Effect of irrigation solution temperature on complications of percutaneous nephrolithotomy: a systematic review of the literature, meta-analysis and trial sequential analysis of randomized clinical trials.

INTRODUCTION: The optimal temperature of irrigation solution in patients undergoing PCNL is still unclear. Accordingly, this study aims to investigate the effects of different irrigation solution temperatures (cold/room temperature irrigation fluid versus warm/body temperature fluid). Our primary endpoint was hypothermia rate. Secondary outcomes were shivering rate, mean temperature decrease, mean patient final temperature, blood loss, and operative time. EVIDENCE ACQUISITION: This systematic review was conducted in accordance with PRISMA guidelines. Multiple databases were searched in November 2023. Among 299 studies screened, eight were selected for full-text review, resulting in four randomized clinical trials that fit inclusion criteria and desired outcomes. Studies selection and data extraction were performed by multiple reviewers and a random-effects model was used for pooling of data. EVIDENCE SYNTHESIS: The primary outcome, hypothermia rate, showed a significant statistical difference between groups, occurring less frequently in the experimental group (35-37 ºC) than in the cold/room temperature irrigation group (RR 0.64;95%CI 0.46, 0.89; P<0.008; I2=33%). Secondary outcomes such as shivering rate (RR 0.46; 95%CI 0.31, 0.67; P<0.0001; I2=0%) and mean final temperatures (MD 0.43; 95%CI 0.12, 0.75; I2=82%) also showed statistically significant differences between groups, favoring the irrigation with heated fluid. CONCLUSIONS: There was a decreased rate of hypothermia and shivering among patients undergoing PCNL with warm irrigation fluid. Mean final temperatures were also higher in the experimental group. As to blood loss, mean hemoglobin decrease showed no statistically significant difference between groups, prompting further investigation of the influence of Irrigation solution temperature on blood loss volume.

PCNL vs. two staged RIRS for kidney stones greater than 20 mm: systematic review, meta-analysis, and trial sequential analysis.

INTRODUCTION: Percutaneous nephrolithotomy (PCNL) is considered the gold standard treatment for kidney stones greater than 20 mm. However, retrograde intrarenal surgery (RIRS) may achieve the same stone-free rate with repeated procedures, and potentially fewer complications. This study aimed to compare the efficacy and safety of PCNL and two-staged RIRS. EVIDENCE ACQUISITION: We conducted a systematic search in PubMed, Embase, Scopus, Cochrane, and Web of Science for studies comparing PCNL and RIRS for kidney stones greater than 20mm. The primary outcome is stone-free rate (SFR) of PCNL and RIRS (repeated once if needed). Secondary outcomes were SFR of PCNL versus RIRS (single procedure), operative time, hospital stay, need for auxiliary procedures, and complications. We performed a subgroup analysis for randomized trials, non-randomized trials, and patients with solitary kidney. We performed a trial sequential analysis for the main outcome. EVIDENCE SYNTHESIS: We included 31 articles, with 1987 patients in the PCNL and 1724 patients in RIRS. We confirmed the traditional result that after a single procedure PCNL has a higher SFR. We also found that comparing the SFR of PCNL and RIRS, repeated up to two times if needed, no difference in SFR was observed. Surprisingly, only 26% (CI95 23%-28%) of the patients required a second RIRS. In the trial sequential analysis, the last point of the z-curve was within futility borders. We observed that PCNL has a higher incidence of complications (RR=1.51; CI95 1.24, 1.83; P<0.0001; I2=28%), specifically CD2 (RR=1.82; CI95 1.30, 2.54; P=0.0004; I2=26%) and longer hospital stay (MD 2.57; 2.18, 2.96; P<0.00001; I2-98%). No difference was observed regarding operative time. CONCLUSIONS: RIRS repeated up to two times is equivalent to PCNL in terms of the SFR and may have the same safety.

EUS-Guided Biliary Drainage Versus ERCP in Malignant Biliary Obstruction Before Hepatobiliary Surgery: An International Multicenter Comparative Study.

