Barogenic perforation of the esophagus: An unusual manifestation / Perforación barogénica del esófago: una presentación inusual

Abstract Introduction: Typically, when esophageal perforation secondary to barotrauma is mentioned as the causal pathophysiological mechanism of perforation, the literature refers to spontaneous esophageal perforation or Boerhaave syndrome as an entity. It involves the longitudinal and transmural rupture of the esophagus (previously healthy) secondary to an abrupt increase in intraluminal esophageal pressure, frequently triggered during vomiting. However, in the medical literature, some reports list mechanisms of barotrauma other than this entity. Case report: A 64-year-old female patient with a history of surgically managed gastric adenocarcinoma (total gastrectomy and esophagoenteral anastomosis) presented with stenosis of the esophagojejunal anastomosis, which required an endoscopic dilatation protocol with a CRETM balloon. The third session of endoscopic dilation was held; in removing the endoscope, we identified a deep esophageal laceration with a 4 cm long perforation at the level of the middle esophagus (8 cm proximal to the dilated anastomosis), suspecting the mechanism of barotrauma as the causal agent. She required urgent transfer to the operating room, where we performed thoracoscopic esophagectomy, broad-spectrum empiric antimicrobial coverage, and enteral nutrition by advanced tube during in-hospital surveillance. The control esophagram at seven days showed a small leak over the anastomotic area, which was managed conservatively. Imaging control at 14 days showed a decrease in the size of the leak, with good evolution and tolerance to the oral route. The patient was later discharged.

Resumen Introducción: típicamente, cuando se menciona la perforación esofágica secundaria a barotrauma como el mecanismo fisiopatológico causal de la perforación, la literatura se refiere a la perforación esofágica espontánea o síndrome de Boerhaave como entidad, la cual hace referencia a la ruptura longitudinal y transmural del esófago (previamente sano) secundaria a un aumento abrupto de la presión intraluminal esofágica, que se desencadena frecuentemente durante el vómito. Sin embargo, en la literatura médica existen algunos reportes que mencionan otros mecanismos de barotrauma diferentes a esta entidad. Reporte de caso: se presenta el caso de una paciente de 64 años con antecedente de adenocarcinoma gástrico manejado quirúrgicamente (gastrectomía total y anastomosis esofagoenteral), quien presentaba estenosis de anastomosis esofagoyeyunal, que requirió un protocolo de dilatación endoscópica con balón CRETM. Se llevó a una tercera sesión de dilatación endoscópica, en la que durante la extracción del endoscopio se identificó una laceración esofágica profunda con perforación de 4 cm de longitud a nivel del esófago medio (8 cm proximal a anastomosis dilatada), y se sospechó del mecanismo de barotrauma como agente causal. Requirió traslado urgente a sala de cirugía, en la que se realizó esofagorrafia por toracoscopia, cubrimiento antimicrobiano empírico de amplio espectro y nutrición enteral por sonda avanzada durante la vigilancia intrahospitalaria. El esofagograma de control a los 7 días mostró una pequeña fuga sobre el área anastomótica, la cual se manejó de manera conservadora. El control imagenológico a los 14 días evidenció una disminución del tamaño de la fuga, con una evolución satisfactoria y tolerancia a la vía oral, y posteriormente se dio el egreso.

Miotomia peroral (POEM) ou cirúrgica para o tratamento da acalasia: revisão sistemática e metanálise / Peroral (poem) or surgical myotomy for the treatment of achalasia: a systematic review and meta-analysis

ABSTRACT BACKGROUND: Achalasia is a neurodegenerative motility esophageal disorder characterized by failure of lower esophageal sphincter relaxation. The conventional treatment option for achalasia has been laparoscopic Heller myotomy (LHM). However, in 2010, Inoue et al. described peroral endoscopic myotomy (POEM), a minimally invasive procedure, as an alternative therapy. To date, some studies with small sample sizes have aimed to compare outcomes of LHM vs POEM. OBJECTIVE: Thus, the aim of this study is to perform a systematic review and meta-analysis to better evaluate the efficacy and safety of these two techniques. METHODS: Individualized search strategies were developed from inception through April 2019 in accordance with PRISMA guidelines. Variables analyzed included operative time, overall adverse events rate, post-procedure gastroesophageal reflux disease (GERD), hospitalization length, post-procedure pain score, and Eckardt Score reduction. RESULTS: Twelve cohort trials were selected, consisting of 893 patients (359 in POEM group and 534 in LHM.) No randomized clinical trials were available. There was no difference in operative time (MD= -10,26, 95% CI (-5,6 to 8,2), P<0.001) or Post-Operative Gastroesophageal Reflux (RD: -0.00, 95%CI: (-0.09, 0.09), I2: 0%). There was decreased length of hospital stay for POEM (MD: -0.6, 95% CI (-1.11, -0.09), P=0.02), and an increased mean reduction in Eckardt score in POEM patients (MD = -0.257, 95% CI: (-0.512 to -0.002), P=0.048), with similar rates of adverse events. CONCLUSION: POEM demonstrated similar results compared to laparoscopic Heller myotomy with regards to improvement of dysphagia, post-procedure reflux, and surgical time, with the benefit of shorter length of hospital stay. Therefore, POEM can be considered an option for patients with achalasia.

