[Endoscopic Submucosal dissection and mucosectomy for the treatment of the epithelial neoplasia and early gastric cancer]. / Diseción Submucosa y mucosectomia en el tratamiento de las neoplasias intraepiteliales y del cancer gástrico temprano.

INTRODUCTION: In Japan, endoscopic mucosal resection and endoscopic submucosal dissection of early gastric cancer are accepted as a treatment options for cases of early gastric cancer where the probability of lymph node metastasis is nil or low. OBJECTIVES: To establish the effectiveness of mucosectomy for the treatment of early gastric cancer and evaluate the extended indications for dysplasia lesions, also, we want to determine if the mucosectomy is relevant for lesions negative for neoplasia at the National Institute for Neoplastic Diseases (INEN), Lima, Peru. We call for estimating the utility and factibility of the endoscopic submucosa dissection with the needle knife. MATERIALS AND METHODS: The study is an observational, prospective, analytical and cross longitudinal. The study was performed in 96 patients with Type 0 Neoplastic lesions at INEN from 1996 to 2008. The revised Vienna classification of gastrointestinal epithelial neoplasia was utilized. The indication for endoscopic mucosal resection as a radical treatment of early gastric cancer is according to the treatment guidelines for gastric cancer in Japan. The lesions were resected with a simple endoscopic snare, with the Olympus cap for some depressed lesions and the needle knife during the submucosal dissection. Lifting of the lesion with submucosal injection was done with saline solution with epinephrine or saline with distillate water. The statistical analysis included the SPPS-12 programme. RESULTS: 96 patients were treated by mucosectomy and endoscopic submucosal dissection from 1996 to 2008. The sample represents patients with a mean age over 50 years old and predominance of female. 55 patients belongs to category 1 of revised Vienna Classification, 9 patients are in the category 3, 31 patients are suitable in category 4 (20 with high grade adenoma/dysplasia and 11 with intramucosal carcinoma) and just 1 patient for the category 5. We resected 305 Type 0 lesions, 85 mucosal neoplasia, low grade (43) and high grade (31 adenoma/dysplasia in 20 patients and 11 intramucosal carcinoma in 11 patients), and 219 lesions negatives for neoplasia. Approximately 200 lesions were resected by mucosectomy. The endoscopic submucosal dissection was done in 03 patients with additional mucosectomy. In general, the complications were bleeding resolved during the same procedure; there were no perforations in the current series. The local recurrence of 2 adenomas (high and low dysplasia), were resolved with Plasma Argon. We have no evidence of neither local nor distant recurrence in patients with intramucosal carcinoma in 5-10 years follow up. The patient treated by mucosectomy and submucosal invasion was operated and his actual survival is 6 years and 7 months. CONCLUSIONS: Mucosectomy is effective for precise variety of early gastric cancer with a median follow up period of 5-10 years in ours first patients, preserve the organ and maintain a high quality of life. Mucosectomy is appropriated for mucosal low and high grade adenoma/dysplasia, the local recurrence can be treated by Plasma Argon. The procedure can extend the indications eventually for lesions that are non-neoplasia. The endoscopic submucosal dissection must be done only in trained centres.

Perforación de angiodisplasia duodenal luego del tratamiento con argón plasma, resuelta con endoclips / Angiodysplasia duodenal perforation after treatment with argon plasma settled with endoclips

El tratamiento estándar para la perforación gastrointestinal secundaria a un procedimiento endoscópico es la reparación quirúrgica; algunos autores propugnan un manejo médico conservador. Los datos actuales sugieren que los endoclips pueden ser usados satisfactoriamente en un grupo selecto de pacientes con perforación gastrointestinal como complicación de una terapia endoscópica. Se describe un caso de perforación duodenal producida con relación al tratamiento con argón plasma de una angiodisplasia sangrante, que se trató con éxito con endoclips.

