The Relationship of Anatomical Localizations of Hiatal Clamp and Oesophagogastric Junction with Body Mass Index / Relación entre las Localizaciones Anatómicas de la Pinza Hiatal y la Unión Esofagogástrica con el Índice de Masa Corporal

SUMMARY: In our study, we aimed to reveal the relationship between the anatomical localizations measured and the Body Mass Index (BMI) in patients scheduled for upper gastrointestinal endoscopy. In this study, anatomical localizations of the hiatal clamp and oesophagogastric junction in 189 female and 137 male patients who applied to the hospital with different gastrointestinal system complaints and underwent esophagogastroduodenoscopy (EGD) were investigated depending on BMI. In addition, the data were compared with the patients' complaints before EGD and the diagnoses they received after EGD. SPSS Statistics 22 (IBM Corp. Turkey) program was used for statistical analysis and p0.05). On the other hand, it was determined that the hiatal clamp distance and the distance of the oesophagogastric junction increased as the height and weight increased (p38. As a result of the study, it can be said that BMI values, hiatal clamp distance and oesophagogastric junction localizations may change in relation to height and weight.

En este estudio, buscamos revelar la relación entre las localizaciones anatómicas y el Índice de Masa Corporal (IMC) en pacientes programados para endoscopía digestiva alta. Se investigaron las localizaciones anatómicas de la pinza hiatal y la unión esofagogástrica en 189 mujeres y 137 hombres que acudieron al hospital con diferentes problemas del sistema gastrointestinal los cuales fueron sometetidos a una esofagogastro- duodenoscopia (EGD) dependiendo del IMC. Además, los datos se compararon con las quejas de los pacientes antes de la EGD y los diagnósticos que recibieron después de la EGD. Se utilizó el programa SPSS Statistics 22 (IBM Corp. Turquía) para el análisis estadístico y el valor de p0,05). Por otro lado, se determinó que la distancia de la pinza hiatal y la unión esofagogástrica aumentaba con la altura y el peso corporal (p38. Como resultado del estudio, se puede decir que los valores de IMC, la distancia de pinzamiento hiatal y las localizaciones de la unión esofagogástrica pueden cambiar en relación con la altura y el peso.

Funduplicatura con disección extensa de la unión esofagogástrica: lecciones aprendidas y resultados tras 178 pacientes consecutivos / Fundoplication with extensive dissection of the esophagogastric junction: Lessons learned and outcomes from 178 consecutives patients

Introducción: La cirugía antirreflujo se asocia con frecuencia a tasas significativas de recurrencia y complicaciones, habiéndose propuesto varias técnicas quirúrgicas para minimizarlas. El objetivo del estudio es evaluar los resultados a tres años de una funduplicatura con disección extensa de la unión esofagogástrica (UEG). Métodos: Estudio observacional retrospectivo que incluyó a 178 pacientes con enfermedad por reflujo gastroesofágico (ERGE) o hernia de hiato (HH) a los que se les realizó una funduplicatura con disección extensa de la UEG entre 2015 y 2020. La recidiva herniaria, los síntomas y la calidad de vida al primer año y a los tres siguientes de la cirugía fueron evaluados mediante tránsito baritado, endoscopia y cuestionarios para síntomas y calidad de vida (Gastro Esophageal Reflux Disease-Health Related Quality of Life [GERD-HRQL]). Resultados: La tasa de pirosis fue de 7,5 y 10,7% al año y a los tres siguientes, respectivamente, regurgitación de 3,8 y 6,9% y disfagia de 3,7 y 7,6%. La presencia de hernia hiatal se evidenció preoperatoriamente en 55,1% y en 7,8 y 9,6% en el seguimiento y la mediana de la escala GERD-HRQL fue de 27, 2 y 0, respectivamente. No aparecieron casos de telescopaje de la funduplicatura ni síntomas que sugieran lesión vagal. No se encontraron diferencias al comparar los distintos tipos de funduplicatura en términos de recidiva del reflujo, complicaciones o recurrencia de la hernia. Conclusiones: La funduplicatura con disección extensa de la UEG contribuye a su correcto posicionamiento y mejor anclaje, lo que asocia bajas tasas de recidiva herniaria y del reflujo, así como disminuye la posibilidad de telescopaje y lesión vagal.(AU)