INTRODUCTION: Endoscopic ultrasound-guided biliary drainage (EUS-BD) is the procedure of choice for patients who cannot undergo endoscopic retrograde cholangiopancreatography (ERCP). The outcomes of patients undergoing surgery after EUS-BD for malignancy are unknown. METHODS: We conducted an international, multicenter retrospective comparative study of patients who underwent hepatobiliary surgery after having undergone EUS-BD or ERCP from 6 tertiary care centers. Patient demographics, procedural data, and follow-up care were collected in a registry. RESULTS: One hundred forty-five patients were included: EUS-BD n=58 (mean age 66, 45% male), ERCP n=87 (mean age 68, 53% male). The majority of patients had pancreatic cancer, cholangiocarcinoma, or gallbladder malignancy. In the EUS-BD group, 29 patients had hepaticogastrostomy, 24 had choledochoduodenostomy, and 5 had rendezvous technique done. The most common surgery was Whipple in both groups (n=41 EUS-BD, n=56 ERCP) followed by partial hepatectomy (n=7 EUS-BD, n=14 ERCP) and cholecystectomy (n=2 EUS-BD, n=2 ERCP). Endoscopy clinical success was comparable in both groups (98% EUS-BD, 94% ERCP). Adverse event rates were similar in both groups: EUS-BD (n=10, 17%) and ERCP (n=23, 26%). Surgery technical success and clinical success were significantly higher in the EUS-BD group compared with the ERCP group (97% vs. 83%, 97% vs. 75%). Total Hospital stay from surgery to discharge was significantly higher in the ERCP group (19 d vs. 10 d, P =0.0082). DISCUSSION: Undergoing EUS-BD versus ERCP before hepatobiliary surgery is associated with fewer repeat endoscopic interventions, shorter duration between endoscopy and surgical intervention, higher rates of surgical clinical success, and shorter length of hospital stay after surgery.

EUS-guided versus percutaneous liver abscess drainage: A multicenter collaborative study.

Background and Objectives: Management of hepatic abscesses has traditionally been performed by image-guided percutaneous techniques. More recently, EUS drainage has been shown to be efficacious and safe. The aim of this study is to compare EUS-guided versus percutaneous catheter drainage (PCD) of hepatic abscesses. Methods: Patients who underwent EUS-guided drainage or PCD of hepatic abscesses from January 2018 through November 2021 from 4 international academic centers were included in a dedicated registry. Demographics, clinical data preprocedure and postprocedure, abscess characteristics, procedural data, adverse events, and postprocedure care were collected. Results: Seventy-four patients were included (mean age, 63.9 years; 45% male): EUS-guided (n = 30), PCD (n = 44). Preprocedure Charlson Comorbidity Index scores were 4.3 for the EUS group and 4.3 for the PCD group. The median abscess size was 8.45 × 6 cm (length × width) in the EUS group versus 7.3 × 5.5 cm in the PCD group. All of the abscesses in the EUS group were left-sided, whereas the PCD group contained both left- and right-sided abscesses (29 and 15, respectively). Technical success was 100% in both groups. Ten-millimeter-diameter stents were used in most cases in the EUS group, and 10F catheters were used in the PCD group. The duration to resolution of symptoms from the initial procedure was 10.9 days less in the EUS group compared with the PCD group (P < 0.00001). Hospital length of stay was shorter in the EUS group by 5.2 days (P = 0.000126). The EUS group had significantly fewer number of repeat sessions: mean of 2 versus 7.7 (P < 0.00001) and trended toward fewer number of procedure-related readmissions: 10% versus 34%. The PCD group had a significantly higher number of adverse events (n = 27 [61%]) when compared with the EUS group (n = 5 [17%]; P = 0.0001). Conclusions: EUS-guided drainage is an efficacious and safe intervention for the management of hepatic abscesses. EUS-guided drainage allows for quicker resolution of symptoms, shorter length of hospital stay, fewer adverse events, and fewer procedural sessions needed when compared with the PCD technique. However, EUS-guided drainage may not be feasible in right-sided lesions.

Photodynamic Therapy (PDT), Radiofrequency Ablation (RFA) With Biliary Stents in Palliative Treatment of Unresectable Extrahepatic Cholangiocarcinoma: A Systematic Review and Meta-analysis.