The gastrointestinal perforation standard treatment secondary to endoscopic procedure is surgical reparation; some authors propose conservative management. Actual data suggest that endoclips could be used in a specific group of patients with gastrointestinal perforation related with an endoscopic therapy complication. Here, we describe a succesfull endoclips treatment of a duodenal perforation related with a bleeding angiodysplasia treated with argon plasma.

[Clinical aspects in polyps of the colon]. / Aspectos clínicos de los pólipos colónicos.

INTRODUCTION: The colonics polyps according to their number, size, location, age of presentation and mainly, according to their histology, have the potentiality of malignant degeneration, which makes of a continuous study and pursuit susceptible. OBJECTIVES: To evaluate the relation between the histologic type of the colon polyps, its location, the degree of dysplasia, the size, its possible commitment by carcinoma, the age, sex and the handling that has occurred them, in a series of 684 patients of the National Institute of Enfermedades Neoplásicas (INEN) between the 1 of January from 1974 to the 31 of March of the 2004. MATERIAL AND METHODS: The revision of clinical histories of 840 patients with the diagnosis of colon polyp was made who attended the service of Gastroenterology of the INEN between the 1 of January from 1974 to the 31 of March of 2004 and a card predesigned for each clinical history filled. The study is of observational, analytical type and of cross section. 1162 resecteds polyps evaluated themselves in this period. 156 patients by diagnosis related to cancer and familiar adenomatouspoliposis did not include themselves. The final sample was of 684 patients, in whom it was 1057 polyps. Other endoscopic findings were: internal hemorrhoids (172), colonic diverticulosis (50), anal fissure (4), and nonspecific ulcerative colitis (2). The statistical processing was made with program SPSS 12. For the qualitative variables the method of the Chi-square was used, for the quantitative variables analyzed the average, the rank and the variance. RESULTS: 1057 polyps extirpated, by means of the endoscopy polipectomy were 1016, with colectomy were 32 and with transanal resection without colectomy they 9. Within the histology of the 1057 polyps, 331 was briefed (31.3%) that were hyperplasic, 448 (42.4%) adenomas, 278 (26.3%) others and 35 (8.2%) adenocarcinomas on adenomas. The average age was of 50 years, was no significant difference with sex. The location but frequence of the adenomas was in the left colon (76.6%). Adenocarcinoma (carcinomas on adenomas), was present mainly in polyps villous type, with dysplasia severe and greater to 10 mm. Nevertheless, in smaller polyps of 5mm with dysplasia severe, was a polyp invaded by cancer, that represents the 0,8% of millimetric polyps. The made handling was mainly endoscopic, with 96% of the resected polyps this way, also slogan transanal resection and segmental colonic resection. The colectomy was necessary in 3% of all the made interventions, dysplasia severe or carcinoma was made in adenomatous polyps with, and in greater percentage in greater polyps of 20 mm (53%). The single polipectomy was sufficient in the level of invasion Haggitt 0. In patients with level of invasion Haggitt 1 and 2, the single polipectomy was the election treatment. On the other hand, in polyps with level of invasion Haggitt 3 and 4, the colectomy was the election treatment. One briefed two complications, one of perforation and peritonitis and another one of digestive hemorrhage loss (both: 0.29%), without mortality events. CONCLUSIONS: The Evaluation of colonic polyps in INEN is predominantly by endoscopy. The polyps are more frequent over the 50 years and have preferred location in the left colon. The carcinoma is more probable with severe dysplasia and greater size of the adenoma. All polyps, from the millimetric ones, including the hyperplasic, must be considered marks of neoplasia and extirpated in its totality.