Introduction: Antireflux surgery is commonly associated with significant recurrence and complication rates, and several surgical techniques have been proposed to minimize them. The aim of this study is to evaluate the results of a fundoplication with extensive dissection of the esophagogastric junction 1 and 3 years after the procedure.Methods: Retrospective observational study including 178 patients with gastroesophageal reflux disease or hiatal hernia who underwent fundoplication with extensive dissection of the esophagogastric junction between 2015 and 2020. Hernia recurrence, symptoms and quality of life at 1 and 3 years after surgery were assessed by barium transit, endoscopy and questionnaires for symptoms and quality of life (GERD-HRQL). Results: Heartburn rate was 7.5% and 10.7% at 1 and 3 years respectively, regurgitation 3.8% and 6.9% and dysphagia was 3.7% and 7.6%. The presence of hiatal hernia was evident preoperatively in 55.1% and in 7.8% and 9.6% at follow-up and the median GERD-HRQL scale was 27, 2 and 0, respectively. There were no cases of slippage of the fundoplication or symptoms suggestive of vagal injury. No differences were found when comparing the different types of fundoplication in terms of reflux and recurrence or complications. Conclusions: Fundoplication with extensive dissection of the esophagogastric junction contributes to correct positioning and better anchorage of the fundoplication, which is associated with low rates of hiatal hernia and reflux recurrence, as well as absence of slippage and lower possibility of vagal injury.(AU)

Fundoplication with extensive dissection of the esophagogastric junction: Lessons learned and outcomes from 178 consecutives patients.

INTRODUCTION: Antireflux surgery is commonly associated with significant recurrence and complication rates, and several surgical techniques have been proposed to minimize them. The aim of this study is to evaluate the results of a fundoplication with extensive dissection of the esophagogastric junction 1 and 3 years after the procedure. METHODS: Retrospective observational study including 178 patients with gastroesophageal reflux disease or hiatal hernia who underwent fundoplication with extensive dissection of the esophagogastric junction between 2015 and 2020. Hernia recurrence, symptoms and quality of life at 1 and 3 years after surgery were assessed by barium transit, endoscopy and questionnaires for symptoms and quality of life (GERD-HRQL). RESULTS: Heartburn rate was 7.5% and 10.7% at 1 and 3 years respectively, regurgitation 3.8% and 6.9% and dysphagia was 3.7% and 7.6%. The presence of hiatal hernia was evident preoperatively in 55.1% and in 7.8% and 9.6% at follow-up and the median GERD-HRQL scale was 27, 2 and 0 respectively. There were no cases of slippage of the fundoplication or symptoms suggestive of vagal injury. No differences were found when comparing the different types of fundoplication in terms of reflux and recurrence or complications. CONCLUSIONS: Fundoplication with extensive dissection of the esophagogastric junction contributes to correct positioning and better anchorage of the fundoplication, which is associated with low rates of hiatal hernia and reflux recurrence, as well as absence of slippage and lower possibility of vagal injury.

Biomecánica esofágica valorada mediante planimetría por impedancia (EndoFLIP™) en sujetos sanos y en pacientes con esofagitis eosinofílica. Valores de normalidad / Esophageal biomechanics assessed by impedance planimetry (EndoFLIPTM) in healthy subjects and in patients with eosinophilic esophagitis. Normality values

Antecedentes: la esofagitis eosinofílica (EEo) activa se asocia a alteraciones en el calibre, la distensibilidad y la motilidad esofágica que podrían revertir con el tratamiento. Objetivos: estudiar el diámetro, la distensibilidad y la contractilidad esofágica en sujetos sanos comparándolos con pacientes con EEo antes y después del tratamiento. Métodos: estudio cuasiexperimental. Mediante EndoFLIP™, se analizaron el cuerpo esofágico y la unión esofagogástrica (UEG) de los tres grupos, y se diseñó un programa para obtener los valores de diámetro, distensibilidad y contractilidad esofágica. Resultados: incluimos diez voluntarios sanos (24-61 años, seis hombres) y nueve pacientes con EEo (21-52 años, siete hombres). El índice de distensibilidad de la UEG fue de 5,07 mm2/Hg en controles, 2,40 mm2/Hg en EEo antes del tratamiento y 2,46 mm2/Hg después; la meseta de distensibilidad fue de 20,02 mm, 15,43 mm y 17,41 mm, respectivamente; y el diámetro, de 21,90 mm, 17,73 mm y 18,30 mm, con diferencias significativas (p < 0,05) excepto entre los diámetros de controles y pacientes tratados (p = 0,079). Las contracciones anterógradas repetitivas aparecieron en el 90 % de los controles, en el 66,7 % de EEo a antes del tratamiento y en el 88,9 % después (p > 0,05). Conclusiones: el índice de distensibilidad de la UEG, la meseta de distensibilidad y el diámetro en controles son mayores que en pacientes, aunque seis semanas de tratamiento parece poco tiempo para ver cambios significativos en la biomecánica esofágica. Las contracciones anterógradas repetitivas son el patrón predominante en sanos y en EEo. Aportamos valores de normalidad de la biomecánica esofágica medida mediante planimetría por impedancia en nuestro entorno.(AU)