BACKGROUND AND AIM: Extrahepatic unresectable cholangiocarcinoma carries a dismal prognosis. In addition to biliary drainage by stent placement; photodynamic therapy (PDT) and radiofrequency ablation (RFA) have been tried to prolong survival. In this meta-analysis, we appraise the current known data on the use of PDT, RFA in the palliative treatment of extrahepatic unresectable cholangiocarcinoma. METHODS: We searched multiple databases from inception through July 2020 to identify studies that reported on PDT and RFA. Pooled rates of survival, stent patency, 30-, 90-day mortality, and adverse events were calculated. Study heterogeneity was assessed using I2% and 95% prediction interval. RESULTS: A total of 55 studies (2146 patients) were included. A total of 1149 patients underwent treatment with PDT (33 studies), 545 with RFA (22 studies), and 452 patients with stent-only strategy. The pooled survival rate with PDT, RFA, and stent-only groups was 11.9 [95% confidence interval (CI): 10.7-13.1] months, 8.1 (95% CI: 6.4-9.9) months, and 6.7 (95% CI: 4.9-8.4) months, respectively. The pooled time of stent patency with PDT, RFA, and stent-only groups was 6.1 (95% CI: 4.2-8) months, 5.5 (95% CI: 4.2-6.7) months, and 4.7 (95% CI: 2.6-6.7) months, respectively. The pooled rate of 30-day mortality with PDT was 3.3% (95% CI: 1.6%-6.7%), with RFA was 7% (95% CI: 4.1%-11.7%) and with stent-only was 4.9% (95% CI: 1.7%-13.1%). The pooled rate of 90-day mortality with PDT was 10.4% (95% CI: 5.4%-19.2%) and with RFA was 16.3% (95% CI: 8.7%-28.6%). CONCLUSION: PDT seemed to demonstrate better overall survival and 30-day mortality rates than RFA and/or stent-only palliation.

Prevalence of Gastrointestinal Symptoms and Fecal Viral Shedding in Patients With Coronavirus Disease 2019: A Systematic Review and Meta-analysis.

Importance: Coronavirus disease 2019 (COVID-19) is a global pandemic and can involve the gastrointestinal (GI) tract, including symptoms like diarrhea and shedding of the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) in feces. Objective: To provide a pooled estimate of GI symptoms, liver enzyme levels outside reference ranges, and fecal tests positive for SARS-CoV-2 among patients with COVID-19. Data Sources: An electronic literature search was performed for published (using MEDLINE/PubMed and Embase) and preprint (using bioRxiv and medRxiv) studies of interest conducted from November 1, 2019, to March 30, 2020. Search terms included "COVID-19," "SARS-Cov-2," and/or "novel coronavirus." Study Selection: Eligible studies were those including patients with SARS-CoV-2 infection who reported GI symptoms. Data Extraction and Synthesis: Data on patients with GI symptoms (ie, diarrhea, nausea, or vomiting), liver enzyme level changes, and fecal shedding of virus were extracted. Quality of studies was examined using methodological index for nonrandomized studies. Pooled estimates (%) were reported with 95% CIs with level of heterogeneity (I2). Main Outcomes and Measures: Study and patient characteristics with pooled detection rates for diarrhea, nausea or vomiting, liver enzyme levels outside reference ranges, and SARS-CoV-2 positivity in feces tests were analyzed. Results: Of 1484 records reviewed, 23 published and 6 preprint studies were included in the analysis, with a total of 4805 patients (mean [SD] age, 52.2 [14.8] years; 1598 [33.2%] women) with COVID-19. The pooled rates were 7.4% (95% CI, 4.3%-12.2%) of patients reporting diarrhea and 4.6% (95% CI, 2.6%-8.0%) of patients reporting nausea or vomiting. The pooled rate for aspartate aminotransferase levels outside reference ranges was 20% (95% CI, 15.3%-25.6%) of patients, and the pooled rate for alanine aminotransferase levels outside reference ranges was 14.6% (95% CI, 12.8%-16.6%) of patients. Fecal tests that were positive for SARS-CoV-2 were reported in 8 studies, and viral RNA shedding was detected in feces in 40.5% (95% CI, 27.4%-55.1%) of patients. There was high level of heterogeneity (I2 = 94%), but no statistically significant publication bias noted. Conclusions and Relevance: These findings suggest that that 12% of patients with COVID-19 will manifest GI symptoms; however, SAR-CoV-2 shedding was observed in 40.5% of patients with confirmed SARS-CoV-2 infection. This highlights the need to better understand what measures are needed to prevent further spread of this highly contagious pathogen.

Comparative study of strategies to prevent esophageal and periesophageal injury during atrial fibrillation ablation.

