SEED Consensus Document on SpyGlass-DS. / Documento de consenso de la Sociedad Española de Endoscopia Digestiva sobre SpyGlass-DS.

Endoscopic retrograde cholangiopancreatography (ERCP) is the technique of choice for the treatment of biliopancreatic pathology. However, fluoroscopic imaging does not always allow an adequate diagnosis. On the other hand, some large stones cannot be removed by the usual methods. In these situations, cholangioscopy has proven to be an essential tool for the diagnosis of biliary strictures and the treatment of large stones. Its role in pancreatic pathology is also increasing. The development of a single-operator, disposable cholangioscope has made it possible to expand the technique to a large number of hospitals that perform ERCP. For this reason, the Spanish Society of Digestive Endoscopy has developed this consensus document on the use of the Spyglass-DS cholangioscope. The document has been prepared by a group of endoscopists with expertise in cholangioscopy, reviewing the scientific evidence on the main current indications for cholangiopancreatoscopy.

Self-expandable metal stents for obstructing colonic and extracolonic cancer: European Society of Gastrointestinal Endoscopy (ESGE) Clinical Guideline.

This Guideline is an official statement of the European Society of Gastrointestinal Endoscopy (ESGE). This Guideline was also reviewed and endorsed by the Governing Board of the American Society for Gastrointestinal Endoscopy (ASGE). The Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system was adopted to define the strength of recommendations and the quality of evidence. Main recommendations The following recommendations should only be applied after a thorough diagnostic evaluation including a contrast-enhanced computed tomography (CT) scan. 1 Prophylactic colonic stent placement is not recommended. Colonic stenting should be reserved for patients with clinical symptoms and imaging evidence of malignant large-bowel obstruction, without signs of perforation (strong recommendation, low quality evidence). 2 Colonic self-expandable metal stent (SEMS) placement as a bridge to elective surgery is not recommended as a standard treatment of symptomatic left-sided malignant colonic obstruction (strong recommendation, high quality evidence). 3 For patients with potentially curable but obstructing left-sided colonic cancer, stent placement may be considered as an alternative to emergency surgery in those who have an increased risk of postoperative mortality, I. e. American Society of Anesthesiologists (ASA) Physical Status ≥ III and/or age > 70 years (weak recommendation, low quality evidence). 4 SEMS placement is recommended as the preferred treatment for palliation of malignant colonic obstruction (strong recommendation, high quality evidence), except in patients treated or considered for treatment with antiangiogenic drugs (e. g. bevacizumab) (strong recommendation, low quality evidence).

Self-expandable metal stents for relieving malignant colorectal obstruction: short-term safety and efficacy within 30 days of stent procedure in 447 patients.

BACKGROUND: The self-expandable metal stent (SEMS) can alleviate malignant colonic obstruction and avoid emergency decompressive surgery. OBJECTIVE: To document performance, safety, and effectiveness of colorectal stents used per local standards of practice in patients with malignant large-bowel obstruction to avoid palliative stoma surgery in incurable patients (PAL) and facilitate bowel decompression as a bridge to surgery for curable patients (BTS). DESIGN: Prospective clinical cohort study. SETTING: Two global registries with 39 academic and community centers. PATIENTS: This study involved 447 patients with malignant colonic obstruction who received stents (255 PAL, 182 BTS, 10 no indication specified). INTERVENTION: Colorectal through-the-scope SEMS placement. MAIN OUTCOME MEASUREMENTS: The primary endpoint was clinical success at 30 days, defined as the patient's ability to maintain bowel function without adverse events related to the procedure or stent. Secondary endpoints were procedural success, defined as successful stent placement in the correct position, symptoms of persistent or recurrent colonic obstruction, and complications. RESULTS: The procedural success rate was 94.8% (439/463), and the clinical success rates were 90.5% (313/346) as assessed on a per protocol basis and 71.6% (313/437) as assessed on an intent-to-treat basis. Complications included 15 (3.9%) perforations, 3 resulting in death, 7 (1.8%) migrations, 7 (1.8%) cases of pain, and 2 (0.5%) cases of bleeding. LIMITATIONS: No control group. No primary endpoint analysis data for 25% of patients. CONCLUSION: This largest multicenter, prospective study of colonic SEMS placement demonstrates that colonic SEMSs are safe and highly effective for the short-term treatment of malignant colorectal obstruction, allowing most curable patients to have 1-step resection without stoma and providing most incurable patients minimally invasive palliation instead of surgery. The risk of complications, including perforation, was low.

[Do metachronous colorectal adenomas show proximal shift?]. / ¿Presentan un desplazamiento hacia segmentos más proximales los adenomas metacrónicos en el cáncer colorrectal?