Background: active eosinophilic esophagitis is associated with esophageal caliber, distensibility and motility changes that may be reversed with treatment. Objectives: to study esophageal diameter, distensibility and contractility in healthy subjects compared to patients with eosinophilic esophagitis, both before and after treatment. Methods: a quasi-experimental study, EndoFLIP™, was used to analyze the esophageal body and esophago-gastric junction (EGJ) in all three groups, and a program was designed to obtain esophageal diameter, distensibility and contractility values. Results: ten healthy volunteers (24-61 years, six men) and nine patients with eosinophilic esophagitis (21-52 years, seven men) were included. The esophagogastric junction distensibility index was 5.07 mm2/Hg in the control subjects, 2.40 mm2/Hg in the subjects with eosinophilic esophagitis before treatment and 2.46 mm2/Hg after treatment. The distensibility plateau was 20.02 mm, 15.43 mm and 17.41 mm, respectively, and the diameter was 21.90 mm, 17.73 mm and 18.30 mm, showing significant differences (p < 0.05), except between control subjects and patients after treatment (p = 0.079). Repetitive antegrade contractions developed in 90 % of control subjects, 66.7 % of eosinophilic esophagitis patients before treatment and 88.9 % of the latter after treatment (p > 0.05). Conclusions: esophago-gastric junction distensibility index, distensibility plateau and diameter values were higher in controls than in patients, although six weeks of treatment seems a short period to observe significant changes in esophageal biomechanics. Repetitive antegrade contractions are the predominant pattern in healthy subjects and eosinophilic esophagitis. We provide normality values for esophageal biomechanics, measured by impedance planimetry in our setting.(AU)

Esophagogastric Junction Contractile Integral (EGJ-CI) in Various Phenotypes of Gastroesophageal Reflux Disease (GERD)

Introduction: Two parameters of high-resolution esophageal manometry are used to observe the function of the esophagogastric junction (EGJ): the anatomical morphology of the EGJ and contractile vigor, which is evaluated with the esophagogastric junction contractile integral (EGJ-CI). To date, how these parameters behave in different gastroesophageal reflux disease (GERD) phenotypes has not been evaluated. Materials and methods: An analytical observational study evaluated patients with GERD confirmed by pH-impedance testing and endoscopy undergoing high-resolution esophageal manometry. The anatomical morphology of the EGJ and EGJ-CI was assessed and compared between reflux phenotypes: acid, non-acid, erosive, and non-erosive. Results: 72 patients were included (63% women, mean age: 54.9 years), 81.9% with acid reflux and 25% with erosive esophagitis. In the latter, a decrease in EGJ-CI (median: 15.1 vs. 23, p = 0.04) and a more significant proportion of patients with type IIIa and IIIb EGJ (83.3% vs 37.1%, p < 0.01) were found. No significant differences existed in the manometric parameters of patients with and without acid and non-acid reflux. Conclusion: In our population, EGJ-CI significantly decreased in patients with erosive GERD, suggesting that it could be used to predict this condition in patients with GERD. This finding is also related to a higher proportion of type III EGJ and lower pressure at end-inspiration of the lower esophageal sphincter in this reflux type.

Introducción: Para observar la función de la unión esofagogástrica (UEG) se utilizan dos parámetros de la manometría esofágica de alta resolución: la morfología anatómica de la UEG y el vigor contráctil, el cual se evalúa con la integral de contractilidad distal de la unión esofagogástrica (IC-UEG). Hasta el momento, no se ha evaluado cómo se comportan estos parámetros en los diferentes fenotipos de enfermedad por reflujo gastroesofágico (ERGE). Metodología: Estudio observacional analítico en el que se evaluaron pacientes con ERGE confirmado por pH-impedanciometría y endoscopia, llevados a manometría esofágica de alta resolución. Se evaluó la morfología anatómica de la UEG y la IC-UEG, y se comparó entre los diferentes fenotipos de reflujo: ácido, no ácido, erosivo y no erosivo. Resultados: Se incluyó a 72 pacientes (63% mujeres, edad media: 54,9 años), 81,9% con reflujo ácido y 25% con esofagitis erosiva. En este último grupo se encontró una disminución de la IC-UEG (mediana: 15,1 frente a 23, p = 0,04) y una mayor proporción de pacientes con UEG tipo IIIa y IIIb (83,3% frente a 37,1%, p < 0,01). No se encontraron diferencias significativas en los parámetros manométricos de los pacientes con y sin reflujo ácido y no ácido. Conclusión: En nuestra población, la IC-UEG estuvo significativamente disminuida en los pacientes con ERGE erosivo, lo que sugiere que podría ser utilizada como un predictor de esta condición en pacientes con ERGE. Este hallazgo también se relaciona con mayor proporción de UGE tipo III y menor presión al final de la inspiración del esfínter esofágico inferior en este tipo de reflujo.

