A Cotton 10 FR prosthesis was placed and 24 hours later the spending decreased to less than 50mL in 24 h. The drainage was removed on the eighth day and three months later the prosthesis was also removed, no mediate or late complications were presented. Conclusion: The conservative treatment does not offer good results; therefore the endoscopic stent placement is a safe and effective therapeutic alternative.

[Gastrointestinal bleeding]. / Hemorragia gastrointestinal.

In the Digestive Disease Week in 2015 there have been some new contributions in the field of gastrointestinal bleeding that deserve to be highlighted. Treatment of celecoxib with a proton pump inhibitor is safer than treatment with nonselective NSAID and a proton pump inhibitor in high risk gastrointestinal and cardiovascular patients who mostly also take acetylsalicylic acid. Several studies confirm the need to restart the antiplatelet or anticoagulant therapy at an early stage after a gastrointestinal hemorrhage. The need for urgent endoscopy before 6-12 h after the onset of upper gastrointestinal bleeding episode may be beneficial in patients with hemodynamic instability and high risk for comorbidity. It is confirmed that in Western but not in Japanese populations, gastrointestinal bleeding episodes admitted to hospital during weekend days are associated with a worse prognosis associated with delays in the clinical management of the events. The strategy of a restrictive policy on blood transfusions during an upper GI bleeding event has been challenged. Several studies have shown the benefit of identifying the bleeding vessel in non varicose underlying gastric lesions by Doppler ultrasound which allows direct endoscopic therapy in the patient with upper GI bleeding. Finally, it has been reported that lower gastrointestinal bleeding diverticula band ligation or hemoclipping are both safe and have the same long-term outcomes.

Disección endoscópica de submucosa en el tratamiento del cáncer precoz de esófago / Endoscopic submucosal dissection in the treatment of early esophageal cancer

Las nuevas tecnologías de imagen con endoscopios de alta resolución y el uso de la cromoscopia asociado al entrenamiento de los endoscopistas han permitido detectar lesiones neoplásicas de esófago en estadios iniciales. Estos avances resultaron en la expansión de las indicaciones del tratamiento endoscópico curativo en pacientes con carcinoma de células escamosas de esófago. En los últimos años se han desarrollado técnicas para la resección endoluminal en bloque de los tumores gastrointestinales precoces, procedimiento denominado disección endoscópica de la submucosa (DES). Inicialmente la DES fue utilizada para tratamiento de tumores gástricos, y posteriormente esta técnica pasó a ser aplicada para tumores de esófago y colorectales. El presente artículo de revisión presenta una descripción de la DES en el manejo de las neoplasias superficiales de esófago, a fin de contribuir para la difusión de este concepto y la incorporación de este procedimiento en Latinoamérica.

The development of high-resolution endoscopes with chromoendoscopy and the education of endoscopists have enabled the detection of early stage esophageal squamous-cell carcinoma (ESCC). Moreover, in recent years there has been an important progress in the management of early gastrointestinal neoplastic lesions after the development in Japan of endoluminal techniques for en-block tumor resection, namely endoscopic submucosal dissection (ESD). The combination of these factors facilitated the expansion of indications for endoscopic minimally invasive curative interventions in selected patients with superficial ESCC. This review article presents a comprehensive overview and detailed description of the ESD procedure for treatment of ESCC in order to facilitate the dissemination of this concept and the incorporation of this new technique in Latin-America.

Diagnóstico y tratamiento endoscópico del cáncer gástrico temprano / Diagnosis and endoscopic treatment of early gastric cancer

El cáncer gástrico es la causa más frecuente de cáncer en países de Asia Oriental, Europa Oriental y algunas regiones de Latino América. El pronóstico del cáncer gástrico avanzado es pobre, sin embargo, el pronóstico del cáncer gástrico temprano (CGT) es muy favorable con datos de sobrevida libre de enfermedad a cinco años, que alcanzan el 100%. El diagnóstico temprano se logra realizando una endoscopia de tamizaje completa, detallada y de alta calidad. Recientemente, se ha propuesto la endoscopia sistemática alfanumérica codificada (SACE), la cual ha probado su eficacia en Colombia al diagnosticar CGT a una tasa de 0,3% en individuos sanos de riesgo medio. Una vez diagnosticado el CGT, la endoscopia terapéutica desempeña un papel fundamental en el tratamiento curativo de la enfermedad. Entre las diferentes técnicas de resección, la disección endoscópica de la submucosa (ESD) ha demostrado excelentes tasas de curabilidad y resultados de sobrevida a cinco años similares a la gastrectomía, pero con menos morbilidad, constituyéndose actualmente en el tratamiento de elección en estos casos. Fundamentos espaciales y visuales, además de entrenamiento bajo la dirección de expertos calificados en centros de formación acreditados, son necesarios para adquirir competencia en ESD. Estas bases educacionales, tanto para el diagnóstico, como para el tratamiento del CGT, son fundamentales para aumentar la frecuencia y la tasa de curabilidad del cáncer gástrico en Latino América y el mundo.

Gastric cancer ranks as the most common malignant tumor in East Asia, Eastern Europe, and parts of Latin America. Although advanced gastric cancer carries a poor prognosis, survival rates of early gastric cancer, however, are favourable with a 5-year disease-free survival reaching almost 100%. High quality screening esophagogastroduodenoscopy is a key stone for early diagnosis. Recently, systematic alphanumeric coded endoscopy (SACE) has been proposed as a new method to improve detection of early gastric cancer. SACE has proved its efficacy in Colombia, diagnosing early gastric cancer at a rate of 0.3% in healthy average risk individuals. After the diagnosis, therapeutic endoscopy is essential to achieve minimally invasive curative treatment. Among other methods, the endoscopic submucosal dissection technique has demonstrated excellent curability and disease-free survival rates, with less morbidity when compared to gastrectomy, currently constituting the preferred treatment for early gastric cancer. Spatial and visual fundaments, along with special training under the supervision of qualified experts and in recognised institutions, are necessary to obtain proficiency in ESD. This educational basis constitutes the fundaments to increase early diagnosis and curative treatment for gastric cancer in Latin America and the world.

[Esophageal diseases: GERD, Barrett, achalasia and eosinophilic esophagitis]. / Enfermedades esofágicas: enfermedad por reflujo gastroesofágico, Barrett, acalasia y esofagitis eosinofílica.

At Digestive Disease Week (DDW) 2014, developments in esophageal disease were presented. Highlights include: the usefulness of impedancemetry to diagnose reflux disease, or the effectiveness of PPIs for treating non-cardiac chest pain. Concerning Barrett's esophagus, its prevalence is identical in patients with and without reflux symptoms, Barrett segments less than 1cm probably do not require follow-up, and in older patients with long-segment Barrett, initial endoscopies overlooked up to 2% of significant lesions. Regarding achalasia, surgical myotomy is no more effective than endoscopic dilation and may even be less effective than peroral endoscopic myotomy (POEM). In terms of eosinophilic esophagitis, it is important to systematically take biopsies in patients with dysphagia so that cases of eosinophilic esophagitis are not overlooked. In addition, for this condition, routine endoscopic dilations not only do not seem useful in improving the course of the disease, but could also worsen the response to medical treatment.