OBJECTIVE: To compare the prevalence of esophageal and periesophageal thermal injury in patients undergoing radiofrequency (RF) atrial fibrillation (AF) ablation using 8 mm tip catheters during three different esophageal protection strategies. METHODS: Forty-five consecutive patients with paroxysmal or persistent AF underwent first ablation procedure, besides esophagogastroduodenoscopy (EGD) combined with radial endosonography (EUS) performed before and after the pulmonary vein (PV) isolation. Before the procedure, patients were randomly assigned to one of three esophageal lesion protection strategies: group I-without any protective or monitoring dispositive and limiting RF applications to 30 W for 20 seconds, in left atrium posterior wall (LAPW); group II-power and time of RF delivery, up to 50 W for 20 seconds at LAPW, limited by esophageal temperature monitoring; group III-applications of RF in LAPW with fixed power application of 50 W for 20 seconds during continuous esophageal cooling. RESULTS: Baseline characteristics of patients were similar in all groups. The four PVs were isolated in 14 (93.3%), 13 (86.7%), and 15 (100%) patients, respectively in groups I, II, and III. The mean RF power was significantly higher (P < .001) in the posterior side of PVs in group III. Post-AF ablation EGD and EUS revealed two esophageal wall ulcerations and two periesophageal mediastinal edemas only in the esophageal cooling group (P = .008). CONCLUSION: Esophageal cooling balloon strategy resulted in a higher RF power energy delivery when ablating at the LA posterior wall, using 8 mm nonirrigated tip catheters under temperature mode control. Despite that, patients presented a relatively low incidence of esophageal and periesophaeal injuries.

Gastrointestinal ischemia: endoscopic findings in the context of vascular insufficiency.

Gastrointestinal ischemia may result from different causes: hemodynamic shock, thromboembolism, endoscopic or surgical complications, among other causes. Its symptoms are pain, vomiting, bleeding and bloating. Endoscopic findings are pale or blackened mucosa, and exudative and confluent ulcerative lesions. This paper aims to report a case of gastroduodenal ischemia associated with hemodynamic shock and disseminated intravascular coagulation (DIC). This is a case of a 56-years- old male with multiple comorbidities, presenting with refractory septic shock and DIC. He underwent an upper gastrointestinal endoscopy (UGE) for investigation of melena, which revealed an extensive deep and exudative gastric ulcer, associated with edematous purplish duodenal mucosa. Due to the severity of the underlying condition, the patient evolved to death, evidencing septic shock as cause of death. Gastroduodenal ischemia is associated with a poor prognosis, in which early diagnosis by UGE is fundamental to guide potential interventions.

Updated analysis of irritable bowel syndrome: a review of the literature / Análisis actualizado del síndrome de intestino irritable: una revisión de la literatura

Irritable bowel syndrome (IBS) is a chronic pathology with disorders of the bowel-brain interaction, characterized by abdominal pain localized anywhere in the abdomen as well as bowel habit alteration (constipation, diarrhea or mixed), in the absence of any disease that can cause these symptoms. With the updated concepts according to the latest meeting of experts in Rome 2016, our goal is to raise awareness about irritable bowel syndrome, by reviewing the literature regarding definition, classification, pathophysiology, clinical aspects, treatment, prognosis and the future. IBS is a chronic pathology, characterized by abdominal pain, at least 1 day per week in the last 3 months, associated with the alteration of the intestinal bowel habits. With a classification based on the alteration of intestinal bowel movements and in addition to constipation induced by opioids or narcotics, the etiology and pathophysiology are not well explained or well-known so far. The clinical aspects are based on the Rome IV criteria. A good doctor-patient relationship is key to reassuring the patient's doubts about his illness, which increases the chances of adherence to individualized treatment from patient to patient depending on the sing and symptoms that may manifest in those that include: dietary advice, psychological support, in some cases pharmacological prescription, suspension of medications or change medications, minimize the dose of drugs or suspend, according to the needs of the patient as is the case of opioids. The prognosis is still uncertain, and a promising future to illustrate new definitions, classifications, pathophysiologies, clinical aspects and treatments according to the type of clinical manifestation of each patient.

El síndrome del intestino irritable (SII) es una patología crónica con desordenes de la interacción cerebro intestino, caracterizado por dolor abdominal localizado en cualquier parte del abdomen además de alteración del hábito intestinal como (constipación, diarrea o mixto), en ausencia de alguna enfermedad que pueda causar estos síntomas. Con los conceptos actualizados conforme en la última reunión de expertos en Roma 2016, nuestra meta es dar a conocer más sobre el síndrome del intestino irritable, mediante revisión de la literatura en cuanto a definición, clasificación, fisiopatología, aspectos clínicos, tratamiento, pronóstico y el futuro. El SII es una patología crónica, caracterizado por dolor abdominal, por lo menos 1 día por semana en los últimos 3 meses, asociado a la alteración del hábito intestinal. Con una clasificación basada en la alteración de los hábitos intestinales y además de constipación inducida por opioides o narcóticos, la etiología y fisiopatología no están bien explicadas ni se conocen bien hasta el momento. Los aspectos clínicos son basados en los criterios de Roma IV. Una buena relación médico-paciente es clave para tranquilizar las dudas del paciente sobre su enfermedad, lo que aumenta las posibilidades de adherencia al tratamiento individualizado de paciente a paciente dependiendo de las sintomatologías y signos que puedan manifestar en los que incluyen: asesoramiento dietético, apoyo psicológico, en algunos casos cambiar medicación, disminuir al mínimo la dosis del medicamento o suspender, según las necesidades del paciente como son los casos de los opiodes. El pronóstico todavía incierto, y un futuro prometedor para ilustrar nuevas definiciones, clasificaciones, fisiopatologías, aspectos clínicos, tratamientos posiblemente de acuerdo con el tipo de manifestación clínica de cada paciente.

