Gerardo Blanco-Velasco

The Per Oral Endoscopic Myotomy (POEM) technique: how many preclinical procedures are needed to master it?

Background and study aim: Per oral endoscopic myotomy (POEM) is a complex technique used in achalasia. Preclinical training is essential but little is known about the number of procedures needed. The aim of this study was to determine the number of procedures required to master POEM in an animal model. Patients and methods: This prospective comparative study was conducted in two swine models at a single institution in Mexico City between November 2012 and October 2014: Group 1 (G1) = 30 ex vivo and Group 2 (G2) = 20 live swine models. POEM was mastered after finishing the five steps without complications. Time, characteristics, and complications were recorded. Velocity of tunnelization and myotomy (VTM) was determined. Ex vivo analysis was done in G1 immediately after finishing POEM and at day 30 in G2. Results: A total of 50 POEM were done in both groups (G1 = 30, G2 = 20). The mean times were 90.17 min (G1) and 89.50 min (G2) (P = 0.92). Myotomy was faster in G2 (21.10 vs 27.97 min; P = 0.009) with a slightly slower tunnelization (40.35 vs 41.13 min; P = 0.86). Myotomy was longer in G2 (9.25 vs 8.83 cm; P = 0.26). VTM between the groups was similar (G1 = 0.159 vs G2 = 0.157 cm/min; P = 0.925). Complications were: mucosotomy (G1 = 18 %, G2 = 8 %; P = 0.430), mediastinal perforation (G1 = 12 %, G2 = 8 %; P = 1.0), and perforation at the gastroesophageal junction (GEJ) level (G1 = 16 %, G2 = 4 %; P = 0.149). Seven models in G2 presented minor bleeding and there was one death not attributed to the procedure. Mastery was obtained after 26 cases. Conclusions: We suggest that centers interested in learning POEM consider 26 procedures in animal models to master it before performing it in patients with achalasia.

Seguridad y eficacia de la polipectomía en intestino delgado utilizando enteroscopio asistido por balones en pacientes pediátricos con síndrome de Peutz-Jeghers

INTRODUCTION AND AIMS Peutz-Jeghers syndrome is an autosomal dominant inherited pathology characterized by gastrointestinal hamartomatous polyps, predominantly in the small bowel, and pigmented mucocutaneous lesions. Guidelines suggest polypectomy with a balloon-assisted enteroscope when polyps are larger than 10mm. Complications in adults can be as high as 6.8%, but there is little information on pediatric populations. Our aim was to describe the safety and efficacy of polypectomy in a group of pediatric patients with Peutz-Jeghers syndrome using balloon-assisted enteroscopy. MATERIALS AND METHODS A retrospective study was conducted at the Hospital de Especialidades del Centro Médico Nacional Siglo XXI on pediatric patients with Peutz-Jeghers syndrome that required balloon-assisted enteroscopy and polypectomy within the time frame of January 2010 and December 2015. Patients that underwent polypectomy with a push enteroscope were excluded from the study. RESULTS A total of 35 polypectomies were performed on 4 patients (female/male: 3/1). The mean age of the patients was 13.7 years (range:11-16). Twelve enteroscopies were carried out, 8 of which were anterograde. A single-balloon enteroscope was used in 7 procedures and a double-balloon enteroscope in 5. The mean size of the polyps was 1.6cm (range: 1-4cm). A major complication (acute pancreatitis) presented in only one case (8.3%). No other major complications associated with the procedures were observed. CONCLUSION Balloon-assisted enteroscopy with polypectomy in children is a safe and effective procedure, with complications similar to those reported in adults.

Extracción endoscópica exitosa de prótesis dental impactada en divertículo de sigmoides

A 75-year-old man had a past surgical history of sigmoidectomy with primary anastomosis due to complicated diverticulitis in 2007. The patient accidentally swallowed a 4-tooth dental prosthesis. Gastroscopy performed 12 h after the accident did not reveal the foreign body. During the ensuing 10-month follow-up, x-rays were taken until repeated images of the foreign body lodged in the sigmoid colon, with no progression, were observed (fig. 1). Through colonoscopy, the impacted prosthesis was identified inside a sigmoid diverticulum, proximal to the anastomosis. It was gently extracted from the diverticulum by means of a 27mm loop polypectomy snare. Once the prosthesis was out of the diverticulum, its large size prevented it from being placed inside the overtube. Thus, it was held in place by the loop and with delicate maneuvers was extracted through the anastomosis to the rectum, without damaging the mucosa. Once in the rectum, the endoscopist eased the prosthesis out with his fingers (fig. 2). This is the first report of a case of a dental prosthesis lodged in a diverticulum of the colon.

Overt gastrointestinal bleeding caused by hookworm infection, diagnosed by capsule endoscopy

A 60-year-old man was admitted due to a chronic anaemia and intermittent melena since two months ago. Laboratory data revealed: haemoglobin 9.4 g/dl, haematocrit 26%, mean corpuscular volume 78 μm3 , white cell count 9500/mm3 with 4% eosinophils. Esophagogastroduodenoscopy and colonoscopy were realized without identifying the bleeding cause. This article is protected by copyright. All rights reserved.

Enfermedad injerto contra huésped gastrointestinal. ¿Cuál es el papel de la cápsula endoscópica? Serie de casos

Allogeneic hematopoietic cell transplantation (AHCT) is an essential part of the therapeutic treatment of malignant hematologic diseases. It has been associated with frequent complications, such as infections and graft-versus-host disease (GVHD). The skin, digestive tract, and biliary tract are the main organs affected by GVHD. It is the most important complication and is associated with high morbidity and mortality. This pathology is divided into acute and chronic disease, depending on whether it presents before or after the first 100 post-transplantation days.1,2 Gastrointestinal GVHD can manifest as nausea, anorexia, vomiting, bloating, diarrhea, abdominal pain, bleeding, ileus, weight loss, and fever with negative cultures. It is associated with an 80% mortality rate, especially in cases that do not respond to first-line treatment.2,3 In regard to its gastrointestinal involvement, GVHD diagnosis is based on panendoscopy and colonoscopy, taking biopsy samples from the antrum, duodenum, and colon. However, the small bowel is the most affected area, given that it is the most extensive immune organ.4 GVHD can present in the small bowel in different manners, affecting it by segments or in its totality. The main findings in this organ are edema, erythema, erosions, ulcers, and bleeding.5 Capsule endoscopy (CE) is a noninvasive tool that allows us to observe the entire small bowel6 and can be very useful in accelerating GVHD diagnosis. The aim of this report is to communicate the usefulness of CE in patients suspected of presenting with gastrointestinal GVHD.