OBJECTIVE: To study the possibility of shift toward more proximal sites in colorectal cancer (CRC) after resection of tumors and synchronous lesions. MATERIAL AND METHODS: We reviewed 382 resected CRC diagnosed and followed-up with complete colonoscopies. The localization of metachronous adenomas was compared with that of synchronous lesions overall and by sex, tumoral size and the number of synchronous lesions. The frequency of exclusively proximal localization in first-, second- and third-generation metachronous adenomas was compared with that of synchronous adenomas. RESULTS: A total of 54.5% of patients with CRC had synchronous adenomas. After a median follow-up of 48 months, with 2.74+/-1.47 colonoscopies/case, 42.4% developed metachronous adenomas, 16.8% second-generation adenomas and 7.3% third-generation lesions. Proximal shift was found in metachronous adenomas in both sexes, independently of tumoral size and the number of initial lesions. The frequency of exclusively proximal localization in adenomas was 21.2% in synchronous lesions, 39.5% in first-generation metachronous adenomas (p=0.0001; OR=2.46 [1.50-3.95]), 42.6% in second-generation metachronous adenomas (p=0.0008; OR=2.77 [1.44-5.31]) and 39.3% in third-generation metachronous lesions (p=0.0003; OR=2.41 [0.97-5.93]). CONCLUSIONS: We found a high incidence of synchronous and metachronous adenomas. Metachronous adenomas showed a proximal shift, independently of sex, tumoral size and the number of synchronous lesions. This tendency was maintained in successive generations of metachronous adenomas, thus demonstrating the need to perform complete colonoscopies throughout the postoperative follow-up period.

Long-term outcomes after stenting as a "bridge to surgery" for the management of acute obstruction secondary to colorectal cancer.

Obstructive symptoms are present in 8% of cases at the time of initial diagnosis in cases of colorectal cancer. Emergency surgery has been classically considered the treatment of choice in these patients. However, in the majority of studies, emergency colorectal surgery is burdened with higher morbidity and mortality rates than elective surgery, and many patients require temporal colostomy which deteriorates their quality of life and becomes permanent in 10%-40% of cases. The aim of stenting by-pass to surgery is to transform emergency surgery into elective surgery in order to improve surgical results, obtain an accurate tumoral staging and detection of synchronous lesions, stabilization of comorbidities and performance of laparoscopic surgery. Immediate results were more favourable in patients who were stented concerning primary anastomosis, permanent stoma, wound infection and overall morbidity, having the higher surgical risk patients the greater benefit. However, some findings laid out the possible implication of stenting in long-term results of oncologic treatment. Perforation after stenting is related to tumoral recurrence. In studies with perforation rates above 8%, higher recurrences rates in young patients and lower disease free survival have been shown. On the other hand, after stenting the number of removed lymph nodes in the surgical specimen is larger, patients can receive adjuvant chemotherapy earlier and in a greater percentage and the number of patients who can be surgically treated with laparoscopic surgery is larger. Finally, there are no consistent studies able to demonstrate that one strategy is superior to the other in terms of oncologic benefits. At present, it would seem wise to assume a higher initial complication rate in young patients without relevant comorbidities and to accept the risk of local recurrence in old patients (> 70 years) or with high surgical risk (ASA III/IV).

Potencial dendroclimático del encino rojo, Quercus sideroxyla (Fagaceae) en México / Dendroclimatic potential of red oak, Quercus sideroxyla (Fagaceae) in Mexico

Resumen Introducción: Los estudios dendrocronológicos en México se han basado principalmente en las coníferas, mientras que las especies de madera dura han sido poco estudiadas. Este ha sido el caso del género Quercus, con una alta diversidad taxonómica en el país pero que no ha sido estudiado con fines dendrocronológicos, a pesar de los valores ecológicos y económicos de sus especies. Objetivo: En la presente investigación se determinó el potencial dendroclimático de Quercus sideroxyla en el noroeste de México, y su relación con variables climáticas como precipitación y temperatura. Métodos: La investigación se desarrolló en el estado de Durango en el ejido Chavarría Viejo en las coordenadas (23º43' N & 105º33' W), se recolectaron muestras de 5 a 7 cm en dos sitios bajo aprovechamiento forestal y se procesaron mediante técnicas dendrocronológicas convencionales. Resultados: Se desarrolló una cronología de ancho de anillo total, la cual se compuso por 30 muestras de 16 árboles para el período de 1917 a 2018 (101 años). Se obtuvieron valores de intercorrelación entre series de 0.43, de sensibilidad media de 0.36, relación señal-ruido de 3.53 y autocorrelación de primer orden (0.58). En cuanto a la relación clima-crecimiento, los valores de índice de ancho de anillo se correlacionaron con datos de la estación climática más cercana al sitio de estudio; donde la precipitación invierno-primavera (enero-mayo) fue la variable de mayor influencia en el crecimiento de la especie. Conclusiones: Con base en los parámetros dendrocronológicos se demuestra el alto potencial de la especie para ser empleada en estudios dendroclimáticos en la región, la respuesta de la especie a la precipitación es similar al de las coníferas con las que cohabita.

