Utilidad del contraste endovenoso en ecoendoscopía pancreática. Reporte de casos / Usefulness of intravenous contrast in pancreatic echoendoscopy. A case series

RESUMEN El empleo del contraste endovenoso permite aumentar la capacidad diagnostica de la ecoendoscopía en muchas condiciones patológicas de forma no invasiva, mediante la evaluación de patrones de realce en tiempo real (hipo, iso e hipercaptación), permitiendo a su vez definir diagnósticos diferenciales o predecir diagnósticos histológicos con alta precisión por medio de la caracterización de la vascularidad o microvasculatura de un órgano o lesión. Sin embargo, su empleo en nuestro medio está limitado por no contar con estos medios de contraste. Reportamos tres casos de ecoendoscopía contrastada realizada en patología pancreática realizada en nuestro hospital, en el que se describe la utilidad en el diagnóstico y manejo de lesiones sólidas y quísticas del páncreas.

ABSTRACT The intravenous contrast (IV) allows for improving the diagnostic accuracy of echoendoscopy for many pathologic conditions. IV contrast provides a non-invasive method that through the use of real-time enhancement patterns (hypo, iso, and hypercaptation), a highly accurate histological diagnosis can be made by characterizing the microvasculature of an organ or a lesion. However, the lack of availability of IV contrast limited its use in our setting. We reported three cases of endoscopic ultrasound with IV contrast performed in the pancreatic department of National Hospital Eduardo Rebagliati Martins in Lima, Peru. We described the effectiveness of IV contrast in the diagnosis and the management of solid and cystic lesions in the pancreas.

Desarrollo de modelos educativos para el aprendizaje de nuevas técnicas endoscópicas: miotomía endoscópica por vía oral (POEM) y elastografía por ultrasonido endoscópico / Educational models for learning Peroral Endoscopic Myotomy (POEM) and Endoscopic Ultrasound Elastography

Resumen Objetivos: presentar el desarrollo de modelos educativos para el aprendizaje de dos técnicas endoscópicas vigentes, ampliamente difundidas y de gran implicación clínica, con la única intención de permitir la adquisición de destrezas básicas y avanzadas a residentes y gastroenterólogos. Materiales y métodos: se idearon dos modelos sencillos, de muy bajo costo, fácilmente reproducibles y reutilizables, con los cuales se logra ejecutar la totalidad de los procedimientos descritos. Además, permiten al operador integrar el desarrollo de habilidades y la adquisición de los conceptos teóricos mínimos requeridos, sin las presiones generadas por el riesgo existente de complicaciones. Resultados: la tendencia actual a nivel mundial se conduce hacia el desarrollo de modelos de enseñanza que aceleren la curva de aprendizaje, así como de procedimientos altamente exigentes y asociados a complicaciones potencialmente graves. Con estos modelos es posible poner a prueba al endoscopista, mediante una evaluación continua y supervisada. Su implementación en unidades de gastroenterología es sencilla, sin la necesidad de una inversión superlativa o el desplazamiento a otros países. Conclusiones: se trata de un gran aporte al desarrollo científico y educativo de nuestro país, ya que la creación y la implementación de nuevas técnicas endoscópicas y su aprendizaje no deben ser asumidos por los pacientes. En este punto, estamos de acuerdo con los conceptos emitidos por diferentes asociaciones médicas respecto a que los cursos teórico-prácticos de corta duración -y en algunas ocasiones virtuales- no constituyen una formación mínima, requerida para lograr la acreditación.

Abstract Objectives: This article presents the development of educational models for learning two widespread recent endoscopic techniques which have great clinical implications. Its sole intention is to allow acquisition of basic and advanced skills by residents and gastroenterologists. Materials and methods: Two simple, very low cost, easily reproducible and reusable models were devised. Procedures are fully described in ways that allow the operator to integrate the development of skills and acquisition of the minimum theoretical concepts required without the pressures generated by risks of complications. Results: The current global trend is to develop teaching models that accelerate the learning curve for highly demanding procedures that are associated with potentially serious complications. With these models it is possible to test endoscopists through continuous supervised evaluations. Implementation by gastroenterology units can be done easily without the need for large investments or travel to other countries. Conclusions: This is a great contribution to the scientific and educational development of Colombia since neither development of new endoscopic techniques nor the process of learning how to perform them should put patients at risk. We agree with the ideas of numerous medical associations regarding theoretical-practical courses of short duration even though some virtual sessions, "do not constitute the minimum training required needed for accreditation".