Diagnóstico y tratamiento de los tumores de la unión esofagogástrica. Experiencia en el Instituto Nacional de Cancerología / Diagnosis and treatment of esophagogastric junction tumors. Experience at the National Cancer Institute

Introducción. El diagnóstico adecuado de los tumores de la unión esofagogástrica es esencial para el tratamiento de estos pacientes. La clasificación propuesta por Siewert-Stein define las características propias, factores de riesgo y estrategias quirúrgicas según la localización. El objetivo de este estudio fue describir las características de los pacientes con adenocarcinoma de la unión esofagogástrica tratados en nuestra institución. Métodos. Estudio retrospectivo, descriptivo, de corte longitudinal, que incluyó los pacientes con diagnóstico de adenocarcinoma de la unión esofagogástrica intervenidos quirúrgicamente en el Instituto Nacional de Cancerología, Bogotá, D.C., Colombia, entre enero de 2012 y mayo de 2017. Resultados. Se operaron 59 pacientes (84,7 % hombres), con una edad media de 62,5 años. En su orden de frecuencia los tumores fueron tipo II (57,6 %), tipo III (30,7 %) y tipo I (11,9 %). El 74,6 % recibieron neoadyuvancia y se realizó gastrectomía total en el 73 % de los pacientes. La concordancia diagnóstica moderada con índice Kappa fue de 0,56, difiriendo con la endoscópica en 33,9 %. El 10,2 % de los pacientes presentó algún tipo de complicación intraoperatoria. La supervivencia a tres años en los tumores tipo II fue del 89,6 % y del 100 % en aquellos con respuesta patológica completa. Conclusión. Es necesario el uso de diferentes estrategias para un proceso diagnóstico adecuado en los tumores de la unión esofagogástrica. En esta serie, los pacientes Siewert II, aquellos que recibieron neoadyuvancia y los que obtuvieron una respuesta patológica completa, tuvieron una mejor supervivencia a tres años

Introduction: Proper diagnosis of gastroesophageal junction tumors is essential for the treatment of these patients. The classification proposed by Siewert-Stein defines its own characteristics, risk factors and surgical strategies according to the location. This study describes the characteristics of patients with adenocarcinoma of the esophagogastric junction treated at our institution. Methods. Retrospective, descriptive, longitudinal study, which includes patients diagnosed with adenocarcinoma of the esophagogastric junction who underwent surgery at the National Cancer Institute in Bogotá, Colombia, between January 2012 and May 2017. Results. Fifty-nine patients (84.7% men) were operated on, with a mean age of 62.5 years. In their order of frequency, the tumors were type II (57.6%), type III (30.7%) and type I (11.9%). 74.6% received neoadjuvant therapy and total gastrectomy was performed in 73% of the cases. The moderate diagnostic concordance with the Kappa index was 0.56, differing from the endoscopic one in 33.9%. 10.2% of the patients presented some type of intraoperative complication. Three-year survival in type II tumors was 89.6% and 100% in those with complete pathologic response. Conclusion. The use of different strategies is necessary for an adequate diagnostic process in tumors of the esophagogastric junction. In this series, Siewert II patients, those who received neoadjuvant therapy, and those who obtained a complete pathological response had a better three-year survival

Obstrucción al flujo de salida de la unión esófago-gástrica: causa poco conocida de disfagia / Gastric-esophageal Junction Outflow Obstruction: Little-known Cause of Dysphagia

RESUMEN La obstrucción al flujo de salida de la unión esófago-gástrica es un trastorno motor esofágico poco conocido debido a su reciente identificación con el advenimiento de la manometría de alta resolución. Su desconocimiento hace que frecuentemente no sea advertido en el área clínica. Se presenta el caso de un paciente de sexo masculino, de 34 años de edad, que hacía aproximadamente 5 años comenzó a notar de manera esporádica sensación de atoro de los alimentos sólidos a nivel torácico, asociado en ocasiones a vómitos postpandriales tempranos. Esta manifestación se hizo más frecuente hacía un año y medio por lo que acudió al facultativo de su provincia sin conseguir diagnóstico ni mejoría clínica, motivo por el cual fue remitido al Instituto de Gastroenterología. Después de realizar las pruebas rutinarias en el estudio de una disfagia se obtuvo el resultado mediante manometría de alta resolución de una obstrucción al flujo de salida de la unión esófago gástrica. La presentación de este caso puede aportar a los especialistas de medicina interna, nuevos conocimientos para que tengan en cuenta esta entidad en pacientes con disfagia donde no se demuestre causa orgánica. Por lo que el objetivo de este reporte es describir el caso de un paciente con disfagia que presenta una obstrucción al flujo de salida de la unión esófago-gástrica.