Abstract Introduction: Dendrochronological studies in Mexico have been mainly based on conifers, while hardwood species have been little studied. This has been the case of the genus Quercus, which has a high taxonomic diversity in the country but has not been previously studied for dendrochronological issues, despite the ecological and economic values of oak species. Objective: In the present investigation, the dendroclimatic potential of Quercus sideroxyla in Northwestern Mexico was determined, as well as its relationship with climatic variables such as precipitation and temperature. Methods: The research was carried out in the state of Durango, Chavarría Viejo with coordinates (23º43' N & -105º33' W). Samples of 5 cm to 7cm were collected in two sites under forest exploitation and processed by conventional dendrochronological techniques. Results: A chronology of total ring width was developed, which was composed of 30 samples from 16 trees for the period from 1917 to 2018 (101 years). Inter-series intercorrelation values of 0.43, mean sensitivity of 0.36, signal-to-noise ratio of 3.53 and first-order autocorrelation (0.58) were obtained. Regarding the climate-growth relationship, the ring width index values were correlated with data from the climatic station nearest to the study site, where winter-spring precipitation (January-May) was the variable with the greatest influence on the growth of the species. Conclusions: Based on the dendrochronological parameters, the high potential of the species that were used in dendroclimatic studies in the region has demonstrated that the response of the species to precipitation is similar to that of the conifers with which the Quercus sideroxyla shares its habitat with.

Medicinal plants in the southern region of the State of Nuevo León, México.

BACKGROUND: Although the flora of the State of Nuevo León is well known, there are few records of ethnobotancial information. An ethnobotanical study was undertaken in order to know the medicinal plants used by people living at the scrublands and oak-pine forest areas in the southern Nuevo León. Collection of plants specimens and interviews were carried out among the people of the municipalities of Aramberri, Galeana, and Zaragoza. Since former studies in the region are scarce, the aim of this work was to record the medicinal species and their uses in the scrublands and oak-pine forest areas, of southern Nuevo León, Mexico, and also to know if there are differences in the number of species and number of uses knowledge by people. METHODS: Field work was carried out over a 2 years period; useful plants were collected and a total of 105 people from 46 different villages were interviewed. A database was compiled using data collected by means of semi structured interviews. The data were analyzed by means of non-parametric statistics, using goodness-of-fit test (Chi-squared) (number of species known by people of each municipality, number of uses known by people of each municipality), Chi-squared modified to incorporate the Yates Correction (number of species known by people living at scrublands and oak-pine forest); the Kruskall-Wallis test (number of species known by women and men of the three municipalities), and the Spearman's rank correlation coefficient (age and number of species known, and age and number of uses). RESULTS: A total of 163 medicinal plant species were recorded in the study area, comprising 108 wild and 55 cultivated plants. A total of 117 species were recorded in the oak-pine forest, and 111 in the scrublands area, a total of 68 were recorded in both areas; 68 medicinal species are used in all three municipalities, 40 wild and 28 cultivated. We documented 235 different medicinal uses. The most common plant parts used for medicinal purposes were found to be leaves (123 species), stems (55), fruits (28), roots (17), and bark (14). No differences were noted in the number of medicinal plant species identified among people, but differences were significant in their knowledge with respect to the number of uses among people of the three municipalities studied; people from both, scrublands and oak-pine forest know similar number of species and number of uses. Men and women of the three different municipalities knew statistically the same number of species and number of uses. There was no correlation between resident's age and number of species known and resident's age and number of uses either in Galeana or in Aramberri, but, there was high correlation among these variables in Zaragoza. CONCLUSION: In southern Nuevo León people use at least 5% of the total State flora as medicinal plants, and most of these species are included in few plant families. Most of medicinal species are wild and indigenous to the region. The two most important major plant communities, scrublands and oak-pine forest provide almost the same number of medicinal species. A third of the medicinal flora recorded are used in all three municipalities, most of them are wild. Leaves, stems and fruits are the plant parts most commonly used for healing, and boiling is the most common method used for this purpose. Men and women from the three municipalities are familiar with nearly the same number of species; however, their knowledge of the number of uses varies significantly. In Galeana and Aramberri there was no correlation between a person's age and number of species recognized, however, in Zaragoza, there existed a high correlation between these two factors.

[Jaundice secondary to giant pancreatic serous cystoadenoma]. / Ictericia secundaria a cistoadenoma seroso pancreático gigante.

Serous cystadenoma is the second most frequent pancreatic cystic neoplasm and accounts for 1-2% of exocrine neoplasms of the pancreas. Recently, they have been identified more frequently, due to the improvement in imaging techniques. Differential diagnosis should be performed with mucinous cystoadenoma, due to the latter´s potential for malignant transformation. We present the case of a female patient who underwent examination for painless jaundice and cholestasis, with a final diagnosis of pancreatic serous cystoadenoma.