Eficacia de la ultrasonografía endoscópica en la estadificación de tumores del recto / Endoscopic ultrasound efficacy in the staging of rectal cancer

Introducción: el cáncer rectal representa un problema de salud en el mundo y la estadificación clínica constituye la llave para definir la conducta a seguir. Objetivo: determinar la eficacia de la ecoendoscopia en el estadiaje T y N del cáncer rectal. Métodos: se realizó un estudio descriptivo, desde enero del 2014 hasta marzo del 2016, se seleccionaron un total de 33 pacientes que se habían realizado ecoendoscopia y que luego fueron intervenidos quirúrgicamente. Se comparó la estadificación mediante ecoendoscopia con el informe anatomopatológico de la pieza quirúrgica obtenida. Se calculó concordancia global y eficacia diagnóstica en los diferentes estadios del cáncer rectal. Resultados: la concordancia global para la etapa T fue 57,6 por ciento y 87,9 por ciento para N. La precisión diagnóstica en pacientes que recibieron adyuvancia resultó del 47,1 por ciento y 82,4 por ciento para las etapas T y N respectivamente. La eficacia diagnóstica por subetapas T resultó en valores respectivos de sensibilidad y especificidad de 71,43 por ciento (95 por ciento CI 64 por ciento-79 por ciento) y 84,6 por ciento (95 por ciento CI 82 por ciento-86 por ciento) en T1; 76,9 por ciento (95 por ciento CI 73 por ciento-81 por ciento) y 70,0 por ciento (95 por ciento CI 67 por ciento-73 por ciento) en T2; y 42,8 por ciento (95 por ciento CI 35,5 por ciento-50,2 por ciento) y 96,2 por ciento (95 por ciento CI 94,2 por ciento-98,1 por ciento) en T3. Conclusiones: la concordancia global en T resultó inferior a lo reportado en la literatura consultada así como la eficacia diagnóstica de la técnica, debido a que 17 pacientes tuvieron tratamiento adyuvante previo. No hubo resultados significativos en la evaluación de la etapa N(AU)

Introduction: Rectal cancer represents a health problem nowadays worldwide, for that reason an accurate clinical staging of the disease is fundamental to define the proper behavior to follow. Objective: To determine the efficacy of endoscopic ultrasound for staging rectal cancer. Methods: A descriptive study was carried out, from January 2014 to March 2016 in Cuban National Center of Minimal Access Surgery in 33 patients (17 men and 16 women) who had undergone endoscopic ultrasound and who underwent surgery too. Their endoscopic ultrasound staging were compared with their anatomopathological reports of the surgical pieces obtained. Global concordance and diagnostic efficacy were calculated. Results: The overall concordance for stage T was 57.6 percent and 87.9 percent for N. The diagnostic accuracy in the patients that received adjuvant treatment previously was lower than the group of patients that not received it. The diagnostic efficacy by sub-steps T resulted in respective values of sensitivity and specificity of 71.43 percent and 84.6 percent in T1; 76.9 percent and 70.0 percent in T2; and 42.8 percent and 96.2 percent in T3. Conclusions: The overall concordance in T was lower than that reported in the literature consulted as well as the diagnostic efficacy of the technique, because 17 patients had previous adjuvant treatment. There were no significant results in the evaluation of stage N(AU)

Esteatosis Pancreática secundaria a tratamiento prolongado con esteroide. Reporte de un caso / Secondary Pancreatic Esteatosis to Prolonged Steroid Treatment. Reporting a Case

Introducción: El reemplazo graso del páncreas, esteatosis o lipomatosis pancreática es un proceso difuso o focal en cualquier segmento del órgano y se ha asociado a obesidad, diabetes mellitus y fibrosis quística. El ultrasonido abdominal y en especial la ecoendoscopia , permiten una mejor caracterización del parénquima de la glándula. Caso Clínico: adolescente femenina de 13 años referida por dolor abdominal crónico. Antecedentes: Gastritis crónica por Helicobacter pylori, Alergia alimentaria múltiple y en tratamiento con Metilprednisolona durante siete años por Artritis Reumatoidea Juvenil. Examen físico : Peso 40,9Kg y talla 134cm, fascie redondeada, catarata bilateral, cuello con hiperqueratosis e hiperpigmentación . Abdomen: globoso, blando, sin visceromegalia. Hipotrofia muscular miembros inferiores. Laboratorio : amilasa: 32U/L, lipasa 12.3U/L, colesterol 206mg%, triglicéridos 117 mg%, aminotransferasa pirúvica 60U/L, PCR ultrasensible 11,6 mg/l, relación insulina/glicemia postprandial alta, 25OHvitamina D: 5,5ng/ ml (déficit), cortisol y androstenediona bajos, exámenes negativos para enfermedad autoinmune En heces: esteatocrito 4.5% y Sudan III:15 a 20 gotas pequeñas. Edad ósea radiológica 11años. Ultrasonido abdominal: hiperecogenicidad periportal, páncreas ligeramente aumentado de tamaño con aumento difuso de su ecogenicidad, cabeza: 30mm, cuerpo:13mm y cola:30mm. Ultrasonido endoscópico: Proceso uncinado y cabeza con parénquima homogéneo, ecogenicidad conservada. En el itsmo, cuerpo y cola parénquima heterogéneo , con tendencia a la hiperecogenicidad. Wirsung: calibre normal. Diagnóstico clínico: Esteatosis pancreática, Síndrome de Cushing Exógeno y Resistencia a la Insulina con déficit vitamina D. Discusión : Se considera que existe relación positiva entre el uso prolongado de esteroide para el reemplazo graso del páncreas y las patologías asociadas como se evidencia en este caso.