ABSTRACT Gastric-esophageal junction outflow obstruction is a poorly understood esophageal motor disorder due to its recent identification with the beginning of high-resolution manometry. His ignorance means that it is frequently not noticed in the clinical area. The case of a 34-years-old male patient is presented, who approximately 5 years ago began to sporadically notice a sensation of clogging of solid foods at the thoracic level, sometimes associated with early postprandial vomiting. This manifestation became more frequent a year and a half ago, so he went to the doctor in his province without obtaining a diagnosis or clinical improvement, that is why he was referred to the Gastroenterology Institute. After performing the routine tests in the dysphagia study, the result was obtained by high resolution manometry of an obstruction to the outflow of the gastric esophagus junction. This case presentation can provide to internal medicine specialists with new knowledge so that they take this entity into account in patients with dysphagia where no organic cause is demonstrated. Therefore, the aim of this report is to describe the case of a patient with dysphagia who presents an obstruction to the outflow of the esophagus-gastric junction.

Resección laparoendoscópica de tumor de la unión gastroesofágica / Laparoendoscopic resection of a tumor of the gastroesophageal junction

RESUMEN La resección gástrica atípica ha demostrado ser beneficiosa para tumores submucosos. La técnica pre senta mayor riesgo cuando estos se desarrollan próximos a la unión esófago-gástrica (UEG). Para esta limitación se propuso la resección intragástrica mediante una técnica mixta combinando laparoscopia y endoscopia. En nuestro medio no existen publicaciones al respecto. Se trata de una mujer de 42 años, con lesión subepitelial-subcardial de 2 cm, evaluada mediante videoendoscopia alta (VEDA), compa tible con tumor del estroma gastrointestinal (GIST) evaluado mediante ecoendoscopia. La lesión fue resecada mediante abordaje combinado laparoendoscópico. Bajo visión laparoscópica se introdujeron en cavidad abdominal trocares con balón, y bajo visión endoscópica intragástrica se introdujeron estos en el estómago y se fijó la pared gástrica a la pared abdominal insuflando dichos balones. Posterior mente se realizó la resección de la lesión con sutura mecánica. El abordaje combinado es seguro y eficaz, simple en manos entrenadas, pero constituye una opción reproducible en casos seleccionados.

ABSTRACT Atypical gastric resection has proved to be beneficial to treat submucosal tumors. The technique is more difficult when these tumors develop next to the gastroesophageal junction (GEJ). Intragastric resection combining endoscopic and laparoscopic approach was proposed to solve this limitation. There are no publications about this technique in our environment. A 42-year-old female patients with a 2-mm subepithelial tumor below the cardia evaluated by upper gastrointestinal (UGI) videoendoscopy and endoscopic ultrasound suggestive of a gastrointestinal stroma tumor (GIST) underwent resection using the combined laparo-endoscopic approach. Under laparoscopic guidance, balloon-tipped trocars were introduced in the abdominal cavity and then into the stomach using endoscopic view. The balloons were inflated to fix the gastirc wall to the abdominal wall. The lesion was resected using mechanical stapler. The combined approach is safe and efficient, and simple to perform for trained professionals, constituting a reproducible option in selected cases.

Diagnostic tests for preoperative staging of esophagogastric junction tumors: performance and evidence-based recomendations. / Pruebas diagnósticas empleadas en la estadificación preoperatoria del cáncer de la unión esofagogástrica: rendimiento y recomendaciones basadas en la evidencia.

Preoperative clinical staging is critical to select those patients whose disease is localized and may benefit from surgery with curative intent. Ideally, such staging should predict tumor invasion, lymphatic involvement and distant metastases. With the cTNM, we are able to select patients who could benefit from endoscopic resection, radical surgery or less radical treatment in patients with distant metastasis. The initial diagnosis of adenocarcinomas of the esophagogastric junction requires endoscopy with biopsies. For clinical staging, thoracoabdominal-pelvic CT scan, endoscopic ultrasound and PET or PET/CT are used. Other useful explorations are: barium swallow, endoscopic mucosal resection or endoscopic submucosal dissection (for assessment in initial stages) and staging laparoscopy. Once the resectability of the tumor has been established, the operability of the tumor should be assessed according to the patient's condition.

Treatment in esophagogastric junction cancer: Past, present and future. / Tratamientos oncológicos en el cáncer de unión esofagogástrica: pasado, presente y futuro.

Adenocarcinomas of the gastroesophageal junction represent 27% of all gastric tumors. n recent years, it has been classified as an entity of its own, with specific treatments that are sometimes differentiated from gastric treatments. Treatment can be based on chemotherapy (CTx) or chemoradiotherapy (CRTx) that is administered preoperatively (neoadjuvant), postoperatively (adjuvant) or perioperatively. There are studies that have tested several treatment modalities, but there is currently no single protocolized sequence. The results point to an improvement in survival when we administer preoperative treatment, with evidence in favor of CRTx and CTx. Studies are already underway with targeted treatment that aim to increase the activity of traditional chemotherapy. In the next few years, we should know the role of immunotherapy in this group of patients.