Gastrointestinal ischemia: endoscopic findings in the context of vascular insufficiency

Gastrointestinal ischemia may result from different causes: hemodynamic shock, thromboembolism, endoscopic or surgical complications, among other causes. Its symptoms are pain, vomiting, bleeding and bloating. Endoscopic findings are pale or blackened mucosa, and exudative and confluent ulcerative lesions. This paper aims to report a case of gastroduodenal ischemia associated with hemodynamic shock and disseminated intravascular coagulation (DIC). This is a case of a 56-yearsold male with multiple comorbidities, presenting with refractory septic shock and DIC. He underwent an upper gastrointestinal endoscopy (UGE) for investigation of melena, which revealed an extensive deep and exudative gastric ulcer, associated with edematous purplish duodenal mucosa. Due to the severity of the underlying condition, the patient evolved to death, evidencing septic shock as cause of death. Gastroduodenal ischemia is associated with a poor prognosis, in which early diagnosis by UGE is fundamental to guide potential interventions.

La isquemia gastroduodenal puede resultar por diferentes causas: shock hemodinámico, tromboembolismo, complicaciones post-procedimientos endoscópicos o quirúrgicos, entre otras. Sus síntomas son dolor, vómito, hemorragia y distensión abdominal. Los hallazgos endoscópicos son mucosa pálida o ennegrecida, lesiones ulcerativas exudativas y confluentes. Este trabajo relata un caso de isquemia gastrointestinal, asociada a choque hemodinámico y coagulación intravascular diseminada (CID). Este es un caso de un hombre de 56 años de edad, con múltiples comorbilidades, que presenta con shock séptico refractario a tratamiento y CID. El paciente se sometió a una endoscopia digestiva alta (EDA) para la investigación de melena, que reveló una extensa úlcera gástrica exudativa y profunda, asociada con mucosa duodenal violácea e inflamada. Debido a la gravedad de la enfermedad de base, el paciente evolucionó a la muerte, siendo el shock séptico como causa principal. La isquemia gastrointestinal es asociada a un mal pronóstico, en el que el diagnóstico precoz por EDA es fundamental para orientar las posibles intervenciones.

Can ultrasound be used as an adjunct for tube thoracostomy? A systematic review of potential application to reduce procedure-related complications.

BACKGROUND: chest tube insertions are commonly performed in various scenarios. Although frequent, these procedures result in a significant complication rate, especially in the acute care setting. Ultrasonography has been incorporated to interventional procedures aiming to reduce the incidence of complications. However, little is known about the applications of ultrasound in tube thoracostomies. The aim of this systematic review is to present the potential applications of ultrasonography as an adjunct to the procedure. METHODS: we searched Medline/Pubmed, EMBASE and Scopus databases. Out of 3012 articles, we selected 19 for further analysis. Thirteen of those were excluded because they did not meet the inclusion criteria. Ultimately, 6 articles were thoroughly evaluated and included in the review. RESULTS: The included articles show that ultrasound can be used to correctly identify a safe insertion site, to accurately find a vulnerable intercostal artery, and is reliable for timely diagnosis of drain malpositioning. CONCLUSION: this systematic review highlights the potential benefits of incorporating ultrasonography in tube thoracostomies. No randomized clinical trials are available. However, it is reasonable to assume that proper use of ultrasound may reduce procedure-related complications.

EUS-guided drainage: Summary of therapeutic EUS consortium meeting.

EUS-guided drainage is a safe and efficacious endoscopic technique for biliary, pancreatic, and gallbladder decompression. Recent literature has described many successful procedural techniques and devices to achieve EUS-guided drainage. This consortium gathering advanced endoscopists with expertise in both ultrasonography and therapeutic endoscopy, discuss the introduction to learning several EUS-guided drainage approaches, devices, and technology involved, possible obstacles to certain procedural and all potential complications.