RESUMO CONTEXTO: A acalasia é um distúrbio esofágico da motilidade neurodegenerativa caracterizado por falha no relaxamento do esfíncter esofágico inferior (EEI). A opção de tratamento convencional para acalasia tem sido a miotomia laparoscópica de Heller (LHM). No entanto, em 2010, Inoue et al. descreveram a miotomia endoscópica peroral (POEM), um procedimento minimamente invasivo, como uma terapia alternativa. Até o momento, poucos estudos com amostras pequenas tiveram como objetivo comparar os resultados do LHM versus POEM. OBJETIVO: Assim, o objetivo deste estudo é realizar uma revisão sistemática e metanálise para melhor avaliar a eficácia e segurança dessas duas técnicas. MÉTODOS: Estratégias de busca individualizadas foram desenvolvidas desde o início até abril de 2019, de acordo com as diretrizes do PRISMA. As variáveis analisadas incluíram tempo operatório, taxa global de eventos adversos, doença de refluxo gastroesofágico (DRGE) pós-procedimento, tempo de internação, escore de dor pós-procedimento e redução do escore de Eckardt. RESULTADOS: Doze estudos de coorte foram selecionados, consistindo em 893 pacientes (359 no grupo POEM e 524 no LHM). Nenhum ensaio clínico randomizado estava disponível. Não houve diferença no tempo operatório (MD = -10,26, IC 95% (-5,6 a 8,2), P<0,001) ou refluxo gastroesofágico pós-operatório (RD: -0,00, 95% IC: (-0,09, 0,09), I2: 0%). Houve diminuição do tempo de permanência hospitalar para POEM (MD: -0,6, 95% CI (-1,11, -0,09), P=0,02) e um aumento da redução média no escore de Eckardt em pacientes POEM (MD= -0,257, IC95%: (-0,512 a -0,002), P=0,048), com taxas similares de eventos adversos. CONCLUSÃO: O POEM demonstrou resultados semelhantes aos da miotomia a Heller por videolaparoscopia, com melhora da disfagia, do refluxo pós-procedimento e tempo cirúrgico, com o benefício de menor tempo de internação hospitalar. Portanto, o POEM pode ser considerado uma opção para pacientes com acalasia.

Utilização da cromoendoscopia com azul de toluidina mais solução de Lugol para diagnóstico precoce de lesões pré-malignas esofágicas e neoplasias superficiais em pacientes de alto risco / Chromoendoscopy using toluidine blue plus lugol's solution for early diagnosis of esophageal premalignant lesions and superficial neoplasms in high-risk patients

ABSTRACT BACKGROUND: Esophageal cancer is the eighth most common cancer. The prognosis is bleak in patients with advanced stages. Patients with early disease have a better prognosis than those with advanced stage. There are several techniques for the screening of premalignant and superficial lesions including chromoendoscopy. OBJECTIVE: This article aimed to determine the effectiveness of chromoendoscopy with toluidine blue combined with Lugol's solution for diagnosis of esophageal premalignant and superficial neoplastic lesions in high risk patients. METHODS: Routine white light upper endoscopy was performed. Toluidine blue was sprayed from the gastroesophageal junction to 20 cm of the dental arch. Then the uptake dye areas were characterized. Later Lugol's solution was sprayed. Areas with less-intense staining were characterized. Biopsy of the toluidine blue capturing areas and areas with less-intense staining of Lugol's solution were taken. In the cases where lesions were not evidenced after application of dyes, biopsies four quadrants of the esophageal mucosa were taken. The samples were evaluated by a digestive pathologist. RESULTS: Barrett's esophagus was the most common premalignant lesion and the early neoplastic lesion was adenocarcinoma with a sensitivity of 100%, specificity 85.7%, positive predictive value 30%, negative predictive value 100%, positive likelihood ratio 7 negative likelihood ratio 0. CONCLUSION: Chromoendoscopy with toluidine blue combined with Lugol's solution is a useful tool in the screening of esophageal premalignant lesions and superficial neoplasms.

RESUMO CONTEXTO: O câncer de esôfago é o oitavo câncer mais comum. O prognóstico é sombrio em pacientes com estágios avançados. Pacientes com doença precoce têm um melhor prognóstico do que aqueles com estágio avançado. Existem várias técnicas para a triagem de lesões pré-malignas e superficiais, incluindo cromoendoscopia. OBJETIVO: Este artigo objetivou determinar a efetividade da cromoendoscopia com azul de toluidina combinada com a solução de Lugol para o diagnóstico de lesões neoplásicas pré-malignas e superficiais esofágicas em pacientes de alto risco. MÉTODOS - A endoscopia de luz branca de rotina foi realizada de forma rotineira. O azul do toluidina foi pulverizado desde a junção gastroesofágica até 20 cm da arcada dentária. As áreas impregnadas pela tintura da tomada foram então caracterizadas. Mais adiante a solução de Lugol foi pulverizada. Áreas com coloração menos intensa foram caracterizadas. Foram realizadas biópsias das áreas de captura de azul de toluidina e áreas com coloração menos intensa da solução de Lugol. Nos casos onde as lesões não foram evidenciadas após a aplicação das tinturas, foram feitas biópsias em quatro quadrantes da mucosa esofágica. As amostras foram avaliadas por um patologista especializado. RESULTADOS: O esôfago de Barrett foi a lesão pré-maligna mais frequente e a lesão neoplásica precoce foi adenocarcinoma com sensibilidade de 100%, especificidade de 85,7%, valor preditivo positivo de 30%, valor preditivo negativo 100%, razão de verossimilhança positiva 7 e razão de verossimilhança negativa 0. CONCLUSÃO: A cromoendoscopia com azul de toluidina combinada com a solução de Lugol é uma ferramenta útil na triagem de lesões pré-malignas esofágicas e neoplasias superficiais.

