O.V. Hernández-Mondragón

Miotomía peroral endoscópica en acalasia. Reporte del primer caso realizado en México

Achalasia is a primary motor disorder of the esophagus characterized by an increase in the relaxation pressure of the lower esophageal sphincter (LES) and esophageal aperistalsis. Its incidence is 1/100,000/year. The symptoms include dysphagia, weight loss, regurgitation, and chest pain, resulting in a negative impact on quality of life. The cause is unknown, but there is an autoimmune component at the level of the myenteric plexus. Diagnosis is manometric and high resolution manometry (HRM) subclassifies the disease into 3 types: type I (classic), type II (pressurized), and type III (spastic). Management is focused on reducing the LES pressure, for which there are 3 types of treatment: medical, endoscopic, and surgical. The latter is the gold standard and consists of a laparoscopic Heller myotomy (LHM) with a partial fundoplication; its efficacy is 86% and it remains up to 70% at 5 years. The first peroral endoscopic myotomy (POEM) carried out on humans was reported in 2010. This technique consists of the performance of an endoscopic myotomy of the circular layer of the esophagus and LES, utilizing a submucosal tunnel with an opening at the entrance of the proximal esophagus. Its preliminary results have been similar to those of the LHM, with the advantages of being less invasive, less expensive, and with fewer days of hospital stay. Our objective was to report the experience of implementing POEM in a Mexican patient presenting with achalasia. A 29-year-old man had dysphagia of one-year progression, together with regurgitation, chest pain, and weight loss of 20 kg. The esophagogastroduodenal series (EGDS) showed a dilated esophagus. Endoscopy and tomography ruled out other lesions. HRM confirmed type II achalasia. The Eckardt score determines the grade of dysphagia through a

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.

Miotomía endoscópica peroral para el tratamiento de acalasia y otros trastornos motores del esófago. Resultados a corto y mediano plazo en un centro de referencia en México

INTRODUCTION AND AIMS Achalasia is characterized by the absence of lower esophageal sphincter relaxation and esophageal aperistalsis. Diagnosis is confirmed through high-resolution esophageal manometry. Laparoscopic myotomy is the standard treatment, but peroral endoscopic myotomy (POEM) is a safe and effective alternative, with good short-term and medium-term results. Our aim was to describe the short-term and medium-term experience with POEM at a tertiary care center. MATERIALS AND METHODS The study was conducted within the time frame of November 2014 and February 2017. Treatment-naïve achalasia patients and previously-treated achalasia patients that were candidates for POEM were included. A protocolized 24-month follow-up was carried out. RESULTS Fifty procedures were included and 31 (68%) were performed on women. Forty-one (82%) of the procedures were carried out on previously untreated patients, 7 (14%) were performed on previously treated patients, and 2 (4%) of the patients had redo-POEM. The mean age of the patients was 48.8±14.1 years. The pre-POEM Eckardt score was 9 and the integrated relaxation pressure was 24.4mmHg. Sixty-eight percent of the patients had type ii achalasia. Procedure time was 80min and myotomy length was 12.6cm. Hospital stay was 3 days and subcutaneous emphysema was the most common adverse event (30%). A total of 22/50 (44%) patients reached the 24-month follow-up, maintaining the Eckardt score and the decrease in the integrated relaxation pressure. There were no deaths. A total of 47.5% of the patients had a positive pH-study at 6 months, 15% had clinical reflux, and 35% presented with mild esophagitis. All the patients were adequately controlled with proton pump inhibitors. CONCLUSION POEM is safe and effective in the short term and medium term for the treatment of achalasia and other esophageal motor disorders in Mexican patients.

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.