Aspectos clínicos de los pólipos colónicos / Clinical aspects of the colonics polyps

Introducción: Los pólipos colónicos de acuerdo a su número, tamaño, localización, edad de presentación y sobre todo, de acuerdo a su estirpe histológica, tienen la potencialidad de degeneración maligna, lo que los hace susceptibles de un continuo estudio y seguimiento. Objetivos: Evaluar la relación entre el tipo histológico de los pólipos de colón, su localización, el grado de displasia, el tamaño, su eventual compromiso por carcinoma, la edad, el sexo y el manejo que se les ha dado, en una serie de 684 pacientes del Instituto Nacional de Enfermedades Neoplásicas (INEN) entre el 1 de enero de 1974 al 31 de marzo del 2004. Material y métodos: Se realizó la revisión de historias clínicas de 840 pacientes con el diagnóstico de pólipo de colon que asistieron al Servicio de Gastroenterología del INEN entre el 1 de enero de 1974 al 31 de marzo de 2004 y se llenó una ficha prediseñada para cada historia clínica. El estudio es de tipo observacional, analítico y de corte transversal. Se evaluaron en este periodo 1162 pólipos resecados. No se incluyeron 156 pacientes por diagnóstico relacionado con cáncer y poliposis adenomatosa familiar. La muestra final fue de 684 pacientes, en los que se encontró 1057 pólipos. Otros hallazgos endoscópicos fueron: hemorroides internas (172), diverticulosis colónica (50), fisura anal (4), y colitis ulcerativa no específica (2). El procesamiento estadístico se realizó con el programa SPSS 12. Para las variables cualitativas se empleó el método de Chi-cuadrado, para las variables cuantitativas se analizaron la media, el rango y la varianza. Resultados: Se extirparon 1057 pólipos, mediante la polipectomía endoscópica fueron 1016, con uso de colectomía fueron 32 y con resección transanal sin colectomía fueron 09. Dentro de la histología de los 1057 pólipos, se consignaron 331 (31.3 por ciento) que fueron hiperplásicos, 448 (42.4 por ciento) adenomas, 278 (26.3 por ciento) otros y 35 (8.2 por ciento) adenocarcinomas sobre adenomas...

Introduction: The colonics polyps according to their number, size, location, age of presentation and mainly, according to their histology, have the potentiality of malignant degeneration, which makes of a continuous study and pursuit susceptible. OBJECTIVES: To evaluate the relation between the histologic type of the colon polyps, itslocation, the degree of dysplasia, the size, its possible commitment by carcinoma, the age, sex and the handling that has occurred them, in a series of 684 patients of the National Institute of Enfermedades Neoplásicas (INEN) between the 1 of January from 1974 to the 31 of March of the 2004. MATERIAL AND METHODS: The revision of clinical histories of 840 patients with the diagnosis of colon polyp was made who attended the service of Gastroenterology of the INEN betweenthe 1 of January from 1974 to the 31 of March of 2004 and a card predesigned for each clinical history filled. The study is of observational, analytical type and of cross section. 1162 resecteds polyps evaluated themselves in this period. 156 patients by diagnosis related to cancer and familiar adenomatouspoliposis did not include themselves. The final samplewas of 684 patients, in whom it was 1057 polyps. Other endoscopic findings were: internal hemorrhoids (172), colonic diverticulosis (50), anal fissure (4), and nonspecific ulcerative colitis (2). The statistical processing was made with program SPSS 12. For the qualitative variables the method of the Chi-square was used, for the quantitative variables analyzed theaverage, the rank and the variance. RESULTS: 1057 polyps extirpated, by means of the endoscopy polipectomy were 1016, with colectomy were 32 and with transanal resection without colectomy they 9. Within the histologyof the 1057 polyps, 331 was briefed (31.3 per cent) that were hyperplasic, 448 (42.4 per cent) adenomas,278 (26.3 per cent) others and 35 (8.2 per cent) adenocarcinomas on adenomas. The average age was of50 years, ...

[Duodenal angiodysplasia perforation after argon plasma therapy; solved with endoclips]. / Perforación de angiodisplasia duodenal luego del tratamiento con argón plasma, resuelta con endoclips.

The gastrointestinal perforation standard treatment secondary to endoscopic procedure is surgical reparation; some authors propose conservative management. Actual data suggest that endoclips could be used in a specific group of patients with gastrointestinal perforation related with an endoscopic therapy complication. Here, we describe a succesfull endoclips treatment of a duodenal perforation related with a bleeding angiodysplasia treated with argon plasma.