Transnasal Esophagoscopy-Our Experience

Abstract Introduction Transnasal esophagoscopy (TNE) is a widely used tool both in the diagnosis and treatment of patients presenting complaints within the head and the neck. This is because this investigative adjunct examination provides the advantage of visualizing above the level of the cricopharyngeus muscle when compared to the more widely used esophagogastroduodenoscopy (EGD). Objectives We have assessed if the implementation of TNE within a district general hospital (DGH) was feasible, and investigated if the resources of our patients could be better directed away from other investigations such as barium swallow and EGD in favor of this novel technique. The TNE technique has been largely applied in central teaching hospitals within the United Kingdom, but there are still no published reports of a DGH investigating its applicability in this smaller-sized clinical environment. Method We have analyzed our theater database to find all the patients who had undergone TNE, and recorded their reason for presenting, the preceding investigations, and the procedural findings. Results Inmost cases, the TNEwas conducted without technical issues, and we were able to identify positive findings in 43% of the patients who underwent Esophagogastroduodenoscopy (EGD).Wewere able to treat patients successfully during the investigationwhen a cricopharyngeal stricture or narrowing was found. A normal EGD did not preclude further investigations with TNE. All but one of our patients were treated as day-case procedures. Conclusion Transnasal esophagoscopy can be successfully delivered within a DGH. A previous EGD does not mean that the TNE will not reveal positive findings due to its superior visualization of the pharynx and the upper esophagus. (AU)

Fish Bone Foreign Body: The Role of Imaging

Abstract Introduction Fish bone foreign body (FFB) impaction in the upper aerodigestive tract is a common cause for emergency department referral. Its management varies in both diagnosis and treatment paradigms. Fish bone foreign bodies are more commonly found in the oropharynx in cases of patients < 40 years old, and in the esophagus in cases of patients > 40 years old. Symptoms are typically non-indicative for the location of the FFB, with the exception of foreign body sensation at/superior to the cervical esophagus. A lack of findings during the physical examination is routinely followed by imaging, with computed tomography (CT) being the preferred modality. In practice, many patients undergo unnecessary imaging studies, including CT scans. Objectives To identify patients with suspected fish bone impaction who do not require CT imaging and can be safely discharged. Data Synthesis We have searched the PubMed database for the following medical subject headings (MeSH) terms: fish bone, fish foreign body AND oropharynx, hypopharynx, esophagus, flexible esophagoscopy, and rigid esophagoscopy. Our search in the English language yielded 32 papers. Case reports were included, since they highlighted rare and serious complications. Conclusion In patients > 40 years old suspected of fish bone impaction, noncontrast CT is recommended and should be urgently performed, even in the presence of ambiguous symptoms. However, in patients < 40 years old presenting within 24 hours from ingestion, imaging has little diagnostic value due to the low probability of esophageal fish bones. For this specific subgroup, in the absence of clinical findings, discharge without imaging studies may be considered safe. (AU)

Dilatación endoscópica en paciente con acalasia durante el embarazo: reporte de caso y revisión de la literatura / Endoscopic dilatation in a patient with achalasia during pregnancy: case report and review of the literature

La acalasia en el embarazo es una condición infrecuente, pobremente conocida y su manejo no esta claramente definido. Las repercusiones sobre el estado nutricional de los pacientes con esta entidad son graves y en una gestante tienen implicaciones serias para el curso de la gestación, con riesgo elevado de restricción del crecimiento intrauterino, parto pretérmino e incluso pérdida fetal; existen síntomas que pueden confundirse con hiperémesis gravídica retrasando el diagnóstico. Dentro de las opciones terapéuticas está el manejo médico, endoscópico e intervenciones quirúrgicas; para decidir cual es tratamiento adecuado se debe tener en cuenta la severidad, edad gestacional y condicien clasificaci de teratogenicidad conocido siendo su uso bienestar del binomioones del paciente, dentro del espectro mencionado en el manejo se incluyen los calcioantagonistas y nitratos, estos con restricciones en el embarazo, además toxina botulínica, dilatación neumática endoscópica, miotomía laparoscópica de Heller y recientemente el POEM; estas últimas con riesgo elevado de complicaciones. En el embarazo existe poca evidencia en la literatura y alrededor de 40 casos reportados, algunos con complicaciones como perdida fetal y muerte materna. Presentamos nuestra experiencia en el Hospital Universitario San Ignacio, Bogotá, Colombia de una mujer de 26 años de edad con diagnóstico de acalasia tipo 2 de novo durante el primer trimestre de gestación, cuadro clínico de disfagia severa asociado a desnutrición, a quien el manejo oportuno con soporte nutricional enteral con sonda nasogástrica para lograr repleción del índice de masa corporal (IMC) y luego de esto manejo endoscópico con dilatación con balón. Permitió llevar con éxito a término la gestación sin efectos adversos sobre la madre o el feto, con evolución adecuada y tolerancia a vía oral sin disfagia. Consideramos que es importante el soporte nutricional previo a la toma de conducta con este tipo paciente, además que el manejo endoscópico con dilatación puede ser seguro y efectivo a mediano plazo para el manejo de acalasia en embarazo.

Achalasia in pregnancy is an infrequent, poorly understood condition and its treatment is not clearly defined. The repercussions on the patients nutritional status are serious and in a pregnant woman have serious implications for the course of gestation, with high risk of intrauterine growth restriction, preterm delivery and even fetal loss; there are symptoms that can be confused with hyperemesis gravidarum delaying the diagnosis. The therapeutic options are medical treatment, endoscopic and surgical interventions; to decide what is the best treatment, we should be taken into account the severity, gestational age and patient conditions. Within the spectrum mentioned in the management include calcium antagonists and nitrates, however these have restrictions in pregnancy, another options are botulinum toxin, endoscopic pneumatic dilation, laparoscopic Heller myotomy and recently POEM. In pregnancy there is a few evidence in the literature and in this moment there are about 40 reported cases, some with complications such as fetal loss and maternal death. We present our experience at the San Ignacio University Hospital in Bogotá, Colombia, with a 26-year-old woman with a novo diagnosis of achalasia type II during the first trimester of pregnancy, with a clinical history of severe dysphagia associated with malnutrition. She was management with enteral nutrition support with nasogastric tube to achieve repletion of the body mass index (BMI) and after that, she had a endoscopic management with Rigiflex balloon dilation. It allowed to successfully carry out pregnancy without adverse effects on the mother or the fetus, with adequate evolution and oral tolerance without dysphagia. We consider that nutritional support is important prior to taking a desicion with this type of patient, in addition that endoscopic management with balloon dilation can be safe and effective for the management of achalasia in pregnancy.