Introduction: Fatty pancreas replacement, steatosis or pancreatic lipomatosis is a diffuse or focal process in any organ segment and has been associated with obesit y, diabetes mellitus and cystic fibrosis. Abdominal ultrasound and, in particular, ultrasound endoscopy allow a better characterization of the parenchyma of the gland. Case Clinical: 13 - year - old female adolescent referred for chronic abdominal pain. Backgr ound: Chronic gastritis by Helicobacter pylori, multiple food allergy and treatment with Methylprednisolone for seven years for Juvenile Rheumatoid Arthritis. Physical examination: Weight 40.9Kg and size 134cm, rounded fascia, bilateral cataract, neck with hyperkeratosis and hyperpigmentation. Abdomen: globose, soft, without visceromegaly. Muscle lower limb hypotrophy. Laboratory: amylase: 32U / L, lipase 12.3U / L, cholesterol 206mg%, triglycerides 117mg%, pyruvic aminotransferase 60U / L, ultrasensitive 1 1.6mg / l, insulin ratio / high postprandial glycemia, 25OH vitamin D: 5ng / ml (deficit), cortisol and low Androstenedione, negative tests for autoimmune disease Feces: steatocrit 4.5% and Sudan III: 15 to 20 small drops. Radiologic bone age 11 years. Abd ominal ultrasound: periportal hyperechogenicity, slightly enlarged pancreas with diffuse increase of its echogenicity, head: 30mm, body: 13mm and tail: 30mm. Endoscopic ultrasound: Uncinate process and head with homogeneous parenchyma, preserved echogenici ty. In the ismo, body and parenchyma heterogeneous, with tendency to hyperechogenicity. Wirsung: normal caliber. Clinical diagnosis: Pancreatic steatosis, Exogenous Cushing's Syndrome and Insulin Resistance with vitamin D deficit. Discussion: It is considered that t here is a positive relationship between prolonged steroid use for fatty replacement of the pancreas and associated pathologies as evidenced in this case.

¿Cuál es el tamaño normal del conducto biliar común? / What is the normal size of the common bile duct?

Resumen Tradicionalmente se ha señalado que el conducto biliar común (CBC) mide hasta 6 mm en pacientes con vesícula y 8 mm en los colecistectomizados; sin embargo, estas recomendaciones se basan en trabajos muy antiguos realizados con ecografía transabdominal (ET). La ecoendoscopia (USE) es el examen con una mayor sensibilidad y especificidad para evaluar la vía biliar, aunque aún no se han realizado estudios en nuestra población que evalúen cual es el tamaño normal del CBC por este método. Objetivo: evaluar el tamaño del CBC en pacientes con o sin vesícula biliar (VB). Materiales y métodos: se realiza un estudio descriptivo prospectivo en pacientes enviados para la realización de USE a la unidad de gastroenterología del Hospital El Tunal, Universidad Nacional de Colombia, se recolectaron los pacientes que fueron enviados para la realización de una USE diagnóstica referidos para la evaluación de lesiones subepiteliales en esófago y/o estómago. Una vez se realizó la evaluación de la lesión y se estableció el diagnóstico ecoendoscópico, se procede a avanzar el transductor hasta la segunda porción duodenal desde donde se realiza una USE biliopancreática. Se midió el tamaño del CBC a nivel de la arteria hepática, como es la recomendación para evitar alterar el tamaño del CBC. Estos datos fueron recolectados en formularios en línea diligenciados durante el procedimiento ecoendoscópico teniendo como base Google drive. Resultados: el trabajo se desarrolla entre enero de 2013 y septiembre de 2013, período durante el cual se realizaron 100 USE por lesiones subepiteliales en el tracto digestivo alto. Dentro de las características específicas de los pacientes se encontró que el promedio de edad fue de 55,6 años; el 65% de los pacientes fueron mujeres; el 18% de los pacientes tenían colecistectomía previa, de este grupo de pacientes el 50 % fueron mujeres. El tamaño del colédoco en promedio fue 4,88 mm (intervalo entre 2,6-7 mm), en el grupo de pacientes con VB (88%) el tamaño promedio del colédoco fue de 4,16 mm (intervalo entre 2,6-6 mm), en el subgrupo de mujeres con vesícula intacta el CBC el promedio fue de 3,9 mm (intervalo entre 2,6-5 mm) y en hombres con vesícula intacta el CBC fue de 4,42 mm (intervalo entre 3-6 mm), en el grupo de pacientes colecistectomizados el tamaño promedio del colédoco fue de 4,88 mm (intervalo entre 3-7 mm), en el grupo de mujeres colecistectomizadas el promedio fue de 4,84 mm (intervalo entre 4,6-7 mm) y en hombres colecistectomizados el promedio fue de 4,92 mm (intervalo entre 3-7 mm). Conclusiones: nuestro trabajo muestra que el tamaño normal del colédoco promedio es de 4,16 mm, menor a lo aceptado por la literatura y 4,88 mm en pacientes colecistectomizados. Esto es interesante, puesto que si se tiene un tamaño mayor, se obligaría a descartar patología biliopancreática con la realización de ecoendoscopia diagnóstica.