Therapeutic options for early cancer of the esophagogastric junction. / Opciones terapéuticas en el tratamiento del cáncer precoz de la unión esofagogástrica.

Early-stage (T1) esophagogastric junction cancer continues to represent 2-3% of all cases. Adenocarcinoma is the most frequent and important type, the main risk factors for which are gastroesophageal reflux and Barrett's esophagus with dysplasia. Patients with mucosal (T1a) or submucosal (T1b) involvement initially require a thorough digestive endoscopy, and narrow-band imaging can improve visualization. Endoscopic treatment of these lesions includes endoscopic mucosal resection, radiofrequency ablation and endoscopic submucosal dissection. Accurate staging is necessary in order to provide optimal treatment. The most precise staging technique in these cases is endoscopic ultrasound. The suspicion of deep invasion of the submucosa, presence of unfavorable anatomopathological characteristics or impossibility to perform endoscopic resection make it necessary to consider surgical resection.

Minimally invasive and robotic surgery in the surgical treatment of esophagogastric junction cancer. / Cirugía mínimamente invasiva y robótica en el tratamiento quirúrgico de las neoplasias de la unión esofagogástrica.

Minimally invasive surgery provides for the treatment of esophagogastric junction tumors under safe conditions, reducing respiratory and abdominal wall complications. Recovery is improved, while maintaining the oncological principles of surgery to obtain an optimal long-term outcome. It is important to have a sufficient volume of activity to progress along the learning curve with close expert supervision in order to guarantee R0 resection and adequate lymphadenectomy. Minimal invasiveness ought not become an objective in itself. Should total gastrectomy be performed, the risk of a positive proximal margin makes intraoperative biopsy compulsory, without ruling out a primary open approach. Meanwhile, minimally invasive esophagectomy has been gaining ground. Its main difficulty, the intrathoracic anastomosis, can be safely carried out either with a mechanical side-to-side suture or a robot-assisted manual suture, thanks to the 3-D vision and versatility of the instruments.

Evidence in follow-up and prognosis of esophagogastric junction cancer. / Evidencia en seguimiento y pronóstico del cáncer de unión esofagogástrica.

Five-year survival of tumors of the esophagogastric junction is 50%, in the most favourable stages and with the most effective adjuvant treatments. More than 40% of patients will have recurrences within a short period, usually the first year after potentially curative surgery. Survival after this recurrence is usually less than 6 months because treatment is not very effective, be it palliative chemotherapy, radiotherapy or surgical excision of single recurrences. As the detection of asymptomatic recurrences allows for earlier and more effective treatments to be used, the type and frequency of follow-up has an influence on survival.

Standardizing the treatment of oesophagogastric junction tumours: Centralization, registries and surgical training. / Proyectos de estandarización del tratamiento del cáncer de la unión esofagogástrica: centralización, registros y formación.

Surgical treatment of oesophagogastric junction adenocarcinomas is based on total gastrectomies or oesophagectomies, which are complex procedures with potentially high morbidity and mortality. Population-based registers show a considerable variability of protocols and outcomes among different hospitals and regions. One of the main strategies to improve global results is centralization at high-volume hospitals, a process that should take into account the benchmarking of processes and outcomes at referral hospitals. Minimally invasive surgery can improve postoperative morbidity while maintaining oncological guaranties, but is technically more demanding than open surgery. This fact underlines the need for structured training and mentorship programs that minimize the impact of surgical teams' training curves without affecting morbidity, mortality or oncologic radicality.

The 8th edition of the AJCC-TNM classification: New contributions to the staging of esophagogastric junction cancer. / La 8.ª edición de la clasificación AJCC-TNM: nuevas aportaciones a la estadificación del cáncer de la unión esofagogástrica.

The new 8th edition of the TNM classification system for esophageal and cardia or esophagogastric junction cancer provides important innovations in the TNM stages. Two classifications are presented, updated by stages, clinical (cTNM) and pathological (pTNM) methods, together with another pathological classification applicable to cases receiving neoadjuvant treatment (ypTNM). There is a notable increase in complexity compared to previous versions, but it is still early to determine whether the current modifications will result in a clear improvement in the prognostic discrimination of survival among the patient groups (which is their main objective), although the initial expectations are favorable.