Agreement between upper endoscopy and esophagography in the diagnosis of megaesophagus in Chagas disease

Abstract INTRODUCTION The diagnosis and classification of megaesophagus can be challenging in patients with Chagas disease. The present study aimed to evaluate the agreement between upper endoscopies and esophagographies for the diagnosis and classification of megaesophagus in Chagas disease. METHODS: A cross-sectional study of 50 patients with Chagas disease with upper digestive symptoms was undertaken. Esophagography and upper endoscopy exams were performed to compare diagnoses. Statistical analysis included sensitivity and specificity used to evaluate the diagnostic accuracy of upper endoscopies, and measures of agreement: linearly weighted Kappa (κw) and Cohen`s classical Kappa (κ) coefficients with 95% confidence intervals (95% CI). RESULTS: Twenty-three patients (46%) were diagnosed with megaesophagus by esophagography. The upper endoscopy sensitivity and specificity for megaesophagus diagnosis were 100% and 33.3%, respectively. Regarding megaesophagus classifications, there was a substantial agreement between the two exams (κw = 0.622; 95% CI: 0.498 to 0.746). Within megaesophagus groups, agreement for group I was slight (κ = 0.096; 95% CI: 0.000 to 0.403); for group II, substantial (κ = 0.703; 95% CI: 0.456 to 0.950); and for groups III and IV, inconclusive (κ = 0.457; 95% CI: 0.000 to 0.967; κ = 0.540; 95% CI: 0.035 to 1.000, respectively). CONCLUSIONS Upper endoscopy has a high sensitivity, but a low specificity to diagnose megaesophagus. Agreement between the two exams varies depending on the megaesophagus grade. Thus, upper endoscopy can be used in the diagnostic workup of a possible Chagas disease megaesophagus, but all identified cases should undergo esophagography.

Tumor de células granulosas del esófago / Granulosa cell tumor in the esophagus

Los tumores de células granulosas afectan raramente al esófago. Presentamos el caso de tumores de células granulosas del esófago y revisar la literatura. Se presenta una paciente de 21 años de edad y piel negra con síntomas de reflujo gastroesofágico. La endoscopia digestiva demostró un tumor de 2 cm que protruía hacia la luz del órgano, localizado en el tercio inferior, con mucosa sana. El esofagograma corroboró el hallazgo en la porción abdominal del órgano y la biopsia endoscópica informó que se trataba de tumores de células granulosas. El acceso videolaparoscópico fue convertido a cirugía convencional debido a la abertura mucosa y a que quedaba un pequeño fragmento del tumor. El periodo posoperatorio transcurrió sin complicaciones. Un año después de la operación no existía evidencia de recidiva. Los tumores de células granulosas son raros en el esófago. Los tumores pequeños (< 1 cm) pueden ser tratados conservadoramente, mientras que los de mayor volumen deben ser resecados mediante diferentes técnicas: endoscópicas y cirugía de mínimo acceso o convencional(AU)

Granulosa cell tumors rarely affect the esophagus. We present the case of granulosa cell tumors of the esophagus and literature review. A 21-year-old patient of black skin presents with symptoms of gastroesophageal reflux. The digestive endoscopy showed a 2-cm tumor that protruded towards the organ lumen, located in the lower third, with healthy mucosa. The esophagogram corroborated the finding in the abdominal portion of the organ, and the endoscopic biopsy reported that there were granulosa cell tumors. Videolaparoscopic access was converted to conventional surgery due to the mucosal opening and because a small fragment of the tumor was remaining. The postoperative period had no complications. One year after the operation, there was no evidence of recurrence. Granulosa cell tumors are rare in the esophagus. Small tumors (smaller than 1 cm) can be treated conservatively, while larger tumors should be resected using different techniques: endoscopic and minimal access or conventional surgery(AU)

Complicaciones durante la esofagoscopía con o sin dilatación con globo y con anestesia general en pacientes pediátricos: estudio prospectivo y observacional / Complications during esophageal endoscopy with or without baloon dilation under general anesthesia in pediatric patients: a prospective and observational study

Antecedentes. Durante una esofagoscopía en niños, pueden ocurrir complicaciones durante la dilatación. Identificamos alteraciones cardiorrespiratorias durante la esofagoscopía con o sin dilatación con globo y las complicaciones posoperatorias, en niños con anestesia. Métodos. Estudio prospectivo, observacional de procedimientos endoscópicos en niños de 0-16 años. Se dividieron en dos grupos: con endoscopía-dilatación (Grupo ED) y dilatación con globo por estenosis esofágica, y con endoscopía sin dilatación (Grupo E): endoscopía diagnóstica, esofagoscopía de control o escleroterapia. Registramos parámetros hemodinámicos y ventilatorios y las complicaciones durante la endoscopía, la dilatación y el seguimiento de dos horas en la sala de recuperación. Resultados. Incluimos 102 procedimientos en 60 pacientes. La presión inspiratoria máxima (PIM) aumentó significativamente en ambos grupos (p < 0,001) y aumentó significativamente durante el procedimiento en el grupo ED (p < 0,001). La diferencia en la PIM antes y después de la endoscopía se correlacionó negativamente en ambos grupos. Al subdividir los grupos según el punto de corte de 2 años para comparar la diferencia en la PIM antes y después de la endoscopía, la PIM aumentó de manera estadísticamente significativa en ambos grupos en los menores de 2 años. En el grupo ED, la frecuencia cardíaca aumentó estadísticamente significativa (p < 0,001). Conclusión. Durante la endoscopía, la PIM aumentó en niños con o sin dilatación con globo, especialmente en el grupo ED, y fue mayor en los niños más pequeños. Es necesario observar y tratar atentamente las complicaciones cardiorrespiratorias graves durante la dilatación con globo y con anestesia general.