Abstract Traditionally, the common bile duct (CBD) has been said to measure up to 6 mm in patients with gallbladders and up to 8 mm in cholecystectomized patients. However, these recommendations are based on very old studies performed with trans-abdominal ultrasound. Echoendoscopy has greater sensitivity and specificity for evaluating the bile duct, but studies had not yet been done in our population to evaluate the normal size of the CBD by this method. Objective: The objective of this study was to evaluate the size of the CBD in patients with gallbladders and patients without gallbladders. Materials and Methods: This is a prospective descriptive study of patients who underwent echoendoscopy at the gastroenterology unit in the El Tunal hospital, Universidad Nacional de Colombia. Patients had been referred for diagnostic echoendoscopy to evaluate subepithelial lesions in the esophagus and/or stomach. Once the lesion had been evaluated and an echoendoscopic diagnosis had been established, the transducer was advanced to the second duodenal portion to perform bilio-pancreatic echoendoscopy. The size of CBC at the hepatic artery was measured to avoid altering the size of the CBC. These data were collected in online forms in Google drive that were filled out during the echoendoscopic procedure. A scatter plot was graphed and analyzed to assess the size of the common bile duct in the entire study population. Results: The study took place between January 2013 and September 2013 during which time 100 echoendoscopies were performed for subepithelial lesions in the upper digestive tract. The average patient age was 55.6 years, 65% of the patients were women, 18% of the patients had had previous cholecystectomies and 50% of these patients were women. The average common bile duct size was 4.88 mm (range: 2.6 to 7 mm). In the group with intact gallbladders (88%) the average CBC was 4.16 mm (range 2.6 to 6 mm), among women with intact gallbladders the average CBC was 3.9 mm (range 2.6 to 5 mm) and among men with intact gallbladders the average CBC was 4.42 mm (range 3 to 6 mm). In the group of cholecystectomized patients the average CBC was 4.88 mm (range 3 to 7 mm), in the group of cholecystectomized women the average was 4.84 mm (range 4.6 to 7 mm), and among cholecystectomized men the average was 4.92 mm (range: 3 to 7 mm). Conclusions: Our study shows that the normal size of the common bile duct is 4.16 mm. This is smaller than the size accepted by the literature and than the 4.88 mm in cholecystectomy patients. This is interesting, since if the common bile duct is indeed larger following cholecystectomy, we could discard biliopancreatic pathology with diagnostic echoendoscopy.

Drenaje de pseudoquiste pancreático guiado por ecoendoscopia sin fluoroscopia: serie de casos / Case Series of Drainage of Pancreatic Pseudocysts Guided by Echoendoscopy without Fluoroscopy

Resumen Introducción: los pseudoquistes pancreáticos pueden ser drenados por métodos quirúrgicos, laparoscópicos, percutáneos y endoscópicos. Este último es el más aceptado en la actualidad dado que es más simple y genera menos morbimortalidad; sin embargo, siempre se ha descrito asociado con el uso de la fluoroscopia, lo cual le suma complejidad. En este trabajo presentamos nuestra técnica de drenaje sin fluoroscopia guiado por ecoendoscopia. Materiales y métodos: el objetivo de este trabajo es describir una técnica de drenaje de pseudoquistes pancreáticos sin el uso de fluoroscopia y con la guía del ecoendoscopio. Se reporta una serie de casos de 10 pacientes a quienes se les realizó drenaje transgástrico, en los que se describen la técnica, complicaciones y resultados en el seguimiento. Resultados: se incluyeron 10 pacientes consecutivos, 5 pacientes eran mujeres y 5 hombres. El 90% de los casos comprometía el cuerpo del páncreas. Se implantó exitosamente 1 stent (metálico) transmural (cistogastrostomía) solo con guía ecoendoscópica en 9 pacientes; en 1 paciente no se logró liberar el stent, por lo cual se realizó el drenaje por aspiración. Los 9 pacientes a quienes se les implantó stent no presentaron recidiva; la paciente a quien se realizó drenaje por aspiración presentó recidiva a nivel del cuerpo de páncreas. La principal complicación fue la migración del stent hacia la cavidad del pseudoquiste en 1 paciente, el cual requirió segundo tiempo endoscópico para retirarlo. Conclusiones: el drenaje transmural del pseudoquiste pancreático con implante de stent es una técnica mínimamente invasiva, segura y efectiva para el tratamiento del pseudoquiste pancreático.