[Primary gastric lymphoma]. / Linfoma gastrico primario.

INTRODUCTION: Primary Gastric Lymphoma is an uncommon malignancy among gastric malignancies. Histology of the Primary Gastric Lymphoma is varied and the extranodal marginal zone B-cells lymphoma is specially significant on account of its potential remission with antibiotic therapy. OBJECTIVES: Observe the clinical characteristics of patients with Primary Gastric Lymphoma, assess the most relevant endoscopic findings, identify the factors that influence survival and evaluate the effects of therapy. MATERIALS AND METHODS: The study is an observational, analytical, cross evaluation including 169 patients with histological diagnosis of Gastric Lymphoma, treated at the National Institute for Neoplastic Diseases, Lima, Peru, from January 1995 to December 2000. Staging was based on the Ann Arbor system, modified by Musshoff and histology, on the REAL-WHO classification. The statistical analysis included the student-t and the chi-square tests. Survival data were entered using the Kaplan Meier curves and prognosis factors, using the Cox regression test. RESULTS: The sample represents patients from the Peruvian Coast, with a mean age of 55 years old and slight predominance of female patients (54.4%). Signs and symptoms are unspecific. Clinical stage I-II corresponds to 75% of the patients. The endoscopic pattern of multiple ulcerated lesions is characteristic of the Gastric Lymphoma. A total of 71% of the patients with extranodal marginal zone B-cells lymphoma showed total remission of the disease with antibiotic therapy (5/7). The histological type of the Gastric Lymphoma in the 169 patients was as follows: Large, diffuse, B-cells Lymphoma, 137 patients, extranodal marginal zone B-cells lymphoma, 16 patients, peripheral T-cell Lymphoma, 6 patients, anaplastic large T-cell Lymphoma, 3 patients, undetermined Lymphoma, 3 patients, mantle cell Lymphoma, 2 patients, adult T-cell Lymphoma, 1 patient and follicular Lymphoma, 1 patient. Global survival after 36 months was of 61.34%, survival according to the histological type was of 92.31% for extranodal marginal zone B-cells Lymphomas, 62.21% for large, diffuse B-cells Lymphomas and 29.63% for T-cell Lymphomas. Survival after 36 months in patients in clinical stage I-II treated with chemotherapy, was of 82.16%, with surgery, 71.89% and with surgery and chemotherapy, 70.39, with similar results in all three groups (p: 0.6530). The groups classified according to the international index, showed a clear difference between them (p:0.0000). The univariate analysis revealed that Zubrod (p:0.0000) DHL (p:0.0073) disease remission (p:0.0000) stage (p:0.0000) treatment (p:0.0000) and location (p:0.0000) had statistical significance. Multivariate analysis showed that in the Cox regression model, remission (OR:13,342, p:0.0000) and location (OR:2.375, p:0.041) fall within the equation of such function. CONCLUSIONS: The multiple ulcerated lesions are characteristic of the Gastric Lymphoma. Remission of the disease in the extranodal marginal zone B-cells Lymphoma is evidenced with the use of antibiotic therapy (5/7). Chemotherapy in patients with EC I-II achieves survival results similar to those treated with surgery and with a combination of both. Validity of the international index is confirmed and the multivariate analysis proved that remission and location of the disease have statistical significance.