Background. Complications can occur during esophagoscopy as a result of applied procedure in children, especially during dilation techic. Our aim was to identify cardio-respiratory alterations during esophagoscopy with or without baloon dilation under anesthesia in children, and to investigate the postoperative complications. Methods. Prospective, observational study of endoscopic procedures in patients 0-16 years. The patients were divided into two groups: the endoscopy-dilation group (Group ED: endoscopy and balloon dilation due to esophageal stricture) and endoscopy without dilation (Group E: endoscopy for diagnostic reasons, control esophagoscopy or sclerotherapy). Hemodynamic and ventilatory parameters alterations and complications during endoscopy, dilation and two-hours follow-up time in the postoperative recovery room were recorded. Results. 102 procedures in 60 patients were included. Peak inspiratory pressure (PIP) values significantly increased after endoscopy in both groups (p<0.001). There was a significant increase in mean PIP values in the dilation group during the procedure (p<0,001). The difference in PIP values before and after the endoscopy was negatively correlated with age in both groups. When the groups were subdivided taking two years of age as a cut-off point in comparing PIP difference before-after endoscopy, PIP increase was statistically significant in both groups under two-years old. In the dilation group, statistically significant increase of HR was detected during the procedure (p<0,001). Conclusion. During endoscopy PIP increased in patients with or without baloon dilation especially in the dilation group. PIP increase was higher in younger children. Severe respiratory and cardiovascular complications during balloon dilation under general anesthesia should be carefully observed and managed.

Miotomía endoscópica por vía oral (POEM) para el tratamiento de la acalasia: experiencia clínica inicial y resultados a corto plazo / Per-oral endoscopic myotomy (POEM) for the treatment of achalasia: initial clinical experience and short term results

Resumen Introducción: La acalasia es el trastorno motor primario más frecuente del esófago. El estándar de tratamiento actual es la miotomía de Heller laparoscópica. En los últimos años, el desarrollo de técnicas endoscópicas avanzadas ha permitido el posicionamiento de la técnica POEM (del inglés: per-oral endoscopic myotomy) como una nueva alternativa terapéutica con resultados promisorios. Objetivo: Presentar nuestra experiencia clínica, con descripción de la técnica utilizada, resultados perioperatorios y seguimiento a corto plazo en el desarrollo de esta alternativa terapéutica. Materiales y métodos: Se realizó un análisis retrospectivo de datos obtenidos en forma prospectiva de 15 pacientes intervenidos mediante POEM en 3 hospitales docentes asociados. Se recopilaron variables demográficas preoperatorias, detalle del intraoperatorio y registro de morbimortalidad operatoria. Se realizó un seguimiento clínico dirigido registrando el puntaje de Eckardt y la presencia de síntomas de reflujo gastroesofágico. Resultados: Entre agosto de 2015 y noviembre de 2016 se realizaron 15 POEM. Seis de estos pacientes eran mujeres, y la edad promedio fue de 49 años. El tiempo operatorio promedio fue de 110 min; no hubo morbimortalidad operatoria. La estadía hospitalaria promedio fue de 2,8 días. El seguimiento fue de entre 1 y 15 meses. El puntaje de Eckardt promedio en el preoperatorio y en el postoperatorio fue de 10,5 y 0,4 puntos, respectivamente. Tres pacientes presentaban síntomas de reflujo gastroesofágico al momento del seguimiento. Conclusión: Los resultados obtenidos en nuestra serie apoyan la efectividad y seguridad del POEM a corto plazo. Se requiere de un seguimiento mayor para determinar el rol definitivo de esta técnica.

Abstract Introduction: Achalasia is the most common primary motor disorder of the esophagus. The current standard of treatment is laparoscopic Heller's myotomy. Recently the development of advanced endoscopic techniques has allowed the positioning of the POEM (per-oral endoscopic myotomy) technique as a new therapeutic alternative with promising results. Objective: To present our clinical experience in POEM, with description of the technique used, peri-operative results and short-term follow-up in the development of this therapeutic alternative. Materials and methods: We performed a retrospective analysis of data obtained prospectively from 15 patients undergoing POEM in three clinical centers in our country. Preoperative demographic variables, intraoperative detail, and operative morbidity and mortality were collected. Clinical follow-up was performed with controls recording Eckardt score and presence of gastroesophageal reflux symptoms. Results: Between August 2015 and November 2016, 15 POEM were performed, six of these patients were women, average age was 49 years. The average operative time was 110 min, we did not have any perioperative morbimortality. Hospital stay was 2.8 days. Follow-up was between 1 and 15 months, Eckardt's preoperative and postoperative score was on average 10.5 and 0.4 points, respectively. Three patients had gastroesophageal reflux symptoms at the time of follow-up. Conclusion: Our results support the effectiveness and security of POEM in short-term follow up. Further monitoring is required to determine the definitive role of this technique.