Abstract Introduction: Pancreatic pseudocysts can be drained by surgical, laparoscopic, percutaneous, and endoscopic methods. Endoscopic methods have become the most widely accepted nowadays since they are simpler and generate less morbidity and mortality. They have always been associated with the use of fluoroscopy, which adds complexity. This study presents our drainage technique which is guided by echoendoscopy rather than fluoroscopy. Materials and methods: The objective of this study is to describe a technique for drainage of pancreatic pseudocysts which does not use fluoroscopy to guide the endoscope. Instead, echoendoscopy guides the instrument. We report a case series of 10 patients who underwent transgastric drainage and describe the technique, complications and results during follow-up. Results: Ten consecutive patients, five women and five men, were included in this study. Ninety percent were cases in which the body of the pancreas had been compromised. Cystogastrostomy was successfully performed in nine patients. It consisted of implantation of a transmural metallic stent under single endoscopic guidance. In one patient the stent was not released and aspiration drainage was performed. The nine patients who had stents implanted have presented no recurrences, but the patient who underwent aspiration drainage presented recurrence in the body of the pancreas. The main complication was migration of the stent into the pseudocyst cavity which occurred in one patient and which required a second endoscopic procedure to remove the stent. Conclusions: Transmural drainage of pancreatic pseudocysts through placement of stents is a safe, effective and minimally invasive technique for the treatment of pancreatic pseudocysts.

Lesões Císticas do Pâncreas / Prancreatic cystic lesions

As lesões císticas do pâncreas são peculiares em relação ao diagnóstico e ao tratamento. O recurso da ecoendoscopia promoveu melhor processo na diferenciação entre as lesões com características benignas e as malignas. Trata-se de afecção de alta possibilidade de cura na ocasião do diagnóstico precoce, oferecendo-se tratamento efetivo e impactante. Didaticamente, podemos dividir em tipos de lesões macro e microcística: a primeira poderá apresentar-se com características de malignidade; já a segunda demonstra-se ser lesão benigna. As lesões císticas tipo IPMN estão detalhadas neste artigo e o tratamento cirúrgico é a opção justificada naqueles pacientes com lesões no ducto pancreático principal. Caso contrário, nos pacientes com IPMN dos ductos secundários, o acompanhamento poderá ser feito pela ecoendoscopia. Finalmente, as lesões císticas do pâncreas devem ser avaliadas por abordagem multidisciplinar, alcançando-se assim o melhor tratamento possível ao paciente.

The cystic pancreatic lesions have particularities regarding diagnostic and treatment ways. The resources on EUS raised up better process to be diferetiating those cases with benign and malignant features. It is a lesion with high probability to bring an early diagnosis and with an effective and prompt treatment. It will be didactly share the types of lesions in macro and microcystics, the first one could be raised up the features of malignancy, on the other hand the last one push up the benigns lesions. IPMN lesions are detailed in the manuscript and in those patients with main pancreatic duct lesions the surgical treatment is the rationale otpion. Otherwise, patients with side branch IPMN, the follow up could be taken by using EUS findings. Finally, pancreatic cystic lesions should be assessed by multidisciplinary approach intending the best treatment chance.

Endoscopic ultrasound practice survey in latin america.

OBJECTIVE: Endoscopic ultrasound (EUS) has become an important imaging modality for the diagnosis, staging and treatment of gastrointestinal disorders. However, no official data exists regarding clinical EUS practice in Latin America (LA). This study assessed current EUS practice and training. PATIENTS AND METHODS: A direct mail survey questionnaire was sent to 268 Capítulo Latino Americano de Ultrasonido Endoscópico members between August 2012 and January 2013. The questionnaire was sent out in English, Spanish and Portuguese languages and was available through the following site: http://www.cleus-encuesta.com. Responses were requested only from physicians who perform EUS. RESULTS: A total of 70 LA physicians answered the questionnaire until January 2013. Most of the participants were under 42 years of age (53%) and 80% were men. Most participants (45.7%) perform EUS in Brazil, 53% work in a private hospital. The majority (70%) also perform endoscopic retrograde cholangiopancreatography. A total 42% had performed EUS for 2 years or less and 22.7% for 11 years or more. Only 10% performed more than 5000 EUS. The most common indication was an evaluation of pancreatic-biliary-ampullary lesions. Regarding training, 48.6% had more than 6 months of dedicated hands-on EUS and 37% think that at least 6 months of formal training is necessary to acquire competence. Furthermore, 64% think that more than 50 procedures for pancreatic-biliary lesions are necessary. CONCLUSION: This survey provides insight into the status of EUS in LA. EUS is performed mostly by young endoscopists in LA. Diagnostic upper EUS is the most common EUS procedure. Most endosonographers believe that formal training is necessary to acquire competence.