Intervencionismo endoscópico en la pancreatitis crónica / Endoscopic Intervention in Chronic Pancreatitis

Resumen La pancreatitis crónica es un trastorno irreversible y progresivo del páncreas caracterizado por inflamación, fibrosis y cicatrización. Las funciones exocrinas y endocrinas se pierden, lo que a menudo conduce al dolor crónico. La etiología es multifactorial, aunque el alcoholismo es el factor de riesgo más importante en los adultos. Si se sospecha pancreatitis crónica, la tomografía computarizada con contraste es la mejor modalidad de diagnóstico por imágenes. Aunque los narcóticos y los antidepresivos proporcionan el mayor alivio del dolor, más de la mitad de los pacientes eventualmente requiere una intervención por endoscopia o cirugía. La colangiopancreatografía retrógrada endoscópica es una alternativa eficaz para una variedad de terapias en el tratamiento de enfermedades benignas y malignas del páncreas. En los últimos 50 años, la endoterapia ha evolucionado hasta convertirse en la terapia de primera línea en la mayoría de las enfermedades inflamatorias agudas y crónicas del páncreas. A medida que avanza este campo, es importante que los gastroenterólogos mantengan un conocimiento adecuado de la indicación del procedimiento, mantengan el volumen de procedimiento suficiente para manejar la endoterapia pancreática compleja y comprendan enfoques alternativos a las enfermedades pancreáticas, incluidos el tratamiento médico, la terapia guiada por ecografía endoscópica, el manejo de las estenosis sintomáticas y cálculos, las intervenciones sobre el plexo celíaco y el drenaje de los pseudoquistes pancreáticos.

Abstract Chronic pancreatitis is an irreversible and progressive disorder of the pancreas characterized by inflammation, fibrosis and scarring. Exocrine and endocrine functions are lost often leading to chronic pain. Its etiology is multifactorial, although alcoholism is the most important risk factor in adults. If chronic pancreatitis is suspected, computed tomography with contrast is the best imaging modality. Although narcotics and antidepressants provide the greatest pain relief, more than half of all patients eventually require intervention by endoscopy or surgery. Endoscopic retrograde cholangiopancreatography (ERCP) is an effective alternative for a variety of therapies for treating benign and malignant diseases of the pancreas. In the last 50 years, endoscopic treatment has evolved to become the first-line therapy for most acute and chronic inflammatory diseases of the pancreas. As this field progresses, it has become important for gastroenterologists to keep their knowledge of indications for this procedure up-to-date and to perform a sufficient volume of procedures to allow them to manage complex pancreatic endoscopic therapy. Keeping up-to-date should include an understanding of alternative approaches to pancreatic diseases including medical treatment, therapy guided by endoscopic ultrasound, management of symptomatic stenoses and stones, interventions on the celiac plexus, and drainage of pancreatic pseudocysts.

Updated analysis of irritable bowel syndrome: a review of the literature.

Irritable bowel syndrome (IBS) is a chronic pathology with disorders of the bowel-brain interaction, characterized by abdominal pain localized anywhere in the abdomen as well as bowel habit alteration (constipation, diarrhea or mixed), in the absence of any disease that can cause these symptoms. With the updated concepts according to the latest meeting of experts in Rome 2016, our goal is to raise awareness about irritable bowel syndrome, by reviewing the literature regarding definition, classification, pathophysiology, clinical aspects, treatment, prognosis and the future. IBS is a chronic pathology, characterized by abdominal pain, at least 1 day per week in the last 3 months, associated with the alteration of the intestinal bowel habits. With a classification based on the alteration of intestinal bowel movements and in addition to constipation induced by opioids or narcotics, the etiology and pathophysiology are not well explained or well-known so far. The clinical aspects are based on the Rome IV criteria. A good doctor-patient relationship is key to reassuring the patient's doubts about his illness, which increases the chances of adherence to individualized treatment from patient to patient depending on the sing and symptoms that may manifest in those that include: dietary advice, psychological support, in some cases pharmacological prescription, suspension of medications or change medications, minimize the dose of drugs or suspend, according to the needs of the patient as is the case of opioids. The prognosis is still uncertain, and a promising future to illustrate new definitions, classifications, pathophysiologies, clinical aspects and treatments according to the type of clinical manifestation of each patient.