Disección submucosa endoscópica de cáncer gástrico temprano transpilórico: Reporte de caso y revisión de la literatura / Endoscopic submucosal dissection of a transpyloric early gastric cáncer: A case report and literature review

La disección submucosa endoscópica (DSE) es una técnica endoscópica avanzada que logra la resección curativa de neoplasias superficiales del tracto gastrointestinal, consiguiendo exéresis en bloque con márgenes libres de neoplasia evitando una cirugía. Sin embargo, los tumores localizados en la unión esófago gástrica, o pilórica son técnicamente más complejos para resecar por DSE. Cuando una neoplasia asienta en el píloro las características anatómicas de esta región pueden afectar la adecuada valoración de los márgenes y la realización del procedimiento. Presentamos el caso de un paciente varón de 70 años a quien en una endoscopia digestiva alta se le evidencia una lesión plana elevada multilobulada de 18 mm x 10 mm, situada mayoritariamente en los 2 cuadrantes inferiores del canal pilórico y compromiso mínimo del cuadrante supero-posterior, abarca principalmente la vertiente gástrica del canal pilórico y se extiende hacia el duodeno. Por todo ello se decide realizar resección en bloque de la lesión con la técnica de disección submucosa endoscópica. Se empleó el sistema ERBEJET con una cuchilla de tipo Hybrid knife, inyección salina con azul de metileno diluido al 0,04% sobre el margen distal, complementándose la inyección submucosa con ácido hialurónico al 0,4%. Se utilizó un "capuchón" o dispositivo plástico distal transparente recto para poder traccionar la lesión y permitir visualizar anterógradamente los márgenes de resección, incluso de la porción intraduodenal, permitiendo una adecuada disección submucosa. Luego de comprobar hemostasia se constató la resección en bloque. La histopatología mostró un adenocarcinoma tubular medianamente diferenciado con bordes quirúrgicos libres de lesión. Gracias a la estrategia de DSE utilizada, nuestro paciente pudo beneficiarse de la resección curativa de su cáncer gástrico con preservación del órgano y con perfecta funcionalidad. Este caso, el primero descrito en el país, muestra el avance de la endoscopía terapéutica nacional.

The endoscopic sumucosal disection (ESD) is an advanced endoscopic technique that achieves the curative resection of superficial neoplasms of the gastrointestinal tract, getting block exeresis with margins free of neoplasia avoiding surgery. However, tumors located in the esophagogastric junction, or pylorus, are technically more complex to resect by ESD. When a neoplasm settles in the pylorus, the anatomical characteristics of this region can affect the adequate assessment of the margins and the performance of the procedure. We present the case of a 70-year-old male patient who, in a high digestive endoscopy, showed a flat multilobulated lesion of 18 mm x 10 mm, located mostly in the lower 2 quadrants of the pyloric canal and minimal compromise of the upper-posterior quadrant, it mainly covers the gastric side of the pyloric channel and extends into the duodenum. Therefore, it was decided to perform en bloc resection of the lesion with the endoscopic submucosal dissection technique. The ERBEJET system was used with a knife type Hybrid knife, saline injection with methylene blue diluted 0.04% on the distal margin, submucosal injection being complemented with 0.4% hyaluronic acid. A "capsule" or straight transparent distal plastic device was used to be able to pull the lesion and allow anterograde visualization of the margins of resection, including the intraduodenal portion, allowing adequate submucosal dissection. Histopathology showed a moderately differentiated tubular adenocarcinoma with surgical edges free of injury. Thanks to the DSE strategy used, our patient could benefit from the curative resection of his gastric cancer with preservation of the organ and with perfect functionality. This case, the first described in the country, shows the progress of national therapeutic endoscopy.

Mortality in patients with esophageal and gastroesophageal tumors treated with self-expandable stents / Mortalidad en pacientes con tumores de esófago y en región gastroesofágica manejados con prótesis autoexpandibles

Abstract Introduction: Esophageal cancer is an aggressive disease and is the eighth cause of malignant tumors worldwide. To treat dysphagia, auto expandable prosthesis (AEP) are used in order to optimize the nutritional status and quality of life of the patients. Objectives: To quantify patients' mortality and to evaluate variables related with this outcome. Materials and methods: Retrospective cohort study that involved 135 patients with esophageal malignant obstruction that required AEP insertion. Survival and incidence density rates were estimated. The effect of these variables on the probability of death was assessed by using Cox models. Results: Overall mortality rate was 13.7 deaths per 100 patients/ month (95%CI: 10.9-17.1). Univariate analysis showed significant differences in survival functions according to pre-intervention albumin levels and the prosthesis size (>12cm). In the Cox model, albumin level (HR=0.53, 95%CI 0.31 to 0.89) was the only significant result. Conclusions: AEP represent a therapeutic option to improve symptoms in patients with advanced esophageal and gastroesophageal junction tumors. This technique has few complications and its clinical success is around 90%. Patients' nutritional status and length of the stenosis caused by the tumor are variables that must be evaluated before performing a procedure as they seem to be related to mortality.