Tratamiento endoscópico del cáncer gástrico temprano y lesiones premalignas gástricas mediante mucosectomía / Endoscopic treatment of early gstric cancer and precancerous gastric lesions with mucosectomy

El tratamiento endoscópico del cáncer gástrico temprano mediante la mucosectomía ha demostrado ser una modalidad efectiva de terapéutica local, especialmente si el tumor está circunscrito a la mucosa, es menor de 3 cm, carece de componente ulceroso, no presenta invasión linfática y tiene los bordes de sección libres de neoplasia. La mucosectomía también ha demostrado ser útil en la resección de lesiones elevadas gástricas, como los adenomas. Sobre un periódo de dos años (1996-1997), cinco pacientes (3 varones y 3 mujeres), con diagnóstico de cáncer gástrico tempranoen 4 de ellos, y adenoma con displasia moderada (el restante), fueron tratados mediante la mucosectomía, empleando para ello un asa de alambre convencional y utilizando solo corriente de coagulación. Para poder completar el procedimiento, en dos pacientes se resecó la lesión en dos partes. Se logro una remoción completa de todas las lesiones en una sola sesión. No hubo complicaciones. Dos pacientes fueron sometidos a tratamiento quirúrgico radical con linfadenectomía, no apreciándose neoplasia residual, ni metástasis ganglionar en los especímenes resecados. Todos los pacientes permanecen libres de recurrencia durante una media de seguimientos de 16 meses (rango de 9 a 29 meses). El cáncer gástrico temprano y los adenomas gástricos pueden ser adecuadamente tratados mediante la mucosectomía, utilizando para ello un estricto criterio de selección de pacientes.

Diarrea crónica: Aspectos clínicos / Chronic diarrea: clinical aspect

Reportamos un estudio retrospectivo acerca del síndrome de diarrea crónica, realizado en 50 historias clínicas correspondientes a pacientes hospitalizados en el Hospital E. Rebagliati M. durante el período de abril de 1983; a marzo de 1988; con la finalidad de evaluar la clínica del síndrome, los agentes causales del mismo y la metodología diagnóstica utilizada. El criterio de selección consideró aquellos pacientes con diagnóstico de ingreso de "diarrea crónica de causas a determinar". Siete fueron excluídos por presentar estudios incompletos mientras que 2 fueron casos de diarrea aguda infecciosa. Cuarenta y un pacientes fueron casos definitivos de diarrea crónica y fueron divididos en dos categorias : la primera como Diarrea Crónica Orgánica (58.53 por ciento) y la restante comop Diarrea Crónica Funcional (41.46 por ciento). Sobre el universo de 41 pacientes con diagnóstico de diarrea crónica nuestros resultados revelan que : (1) el síndrome afecta principalmente a la población económicamente activa y el tiempo de enfermedad es mayor de 3 semanas en todos los casos; (2) la anemia, fiebre, baja ponderal, evacuaciones nocturnas y deposiciones con sangre, orientan a la organicidad; mientras que los disturbios psiquiatricos, las evacuacines diurnas, el dolor abdominal, la recurrencia de la enfermedad y la ausencia de patología orgánica detectable, suguieren el caracter funcional del síndrome; (3)la causa más frecuente de diarrea crónica es el síndrome de intestino irritable seguido de las enfermedades infecciosas, con la parasitosis en primer término y (4) siendo la afección colónica predominante y las enfermedades infecciosas preponderantes, la metodología diagnóstica orientada hacia aquellas, tendrá un buen rendimiento diagnóstico

Colangitis esclerosante primaria asociada a síndrome de Sjogren, fibrosis retroperitoneal y pancreatitis crónica: reporte de un caso / Primary sclerosing cholangitis associated with Sjogren syndrome, retroperitoneal fibrosis and chronic pancreatitis: report of case

La Colangitis Esclerosante Primaria (CEP) es una enfermedad de presentación poco frecuente y de etiología desconocida que suele presentarse como un cuadro de colestasis crónica afectando sobre todo a gente adulta joven, con una relación estrecha con al Colitis Ulcerativa Idiopática. Reportamos un casos de CEP asociada a Síndrome de Sjogren, Pancreatitis Crónica y Fibrosis Retroperitoneal, sin afección colónica, en una mujer de treinta años procedente de la amazonía peruana, tratada a base de drenaje externo y con un seguimiento por doce meses. Se hace una revisión de la literatura sobre la posible etiología autoinmune y sobre los conceptos clínicos, bioquímicos, radiológicos, histológicos y de terapia en esta entidad