Uso seguro y eficaz del IT-Knife-2 en el manejo endoscópico del divertículo de Zenker (DZ) / Efficacy and safety of the endoscopic management of Zenker diverticulum with IT-Knife 2 device

Objetivo: Evaluar la eficacia y seguridad del manejo endoscópico del DZ con IT-knife 2. Materiales y métodos: Estudio prospectivo, multicéntrico (Hospital Nacional Edgardo Rebagliati Martins y la Clínica El Golf). Se incluyeron todos los pacientes con DZ sintomáticos desde setiembre 2013 a agosto 2016, los cuales fueron sometidos a miotomía cricofaringea endoscópica. Técnica: se afrontó el septo del DZ con un cap y luego se seccionó con el IT-Knife 2 (ENDOCUT Q Efecto 3-2-5) hasta su base. Se comparó la escala de disfagia antes y después del procedimiento, al 1er mes y luego de los 3 meses. Resultados: Se incluyeron 20 pacientes (11 varones; edad promedio: 71 años). El tamaño promedio del DZ fue de 40,5 mm. El tiempo promedio de la miotomía cricofaringea fue de 13,75 minutos. El éxito clínico fue del 100%, presentando un descenso estadísticamente significativo (p<0,001) en el score de disfagia de 2+/-0,86 pre-tratamiento a 0,05+/-0,22 al primer mes post- tratamiento. La recurrencia clínica a partir del tercer mes fue de 15%, resolviendo por completo con un segundo tratamiento endoscópico. No se presentó ningún caso de perforación ni sangrado. Dos pacientes cursaron con neumonía. Conclusión: El tratamiento endoscópico del DZ mediante el uso del IT-knife 2 es altamente eficaz y seguro, y de menor complejidad que la experiencia previa

Objective: To evaluate the efficacy and safety of the endoscopic management of Zenker Diverticulum with IT-Knife 2 device. Materials and methods: prospective and multicenter study (Edgardo Rebagliati Martins National Hospital and Golf Clinic). We included all patients with sintomatic Zenker Diverticulum that were treated with endoscopic cricopharyngeal miotomy from september 2013 until august 2016. Technique: the diverticulum septum was faced with a cap, and then it was cut by the IT-Knife 2 (ENDOCUT Q, effect 3-2-5) until its baseline. Disphagia score was compared before and 1 and 3 months after the procedure. Results: 20 patients were included (11 men; average age: 71 years). The median size of Zenker Diverticulum was 40.5 mm. The median duration of the cricopharyngeal miotomy was 13.75 minutes. Clinical success was 100%. There was a significative decrease (p<0.001) in the disphagia score from 2+/-0.86 before the procedure to 0.05+/-0.22 one month after it. Recurrence after 3 months was 15% and it was completely solved after a second endoscopic treatment. Niether perforation nor bleeding was reported. Two patients had pneumonia. Conclusion: the endoscopic management of Zenker Diverticulum with IT-Knife 2 is highly effective, safe and less complex than previous technique experience

Cromoscopia vital com Lugol versus cromoscopia óptica na detecção de câncer de esôfago em pacientes com estenoses cáusticas esofagianas / Lugol's iodine chromoendoscopy versus narrow band image enhanced endoscopy for the detection of esophageal cancer in patients with stenosis secondary to caustic/corrosive agent ingestion

ABSTRACT BACKGROUND The diagnosis of corrosion cancer should be suspected in patients with corrosive ingestion if after a latent period of negligible symptoms there is development of dysphagia, or poor response to dilatation, or if respiratory symptoms develop in an otherwise stable patient of esophageal stenosis. Narrow Band Imaging detects superficial squamous cell carcinoma more frequently than white-light imaging, and has significantly higher sensitivity and accuracy compared with white-light. OBJECTIVE To determinate the clinical applicability of Narrow Band Imaging versus Lugol´s solution chromendoscopy for detection of early esophageal cancer in patients with caustic/corrosive agent stenosis. METHODS Thirty-eight patients, aged between 28-84 were enrolled and examined by both Narrow Band Imaging and Lugol´s solution chromendoscopy. A 4.9mm diameter endoscope was used facilitating examination of a stenotic area without dilation. Narrow Band Imaging was performed and any lesion detected was marked for later biopsy. Then, Lugol´s solution chromoendoscopy was performed and biopsies were taken at suspicious areas. Patients who had abnormal findings at the routine, Narrow Band Imaging or Lugol´s solution chromoscopy exam had their stenotic ring biopsied. RESULTS We detected nine suspicious lesions with Narrow Band Imaging and 14 with Lugol´s solution chromendoscopy. The sensitivity and specificity of the Narrow Band Imaging was 100% and 80.6%, and with Lugol´s chromoscopy 100% and 66.67%, respectively. Five (13%) suspicious lesions were detected both with Narrow Band Imaging and Lugol's chromoscopy, two (40%) of these lesions were confirmed carcinoma on histopathological examination. CONCLUSION Narrow Band Imaging is an applicable option to detect and evaluate cancer in patients with caustic /corrosive stenosis compared to the Lugol´s solution chromoscopy.

RESUMO CONTEXTO A suspeita do câncer de esôfago na lesão cáustica ocorre quando os pacientes com estenoses previamente estáveis, após um período latente sem sintomas, apresentam disfagia, baixa resposta as dilatações ou sintomas respiratórios. A cromoscopia com luz de banda estreita detecta o câncer superficial de esôfago mais frequentemente que a luz branca, com alta sensibilidade e acurácia. OBJETIVO Determinar a aplicabilidade clínica da luz de banda estreita versus a cromoscopia vital com Lugol na detecção do câncer precoce de esôfago em pacientes com lesões cáusticas. MÉTODOS Um total de 38 pacientes, entre 28 e 84 anos, foram alocados seguidamente e submetidos à cromoscopia com luz de banda estreita e com Lugol. Um gastroscópio de 4,9 mm de diâmetro foi usado para facilitar o exame da área estenosada, sem necessidade de dilatação. A cromoscopia com luz de banda estreita era realizada primeiro e as áreas suspeitas anotadas. Depois, a cromoscopia com Lugol era realizada e as áreas suspeitas biopsiadas. RESULTADOS Detectamos nove lesões suspeitas com a luz de banda estreita e 14 com o Lugol. A sensibilidade e especificidade da cromoscopia com luz de banda estreita foi de 100% e 80,6%, e a do Lugol foi de 100% e 66,67% respectivamente. Cinco (13%) lesões suspeitas foram detectadas coincidentemente pelos dois métodos, sendo duas (40%) com diagnóstico anatomopatológico de câncer de esôfago. CONCLUSÃO A cromoscopia com luz de banda estreita é opção concreta para o diagnóstico de câncer em pacientes com estenoses esofágicas por corrosões cáusticas, comparado a cromoscopia com Lugol.