Pancreatite autoimune: diagnóstico por ecoendoscopia associada à punção aspirativa / Autoimmune pancreatitis: diagnosis by endoscopic ultrasound and fine needle aspiration

As lesões sólidas do pâncreas são constituídas, na maioria dos casos, pelo adenocarcinoma ductal. Contudo parcela considerável de casos apresentam lesões de outra natureza, as quais requerem abordagens cirúrgicas menos extensas ou tratamento clínico conservador com quimio ou corticoterapia. Neste relato, apresentamos o caso de uma paciente de 56 anos com icterícia e uma massa na cabeça do pâncreas mimetizando um quadro neoplásico. O diagnóstico de pancreatite autoimune foi firmado por meio da ecoendoscopia associada à punção aspirativa (AU)

Solid lesions of the pancreas are, in most cases, constituted of the ductal adenocarcinoma, but a considerable portion of cases have lesions of a different nature, which require less extensive surgical approaches or conservative medical treatment with chemotherapy or corticosteroids. In this report, we present the case of a 56-year-old female patient with jaundice and a mass in the head of the pancreas mimicking a neoplasm. The diagnosis of autoimmune pancreatitis was confirmed by endoscopic ultrasound-guided fine needle aspiration (AU)

Neoplasia sólido papilar de páncreas: correlación clinicopatológica de punción aspiración con aguja fina dirigida por ecoendoscopia / Solid papillary pancreatic neoplasia: cclinicopathological correlation of fine needle aspiration directed by echoendoscopy

Introducción: La neoplasia sólido papilar del páncreas (NSPP) descrita por Frantz en 1959 es una lesión rara, indolente, cuyo origen no ha sido dilucidado. La OMS lo establece como una neoplasia usualmente benigna, con un incremento en su frecuencia en los últimos años. Se presenta en mujeres jóvenes cuya edad promedio es 30 años. Raros casos son reportados en hombres. El presente estudio tiene como finalidad determinar el patrón al USE de la neoplasia solido papilar y correlacionarlos con los hallazgos citológicos de la punción aspiración por aguja fina. (PAAF). Métodos: Se evaluaron retrospectivamente 10 casos visualizados por USE y diagnosticados por PAAF como NSP durante Julio del 2006 a Junio del 2009. Resultados: 90% de los casos eran de género femenino, cuya edad promedio fue 35,2 años. El 90% fueron tumores únicos, con un tamaño tumoral predominante entre 4 a 6 cm en el 60%. No hubo preferencias en la localización. Al USE las lesiones eran de paredes gruesas, 90% ecomixtas, con áreas hiper e hipoecogénicas, macro, microquistes y áreas sólidas, el 10% mostró calcificaciones. En el 100% de los casos los extendidos citológicos presentaron, estructuras papilares con material metacromático en patrón de letras chinas, células con núcleos uniformes, cromatina finamente granular y hendiduras. Conclusión: La PAAF guiada por USE es un método eficaz para el diagnóstico de las NSPP.

Introduction: Solid papillary neoplasia of the pancreas (NSPP) described by Frantz in 1959 is a rare lesion, indolent, whose origin has not been elucidated. WHO establishes it as a neoplasm usually benign, with an increase in frequency in recent years. It occurs in young women whose average age is 30 years. Rare cases are reported in men. This study aims to determine the USE pattern of the solid papillary neoplasia and correlate them with the cytological findings of fine needle aspiration (PAAF). Methods: 10 cases were evaluated retrospectively visualized by USE and diagnosed by PAAF as NSP during July 2006 to June 2009. Results: 90% of the cases were female, whose average age was 35.2 years. 90% were single tumors with a predominant tumoral size between 4 to 6 cm in 60%. There was no preference in location. At USE the lesions were thick-walled, 90% mixed echogenic images with hyper and hypoechoic areas, macro, micro-cysts and solid areas, 10% showed calcifications. In 100% of the cases the cytological study presented papillary structures with metachromatic material in chinese characters pattern, cells with uniform nuclei, finely granular chromatin and crevices. Conclusion: PAAF guided by USE is an effective method for diagnosis of the NSPP.

Lipoma gástrico sintomático resecado endoscópicamente, papel del ultrasonido endoscópico: reporte de un caso / Symptomatic gastric lipoma with endoscopic resection: role of the endoscopic ultrasound, a case report

Los lipomas gástricos representan el 5% de los lipomas gastrointestinales y entre el 1 a 3% de los tumores gástricos benignos. Suelen cursar asintomáticos y ser hallazgos incidentales o pueden manifestarse de distintas maneras, presentando desde dispepsia y dolor abdominal hasta hemorragia digestiva e intususcepción. La gastroscopia, TC y la endosonografía son útiles para el diagnóstico de estos lipomas. En caso de existir síntomas, se puede considerar la enucleación quirúrgica o endoscópica de la lesión. Presentamos el caso de una femenina de 39 años con un lipoma gástrico, que fue evaluado endosonográficamente y resecado endoscópicamente...