Rendez-Vous laparoendoscopic after ERCP failure in patient with Billroth II gastrectomy / Laparoscopía por Rendez-Vous luego de falla de CPRE en un paciente con gastectomía Billroth II

Endoscopic retrograde cholangiopancreatography (ERCP) is the treatment of choice in patients with choledocholithiasis. However, despite its high success rate, in some cases it is not successful, requiring alternative therapy. Billroth II partial gastrectomy is a condition associated with an important failure rate of ERCP. When endoscopic treatment fails, surgical exploration of the bile duct is the most common approach. However, the surgery is related to a greater complexity of execution and morbimortality. We describe the case of a patient with choledocholithiasis and Billroth II partial gastrectomy, submitted to the combined treatment called rendez-vous laparoendoscopic, after failure of ERCP, which unites in a single stage the endoscopic treatment of choledocholithiasis and laparoscopic removal of the gallbladder. We conclude that this therapeutic approach was effective, safe, with low cost and without complications.

La colangiopancreatografía endoscópica retrógrada (CPRE) es el tratamiento de elección en pacientes portadores de coledocolitiasis. Sin embargo, a pesar de su elevada tasa de éxito, en algunos casos no es exitosa, exigiendo terapia alternativa. La gastrectomía parcial con reconstrucción a Billroth II es una condición asociada a la importante tasa de fracaso de la CPRE. Cuando el tratamiento endoscópico falla, la exploración quirúrgica de la vía biliar es un enfoque más común. Sin embargo, la cirugía se relaciona con una mayor complejidad de ejecución y morbimortalidad. Describimos el caso de un paciente con coledocolitiasis y gastrectomía parcial con reconstrucción a Billroth II, sometido al tratamiento combinado denominado rendez-vous laparoendoscópico tras fallo de la CPRE, que une en una sola etapa el tratamiento endoscópico de la coledocolitiasis y la retirada laparoscópica de la vesícula biliar. Llegamos a la conclusión de que este enfoque terapéutico fue eficaz, seguro, de bajo costo y sin complicaciones.

FULL-THICKNESS ENDOSCOPIC GASTRIC RESECTION USING A STAPLER AND GASTROSTOMY: A FEASIBILITY STUDY.

BACKGROUND: Laparoscopic sleeve gastrectomy (LSG) is currently the most frequently performed bariatric procedure in Turkey. The goal of weight reduction surgery is not only to decrease excess weight, but also to improve obesity related comorbidities and quality of life (QoL). AIM: To evaluate the impact of LSG on patient quality of life, weight loss, and comorbidities associated with morbid obesity according to the updated BAROS criteria. METHODS: Eleven hundred thirty-eight adult patients were undergone to LSG by our bariatric surgery team between January 2013 and January 2016. A questionnaire (The Bariatric Analysis and Reporting Outcome System - BAROS) was published on social media. The data on postoperative complications were collected from hospital database. RESULTS: Number of respondants was 562 (49.4%). Six of 1138 patients(0.5%) had leakage. All patients who had leakage were respondants. The overall complication rate was 7.7%. After a mean period of 7.4±5.3 months(1-30), mean excess weight loss was 71.3±27.1% (10.2-155.4). The respondants reported 772 comorbidities. Of these, 162 (30%) were improved, and 420 (54.4%) were resolved. The mean scores for QoL were significantly increased after LSG (range, p<0.05 to <0.001). Of the 562 patients, 26 (4.6%) were classified as failures; 86 (15.3%) fair; 196 (34.9%) good; 144 (25.6%) very good, and 110 (19.6%) excellent results according to the updated BAROS scoring system. CONCLUSION: LSG is a highly effective bariatric procedure in the manner of weight control, improvement in comorbidities and increasing of QoL in short- and mid-term.

Upper gastrointestinal endoscopy applied in pediatrics: endoscopic and histological findings, including Helicobacter pylori.

OBJECTIVE: To present and discuss the endoscopic and histological results, as well as the incidence of Helicobacter pylori and other diseases, indications and characteristics of upper digestive endoscopies performed in children. MATERIAL AND METHODS: Twenty-five endoscopies were performed in children aged six months to 11 years (mean 7.69 years), from February 2013 to January 2016. In 200 patients, endoscopies were diagnostic and serial biopsies were performed (esophagus, stomach and duodenum), in 120 of them. RESULTS: The indication of endoscopy was diagnosed in 88.89% of the patients, and in 26 patients, a therapeutic procedure was performed. The most frequent endoscopic findings were esophagitis in 49 patients, gastritis in 84 and duodenitis in 16 patients. Four duodenal ulcers were diagnosed. In the therapeutic endoscopies, six gastrostomies were performed, 14 foreign body withdrawals, five nasoenteral tube passages and esophageal dilatation. The H. pylori survey was performed by anatomopathological method and was positive in 26 (13%) of the 200 patients in whom it was searched. CONCLUSION: pediatric endoscopy is an important niche of the digestive endoscopy, where it is important to emphasize the relevance of the institutional structure that performs these procedures, in order to conduct them safely, being able to treat possible and feasible complications.