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.

Tratamiento paliativo del cáncer esofágico y de la unión gastro-esofágica mediante colocación de prótesis transtumoral por vía endoscópica / Esophageal stents for symptomatic treatment of esophageal cancer: experience in 35 patients

Background: Esophageal cancer is usually diagnosed when it is beyond surgical ablation. Aim: To report the results of palliative treatment of dysphagia secondary to non-resectable esophageal carcinoma using self-expanding stents. Material and Methods: Review of medical records of 35 patients aged 57 to 94 years (21 males) with a non resectable esophageal carcinoma in whom a self-expanding stent was placed. Results: Eighty six percent of patients had severe dysphagia and it improved in all after the procedure. Two patients experienced a displacement of the stent. Three patients required the placement of a second stent. One patient died 30 days after the procedure due to pneumonia. Conclusions: Self expandable stents provide symptomatic relief to patients with non resectable esophageal carcinoma.

Objetivo: Mostrar método de paliación de disfagia por medio de prótesis autoexpandible, en pacientes con cáncer de esófago o unión esófago-gástrica en etapa IV, o considerados inoperables por patologías concomitantes severas. Material y Método: Estudio retrospectivo, 112 pacientes atendidos en nuestro hospital por cáncer de esófago, 43 en etapa IV se consideraron irresecables, de este grupo, en 8 se efectuó dilatación o gastrostomía endoscópica percutánea. Los otros 35 pacientes con disfagia de origen tumoral fueron tratados con prótesis esofágica como método paliativo al no resultar candidatos para tratamiento quirúrgico por estado de avance de enfermedad o sufrir patologías agregadas que la contraindicaban. Resultados: Tipo histológico más frecuente fue carcinoma epidermoide; nivel de disfagia fue grado 3 en mayoría de los pacientes (86,4 por ciento), la que mejoró luego de la instalación de prótesis alcanzando nivel de disfagia grado 1 (81,8 por ciento). Conclusiones: El uso de prótesis autoexpandibles es útil en el tratamiento de disfagia en pacientes con obstrucción de lumen esofágico secundario a crecimiento de tumor maligno.

Differential Diagnosis and Treatment of Isolated Pathologies of the Sphenoid Sinus: Retrospective Study of 46 Cases

Introduction Isolated disease of the sphenoid is rare and has often been overlooked due to its remote location and difficult access. Objective A retrospective study of the main causes of isolated sphenoid sinus diseases with discussion of the most appropriate methods of diagnosis and treatment. Methods A total of 46 cases of isolated sphenoid disease treated between January 2008 and December 2013 were evaluated by objective ear, nose, and throat examination and video endoscopy, computed tomography of the paranasal sinuses, and, in some cases, magnetic resonance imaging. In each case, we decided between drug and/or endoscopic treatment. Results We identified 12 cases of isolated sphenoiditis (26.1% ), 3 cases of fungal sphenoiditis (6.5% ), 3 cases of sphenochoanal polyps (6.5% ), 22 cases of mucocele (47.8% ), 2 cases of cerebrospinal fluid leak (4.3% ), and 1 case each of meningoencephalocele (2.1% ), inverted papilloma (2.1% ), fibrous dysplasia (2.1% ), and squamous cell carcinoma (2.1% ). Conclusion A prevalence of inflammatory and infectious diseases was found, and endoscopic surgery for the sphenoid sinus approach is effective in treating various diseases of the isolated sphenoid, whether complicated or not. .

Two-stage Surgery for an Aortoesophageal Fistula Caused by Tuberculous Esophagitis

An aortoesophageal fistula (AEF) is an extremely rare, potentially fatal condition, and aortic surgery is usually performed together with extracorporeal circulation. However, this surgical method has a high rate of surgical complications and mortality. This report describes an AEF caused by tuberculous esophagitis that was treated successfully using a two-stage operation. A 52-yr-old man was admitted to the hospital with severe hematemesis and syncope. Based on the computed tomography and diagnostic endoscopic findings, he was diagnosed with an AEF and initially underwent thoracic endovascular aortic repair. Esophageal reconstruction was performed after controlling the mediastinal inflammation. The patient suffered postoperative anastomotic leakage, which was treated by an endoscopic procedure, and the patient was discharged without any further problems. The patient received 9 months of anti-tuberculosis treatment after he was diagnosed with histologically confirmed tuberculous esophagitis; subsequently, he was followed as an outpatient and has had no recurrence of the tuberculosis or any further issues.

Perspective on Peroral Endoscopic Myotomy for Achalasia: Zhongshan Experience

Worldwide, peroral endoscopic myotomy (POEM) has achieved remarkable initial outcomes in the treatment of achalasia. In China, POEM has developed very quickly since the first case was performed in our center in August 2010. With experience, we have successfully performed POEM for special cases (such as pediatric patients, patients with sigmoid-type esophagus, and patients with recurrent symptoms after previous surgery) and have altered our technique to achieve long-term symptom remission and simplify the POEM procedure. These changes include posterior wall incision, full-thickness myotomy, a "push-and-pull" technique for myotomy, and water-jet assisted POEM. In this article, our experiences in POEM are summarized, including changes in technique, applications of the procedure, and the management of possible complications.