Gastric lipomas represent 5% of gastrointestinal lipomas, and between 1-3% of benign gastric tumors. They use to be asymptomatic and incidentally found, or may be manifested in different manners, presenting even dyspepsia and abdominal pain and up to digestive hemorrhage and intussusception. Gastroscopy, CT, and endosonography are useful for diagnosing these lipomas. In case of existing symptoms, surgical or endoscopic enucleation of the lesion might be considered. The case presented here is of a 39-year old female with a gastric lipoma that was endosonography-assessed and an endoscopic resection was performed...

Effectiveness of the echoendoscopic puncture in the diagnosis of solid pancreatic mass / Efetividade da punção ecoendoscópica no diagnóstico de massa pancreática sólida

BACKGROUND: Echoendoscopy is a mixed technique which adds the advantages of endoscopy to those of transabdominal ultrasonography through an endoscope with transductor in its distal extremity, allowing for the evaluation of the abdominal organs reached by the endoscope and in contact with the intestinal wall. AIM: To verify the positivity rate of the echoendoscopy with puncture with thin needle (EEPTN) or (EE-PAF) in solid pancreatic mass based on the technique used in the Gastrointestinal Endoscopy Unit of Hospital das Clínicas, University of São Paulo. METHODS: Retrospective evaluation - cohort study - of 138 patients who were submitted to echoendoscopy through aspiration puncture between May 2004 and June 2007. The data were collected through the medical charts present in the medical files of Hospital das Clínicas (Clinical Hospital) of the University of São Paulo, having as inclusion criterion the presence of solid pancreatic mass in computerized tomography and as exclusion criterion the presence of non solid pancreatic tumor. The routine technique was the one used in the Gastrointestinal Endoscopy Unit focusing the following variables: mass characteristics (size, location, presence of peripancreatic lymph node, presence of lymph node in celiac trunk); number of punctures to obtain microfragment for cytology, and experience of the professional in charge. The equipment used was an echoendoscopy device model Olympus EUS (EYES) Exera EU - C60, with electronic sectorial transductor and 22 gauges Wilson-Cook needles. RESULTS: Seventy six (55,4 percent) male patients and 61 (44.5 percent) female were enrolled. Age ranged from 16 to 87 years and means 59,9 years. The lesions were cephalic in 94 (68,1 percent). Mass larger than 4 cm had a higher percentage of positivity reaching 40 percent, but lesions smaller than 2 cm had a percentage of 43 percent of inconclusive. Microfragments were obtained in 100 percent of the positive cases and ...

RACIONAL: Ecoendoscopia é técnica mista que adiciona as vantagens da endoscopia àquelas da ecografia, somente que o procedimento ecográfico é realizado do interior dos órgãos para fora deles, no sentido centrífugo. OBJETIVO: Verificar a positividade da ecoendoscopia na punção com agulhas (EEPTN) ou (EE-PAF) em tumores sólidos pancreáticos baseados na técnica utilizada pelo Serviço de Endoscopia Digestiva do Hospital de Clínicas da Universidade de São Paulo. MÉTODOS: Cohorte retrospectiva de 138 pacientes que realizaram ecoendoscopia com punção aspirativa por agulha fina (EE-PAAF) no período de maio de 2004 a junho de 2007. Os dados foram coletados por meio de consulta aos prontuários, constantes do arquivo médico. O critério de inclusão foi a presença de massa pancreática sólida à tomografia computadorizada e o critério de exclusão a presença de tumor pancreático não sólido. Foram utilizadas as seguintes variáveis: característica da massa (tamanho, localização, presença de linfonodo peripancreático, presença de linfonodo em tronco celíaco); número de punções para obtenção de microfragmento; citologia e experiência do profissional executante. O aparelho utilizado foi um ecoendoscópio da marca Olympus, modelo OLYMPUS EUS (EYS) EXERA EU-C60, com transdutor setorial eletrônico e agulhas de 22 gauges da marca Boston Scientific. RESULTADOS: Setenta e seis (55,4 por cento) deles eram do sexo masculino e 61 (44,5 por cento) do feminino. A idade variou de 16 a 87 anos, com média de 59,9 anos. As lesões foram cefálicas em 94 (68,1 por cento) dos casos. Massas maiores que 4 cm tiveram percentual de positividade maior, chegando a 40 por cento, mas as lesões menores que 2 cm obtiveram percentual de 43 por cento de inconclusivo. A obtenção de microfragmentos foi conseguida em 100 por cento dos casos positivos e apenas 73,1 por cento, quando negativo (P=0,004). Não houve diferença estatística em relação à experiência do endoscopista. Apenas 80 ...