Ex vivos models to teaching therapeutic endoscopic ultrasound (T-EUS).

BACKGROUND: Endoscopic ultrasound training has a learning curve greater than the other endoscopic therapeutic techniques. One of the preclinical teaching methods is the use of ex vivo porcine models. AIM: To describe five ex vivo porcine models for training in therapeutic echoendoscopic procedures. MATERIALS AND METHODS: Using porcine digestive tract containing esophagus, stomach, duodenum, spleen, liver and gallbladder, five models for therapeutic echoendoscopy training were described. With other segments of the porcine pieces (such as the bladder, spleen segment and omentum segment) and with easily accessible materials (such as grape and ultrasound gel), lesions were simulated to be treated. These models were applied in the Hands on course at the IRCAD (Institut de recherche contre les cancers de l'appareil digestif) Barretos of 2017. Endoscopic equipment and instruments are the same as those used in clinical practice. RESULT: The models are easily reproducible and do not require exchange during the hands on course period. Endoscopic and echographic imaging and tactile sensitivity are similar to the real one. CONCLUSION: The models described in this study demonstrated to be realistic, easy to reproduce and allow repetition during the same session. However, comparative studies are necessary to verify the real impact on teaching.

Upper gastrointestinal endoscopy applied in pediatrics: endoscopic and histological findings, including Helicobacter pylori / Endoscopia digestiva alta aplicada em pediatria: hallazgos endoscópicos e histológicos incluyendo al Helicobacter pylory

Objective: To present and discuss the endoscopic and histological results, as well as the incidence of Helicobacter pylori and other diseases, indications and characteristics of upper digestive endoscopies performed in children. Material and methods: Twenty-five endoscopies were performed in children aged six months to 11 years (mean 7.69 years), from February 2013 to January 2016. In 200 patients, endoscopies were diagnostic and serial biopsies were performed (esophagus, stomach and duodenum), in 120 of them. Results: The indication of endoscopy was diagnosed in 88.89% of the patients, and in 26 patients, a therapeutic procedure was performed. The most frequent endoscopic findings were esophagitis in 49 patients, gastritis in 84 and duodenitis in 16 patients. Four duodenal ulcers were diagnosed. In the therapeutic endoscopies, six gastrostomies were performed, 14 foreign body withdrawals, five nasoenteral tube passages and esophageal dilatation. The H. pylori survey was performed by anatomopathological method and was positive in 26 (13%) of the 200 patients in whom it was searched. Conclusion: pediatric endoscopy is an important niche of the digestive endoscopy, where it is important to emphasize the relevance of the institutional structure that performs these procedures, in order to conduct them safely, being able to treat possible and feasible complications

Objetivo: Presentar y discutir los hallazgos endoscópicos e histológicos, así como la incidencia de Helicobacter pylori y otras enfermedades, indicaciones y características de endoscopia digestiva alta realizada en niños. Material y métodos: Fueron realizadas 225 endoscopias en niños de seis meses a 11 años (media de 7,69 años) a partir de febrero de 2013 hasta enero de 2016. En 200 pacientes, en las endoscopias diagnósticas se llevan a cabo biopsias seriadas (esófago, estómago y duodeno) en 120 de ellos. Resultados: La indicación de endoscopia fue diagnóstica en el 88,89% de los pacientes y en 26 pacientes se realizaron un procedimiento terapéutico. Los hallazgos endoscópicos más frecuentes fueron esofagitis en 49 pacientes, gastritis y duodenitis 84 y en 16 pacientes se diagnosticaron cuatro úlceras duodenales. En endoscopias terapéuticas fueron realizadas seis gastrostomías, catorce extracciones de cuerpos extraños, cinco pasajes de sonda nasogástrica y una dilatación esofágica. El estudio de H. pylori se realizó por el método histopatológico y fué positivo en 26 (13%) de 200 pacientes en los que se han buscado. Conclusión: La endoscopía pediátrica es un nicho importante de la endoscopía digestiva donde es importante enfatizar la relevancia de la estructura institucional que realiza estos procedimientos para conducirlos con seguridad y ser capaces de tratar las complicaciones posibles