Resumen Introducción. El cáncer de esófago es una entidad agresiva y la octava causa de tumores malignos en el mundo. Para manejar la disfagia se insertan prótesis esofágicas autoexpandibles (PEA) que optimizan la ingesta y permiten mejorar el estado nutricional y la calidad de vida de los pacientes. Objetivos. Cuantificar la mortalidad en los pacientes y evaluar las variables asociadas con este desenlace. Materiales y métodos. Estudio de cohorte retrospectivo realizado en 135 pacientes con obstrucción esofágica maligna que requirieron inserción de PEA. Se estimó la función de supervivencia, se calcularon tasas de incidencia y se evaluó el efecto de las variables descritas sobre la probabilidad de morir utilizando modelos de Cox. Resultados. La tasa de mortalidad fue de 13.7 muertes por 100 pacientes/mes (IC95%: 10.9-17.1). Los análisis univariados mostraron diferencias significativas en las funciones de supervivencia según niveles de albúmina previa y tamaño de la prótesis (>12cm). En el modelo de Cox solo resultó significativo el nivel de albúmina (HR=0.53, IC95%: 0.31-0.89). Conclusiones. Las PEA representan una alternativa de mejoría de síntomas en pacientes con tumores esofágicos en estadios avanzados. Esta técnica presenta pocas complicaciones y tiene probabilidades de éxito técnico y clínico cercanas al 90%. El estado nutricional del paciente y la longitud de la estenosis producida por el tumor son variables que deben evaluarse antes de cada procedimiento ya que parecen relacionarse con la mortalidad.

Esophageal cancer: anatomic particularities, staging, and imaging techniques. / Cáncer de esófago: particularidades anatómicas, estadificación y técnicas de imagen.

Cancer of the esophagus is a tumor with aggressive behavior that is usually diagnosed in advanced stages. The absence of serosa allows it to spread quickly to neighboring mediastinal structures, and an extensive lymphatic drainage network facilitates tumor spread even in early stages. The current TNM classification, harmonized with the classification for gastric cancer, provides new definitions for the anatomic classification, adds non-anatomic characteristics of the tumor, and includes tumors of the gastroesophageal junction. Combining endoscopic ultrasound, computed tomography, positron emission tomography, and magnetic resonance imaging provides greater accuracy in determining the initial clinical stage, and these imaging techniques play an essential role in the selection, planning, and evaluation of treatment. In this article, we review some particularities that explain the behavior of this tumor and we describe the current TNM staging system; furthermore, we discuss the different imaging tests available for its evaluation and include a diagnostic algorithm.

Intragastric laparoscopic surgery: An option for gastric lesions not resectable by endoscopy.

Gastric mucosal and submucosal lesions can be resected by endoscopy, laparoscopy or open surgery. Operative methods have varied depending on the location, endophytic growth and size of the lesion. Interest in minimally invasive surgery has increased and many surgeons are attempting laparoscopic approaches, especially in lesions of the stomach near the esophagogastric junction not amendable to endoscopic removal, because conventional surgery can produce stenosis and distort the postoperative anatomy, and increase morbimortality. We report our experience with laparoscopic intragastric surgery in 3 consecutive patients, with no complications. Laparoscopic intragastric surgery extends the surgeons' armamentarium to resect complex gastric lesions, while offering patients the benefits of minimal access surgery.

Carcinoma de la unión esofagogástrica: una mirada a un terreno difícil: [revisión] / Gastroesophageal junction carcinoma: an overview to a difficult terrain: [review]

Justificación. En el mundo occidental ha disminuido el carcinoma gástrico. El carcinoma de la unión gastroesofágica presenta una incidencia en aumento, y una aparente falta de estudio. Objetivo. Revisar los datos actualizados en relación al Carcinoma de la unión gastroesofágica, con el fi n de estimular un mayor estudio al respecto. Materiales y métodos. Se realizó una búsqueda, en la base de datos de MEDLINE, entre los años 1990 y 2006, con base en Cochrane Reviews Manual. Se utilizaron los términos Esophagogastric junction Carcinoma. De los artículos obtenidos inicialmente, fueron seleccionados los más relevantes por su actualidad. Conclusiones: la clasifi cación de Siewert es fundamental para el tratamiento del carcinoma de la unión gastroesofágica. La quimioterapia y radioterapia adyuvantes son una buena opción para disminuir la tasa de recaídas y mejorar pronóstico. Aún faltan estudios que indiquen el tamizaje y que profundicen en los parámetros adecuados para el tratamiento del CUEG.

Justification. In the western world the gastric carcinoma has decreased. The gastroesophageal junction carcinoma shows an arising incidence, and an apparent lack in its study. Objective. To revise the actualized data regarding the Gastroesophageal junction carcinoma. Materials and methods. A research was made, through the MEDLINE database, between the years 1990 to 2006, with base in the Cochrane Reviews Manual. The terms used were Esophagogastric junction carcinoma. Of the initially obtained articles, the most relevant were selected because their actuality. Conclusions. The Siwert’s classification is fundamental of the treatment of the Gastroesophageal junction. The adjuvant chemotherapy plus radiotherapy is a good choice to improve the overall and relapse-free survival. There are still not enough studies that indicate the screening and all the parameters to determine the treatment of Gastroesophageal junction carcinoma.