Endoscopic ultrasound in clinical practice: [revision] / La ecoendoscopía en la práctica clínica: [revisión]

Endoscopic ultrasonography (EUS) is an accurate technique for the diagnosis and staging of benign and malignant lesions in the gastrointestinal tract and the mediastinum. EUS overcomes the limitations of other imaging diagnostic methods and gives the possibility to obtain tissue for histologic diagnosis (EUS guided FNA). The most useful indications of EUS are differentiation of submucosal tumors, staging for neoplasia, examination of the pancreato-biliary system and therapeutics. EUS can distinguish extrinsic compressions from intramural lesions and defines their nature (solid, cystic or vascular) and origin. EUS is useful for local staging of esophageal, gastric, duodenal, and rectal cancer using the TNM (tumor, node, metastases) system, as well as for diagnosing and staging of pancreatic lesions. The addition of EUS-guided FNA has improved the ability to detect malignant lymph node invasion. EUS is also highly sensitive for the diagnosis of choledocholithiasis, avoiding unnecessary danger of diagnostic ERCP. New therapeutic indications of EUS include drainage of pancreatic pseudocysts and abscesses and celiac plexus block and neurolysis. EUS has become an indispensable diagnostic method in gastroenterological everyday practice and should be part of most endoscopy units.

La ultrasonografía endoscópica (EUS) es una técnica precisa para el diagnóstico y estadío de lesiones benignas y malignas en el tracto gastrointestinal y el mediastino. La EUS supera las limitaciones de otros métodosde diagnóstico de imágenes y da la posibilidad de obtener tejido para diagnóstico histológico (EUS guiadoFNA). Las indicaciones más útiles de la EUS son la diferenciación de tumores submucosos, en estadío de neoplasia, examen y terapéutica del sistema pancreatobiliar. La EUS puede distinguir compresiones extrínsecas de lesiones intramuros y define su naturaleza (sólido, quístico o vascular) y el origen. La EUS es útil para el estadío local de cáncer del esófago gástrico duodenaly rectal usando el sistema de TNM (tumor, nódulo, metástasis), así como para el diagnóstico y estadío delesiones pancreáticas. La incorporación de EUS-FNA guiado ha mejorado la capacidad de detectar la invasiónde los nódulos linfáticos malignos. La EUS también es altamente sensible para el diagnóstico de colédoco litiasis, evitando el peligro innecesario de diagnóstico de ERCP. Nuevas indicaciones terapéuticas de la EUS incluyen el drenaje de pseudoquistes pancreáticos y abscesos, y bloqueo del plexo celíaco y neurolisis. La EUS se ha convertido en un método de diagnóstico indispensable en la práctica diaria gastroenterológica y debe formar parte de la mayoría de las unidades de endoscopía.

Localización pancreática de fasciola hepática en un caso humano autóctono proveniente del Edo. Bolívar, Venezuela

La fasciolosis humana es una entidad poco frecuente reportada previamente 8 veces en Venezuela, de personas provenientes del centro y los estados occidentales. Se presenta el caso de un paciente masculino de 25 años, natural y procedente del Estado Bolívar, donde practica equitación y supervisa tareas de corral del ganado equino y bovino. La enfermedad actual se inicia con diarreas desde los 14 años, acompañada de persistente eosinofilia. ELISA e "Immunoblot", resultaron francamente positivos al antígeno de excreción- secreción de Fasciola hepática. Ante persistente dolor epigástrico, se practicó eco-endoscopia, resultando en la visualización de dilatación quística del ducto pancreático con una estructura interna probablemente correspondiente a un parásito. El examen parasitológico del contenido duodenal y heces reportó huevos de Fasciola hepática en este último material. Se administró tratamiento con Bithionol luego de lo cual disminuyó la eosinofilia y hubo franca mejoría clínica. Es el primer caso de fasciolosis humana proveniente del sureste del país, donde la fasciolosis bovina o humana no había sido descrita y en el cual además, ocurrió una localización ectópica pancreática de difícil diagnóstico clínico.

Human fasciolosis in Venezuela is an infrequent disease, reported only 8 times previously in persons coming from the center and the western states of the country. The case of a 25 years old masculine patient from Bolivar State, where he practices equitation and supervises tasks of corral of equine and bovine cattle is reported. The disease began with diarrhea at 14 years old, accompanied by persistent eosinofilia. ELISA and "Immunoblot" were strongly positive to excretion-secretion Fasciola hepatica antigen. Given the presence of persistent epigastric pain, echo-endoscopy was practiced, resulting in the visualization of cyst expansion of the pancreatic duct with an internal structure probably corresponding to a parasite. The parasitologic examination of the duodenal content and feces reported Fasciola hepatica eggs this last material. After treatment with Bithionol, eosinofilia diminished and there was frank clinical improvement. It is the first case of human fasciolosis of the southeastern part of the country, where bovine or human fasciolosis had not been described in which additionally, an ectopic pancreatic location of difficult clinical diagnosis occurred.