Perspective on Peroral Endoscopic Myotomy for Achalasia: Zhongshan Experience

Worldwide, peroral endoscopic myotomy (POEM) has achieved remarkable initial outcomes in the treatment of achalasia. In China, POEM has developed very quickly since the first case was performed in our center in August 2010. With experience, we have successfully performed POEM for special cases (such as pediatric patients, patients with sigmoid-type esophagus, and patients with recurrent symptoms after previous surgery) and have altered our technique to achieve long-term symptom remission and simplify the POEM procedure. These changes include posterior wall incision, full-thickness myotomy, a "push-and-pull" technique for myotomy, and water-jet assisted POEM. In this article, our experiences in POEM are summarized, including changes in technique, applications of the procedure, and the management of possible complications.

Tratamiento quirúrgico de enfermedades benignas y malignas del esófago / Surgical treatment of benign and malignant esophageal diseases

Introducción: las resecciones esofágicas son técnicas complejas que se han ido perfeccionando con el tiempo con el objetivo de disminuir la morbilidad y mortalidad en los pacientes con afecciones de esófago. Objetivo: identificar el comportamiento de los pacientes que fueron sometidos a resecciones esofágicas por enfermedades benignas y malignas. Métodos: se realizó un estudio descriptivo y retrospectivo de pacientes con resecciones esofágicas en el Hospital Provincial Universitario Carlos Manuel de Céspedes, en el período de enero de 2010 hasta diciembre de 2013. La muestra estuvo conformada por 24 pacientes. Resultados: el grupo de edad más afectado fue el de 60 a 69 años y el sexo masculino; la técnica de resección usual: la transhiatal, los tumores constituyeron la principal causa de resección, la yeyunostomía como vía alimentaria, se utilizó el estómago casi total, con piloroplastia como forma de reemplazar el esófago, se utilizó un solo plano de sutura en las anastomosis. La fístula cervical fue la complicación más frecuente, el neumotórax y la bronconeumonía fueron la principal causa de reintervención y muerte respectivamente. Conclusiones: las resecciones esofágicas se efectúan con mayor frecuencia a edad avanzada de la vida, generalmente a individuos con neoplasias e induce a gran número de complicaciones, las infecciones respiratorias son las más graves. La esofagectomía transhiatal, utilizando el estómago casi total y la yeyunostomía como vía alimentaria alternativa y transitoria son ventajosas para este tipo de pacientes, pues la mayoría de las complicaciones resuelven con medidas conservadoras y procedimientos quirúrgicos de menor complejidad(AU)

Introduction: the esophageal resection is a complex technique that have been improving in order to decrease the morbidity and mortality rates in the patient who suffer esophageal illness. Objective: to identify the behavior of patients with esophageal resection. Methods: a retrospective and descriptive study was conducted in order to identify the behavior of patients with esophageal resections in Carlos Manuel de Cespedes hospital in the period from January 2010 to December 2013. The sample consisted of 24 patients. Results: the most affected age group was 60 to 69 years and male sex; the usual resection technique was transhiatal; the tumors were the main cause of resection, the jejunostomy as feeding pathway, using the almost the whole stomach, with pyloroplasty replacing the esophagus, one layer suture in anastomosis. The cervical fistula was the most frequent complication whereas pneumothorax and bronchopneumonia were the main causes of re-operation and death respectively. Conclusions: the esophageal resections are performed more often in aged patients, usually in individuals with malignancies, and are associated with many complications, being the respiratory infections the most severe ones. The transhiatal esophagectomy using almost the complete stomach and jejunostomy are advantages for this type of patients, since most of the complications can be resolved with conservative measures and less complex surgical procedures(AU)

Submucosal tunneling endoscopic resection for upper gastrointestinal multiple submucosal tumors originating from the muscular propria layer: A feasibility study.

BACKGROUND AND AIMS: In recent years, submucosal tunneling endoscopic resection (STER) was applied more and more often for single gastrointestinal (GI) submucosal tumor (SMT). However, little is known about this technique for treating multiple SMTs in GI tract. In the present study, we investigated the feasibility and outcome of STER for upper GI multiple SMTs originating from the muscularis propria (MP) layer. PATIENTS AND METHODS: A feasibility study was carried out including a consecutive cohort of 23 patients with multiple SMTs from MP layer in esophagus, cardia, and upper corpus who were treated by STER from June 2011 to June 2014. Clinicopathological, demographic, and endoscopic data were collected and analyzed. RESULTS: All of the 49 SMTs were resected completely by STER technique. Furthermore, only one tunnel was built for multiple SMTs of each patient in this study. En bloc resection was achieved in all 49 tumors. The median size of all the resected tumors was 1.5 cm (range 0.8–3.5 cm). The pathological results showed that all the tumors were leiomyoma, and the margins of the resected specimens were negative. The median procedure time was 40 min (range: 20–75 min). Gas‑related complications were of the main complications, the rates of subcutaneous emphysema and pneumomediastinum, pneumothorax, and pneumoperitoneum were 13.0%, 8.7% and 4.3%. Another common complication was thoracic effusion that occurred in 2 cases (8.7%), among which only 1 case (4.3%) with low‑grade fever got the drainage. Delayed bleeding, esophageal fistula or hematocele, and infection in tunnel were not detected after the operation there were no treatment‑related deaths. The median hospital stay was 4 days (range, 2–9 days). No residual or recurrent lesion was found during the follow‑up period (median 18, ranging 3–36 months). CONCLUSION: Submucosal tunneling endoscopic resection is a safe and efficient technique for treating multiple esophageal SMTs originating from MP layer, which can avoid patients suffering repeated resections.