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Background and study aims Transoral outlet reduction (TORe) has long been employed in treating weight regain after Roux-en-Y gastric bypass. However, its impact on gut hormones and their relationship with weight loss remains unknown. Patients and methods This was a substudy of a previous randomized clinical trial. Adults with significant weight regain and dilated gastrojejunostomy underwent TORe with argon plasma coagulation (APC) alone or APC plus endoscopic suturing (APC-suture). Serum levels of ghrelin, GLP-1, and PYY were assessed at fasting, 30, 60, 90, and 120 minutes after a standardized liquid meal. Results were compared according to allocation group, clinical success, and history of cholecystectomy. Results Thirty-six patients (19 APC vs. 17 APC-suture) were enrolled. There were no significant baseline differences between groups. In all analyses, the typical postprandial decrease in ghrelin levels was delayed by 30 minutes, but no other changes were noted. GLP-1 levels significantly decreased at 12 months in both allocation groups. Similar findings were noted after dividing groups according to the history of cholecystectomy and clinical success. The APC cohort presented an increase in PYY levels at 90 minutes, while the APC-suture group did not. Naïve patients had significantly lower PYY levels at baseline ( P = 0.01) compared with cholecystectomized individuals. This latter group experienced a significant increase in area under the curve (AUC) for PYY levels, while naïve patients did not, leading to a higher AUC at 12 months ( P = 0.0001). Conclusions TORe interferes with the dynamics of gut hormones. APC triggers a more pronounced enteroendocrine response than APC-suture, especially in cholecystectomized patients.

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Background and study aims Noninvasive ampullary neoplasms may be removed by surgery or endoscopy. However, given the morbidity and mortality associated with surgery, endoscopic papillectomy (EP) is the preferred approach. Radiofrequency ablation (RFA) after EP has emerged as a promising alternative therapy to avoid surgery after incomplete EP. Our goal was to evaluate the efficacy and safety of RFA for residual or recurrent lesions with intraductal extension after endoscopic papillectomy. Patients and methods The inclusion criteria include clinical trials, cohort studies, and case series evaluating patients with residual or recurrent lesions with intraductal extension after EP treated with RFA. Case reports, duplicated data, and studies with follow-up periods < 10 months were excluded. The metanalysis evaluated adverse events, surgical conversion rate, clinical success and recurrence. Results Seven studies were selected, totaling 124 patients. RFA was associated with a clinical success rate of 75.7% (95% confidence interval [CI] 65.0-88.0%; I 2 = 23.484) in a mean follow-up period < 10 months. However, the biliary stricture rate was 22.2% (95% CI 12.1-28.4%; I 2 = 61.030), 14.3% of pancreatitis (95% CI 8.8-22.3%; I 2 < 0.001), 7.0% of cholangitis (95% CI 3.3-14.5%; I 2 < 0.001), 4.0% of bleeding (95% CI 1.7-9.3%; I 2 < 0.001), and recurrence of 24.3% (95% CI 16.0-35.0%; I 2 = 23.484). Conclusions RFA is feasible and appears to be effective for managing residual or recurrent lesions with intraductal extension after EP. However, long-term follow-up and high-quality studies are required to confirm our findings.

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BACKGROUND AND AIMS: Upper GI bleeding (UGIB) is a medical emergency associated with elevated mortality and significant costs to the health care system. EGD is currently the method of choice for the diagnosis and management of these conditions. However, the location of bleeding lesions and technical difficulties in achieving endoscope stability may challenge even the most experienced endoscopists. Herein, we demonstrate the use of the cap and underwater technique as a helpful aid in these situations. METHODS: We present a case series of 4 patients with acute UGIB who underwent EGD with suboptimal endoscopic visualization or technical difficulties in identifying the source of bleeding. A transparent plastic cap was attached to the distal tip of the gastroscope, and the water immersion technique (underwater) was used for endoscopic re-evaluation of the bleeding site. RESULTS: Three patients presented with duodenal bleeding, and 1 was diagnosed with diffuse bleeding from the esophagus. The clear and accurate identification of the source of bleeding and effective hemostasis were possible after cap and underwater technique evaluation in all patients. CONCLUSION: The use of the cap and underwater technique is a simple, safe, and low-cost strategy that improves the identification and control of UGIB in locations with poor visibility and technical challenges during endoscopic evaluation.

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BACKGROUND AND PURPOSE: Perioperative chemotherapy (periCTX) based on the "MAGIC" scheme has become a standard treatment in Europe for locally advanced oesophagogastric cancer. We assessed implementation and long-term oncological outcomes of MAGIC periCTX for locally advanced gastric cancer. METHODS: Population-based cohort study of all patients with locally advanced gastric cancer undergoing surgical resection with curative intent in Catalonia and Navarra (the first two autonomous communities included in the EURECCA Upper GI Spanish Working Group) between January 2011 and December 2013. The main variable was the percentage of patients treated with MAGIC periCTX. Kaplan-Meier analysis and Cox proportional hazards model were used to assess the survival benefit of periCTX. RESULTS: Among 814 patients, 217 (26.6%) received periCTX (especially patients more likely to receive it: aged < 70 years, with proximal tumors, low anesthetic risk, and cT3-4/cN+ clinical stage). 35% did not complete perioperative chemotherapy, with no relationship with age. PeriCTX showed no effect on postoperative morbimortality. Histological tumor regression was more often absent or poor (38.2%) than total or almost total (27.8%), although clinico-pathological lymph-node downstaging was higher than expected by staging inaccuracy (38.7% vs. 24.2%). PeriCTX was associated with a better survival only in cT3-4 and cN+ patients, showing less prognostic relevance than optimal oncological surgery with D2 lymphadenectomy. CONCLUSIONS: Only 26.6% of locally advanced resectable gastric cancer patients received PeriCTX. Pathological response was poor, although some degree of nodal downstaging was observed. Survival benefit of periCTX was limited to cT3-4 and cN+ patients, being less relevant than D2 lymphadenectomy.

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Detection and treatment of gastric cancer (GC) in early stages is the most effective approach for improving prognosis. Patients with early gastric cancer (EGC), defined as a type of cancer affecting only mucosa and submucosa, has a good prognosis in the long-term, and if some criteria are met, endoscopic therapy is curative. Unfortunately EGC diagnosis is rare, except in case of some Asian countries, where more than 50% of tumors are diagnosed in this stage. In Japan, the main technique for early diagnosis is opportunistic screening, i.e. endoscopy performed for different reasons. Some of the factors that affect endoscopic diagnose include: characteristics of the lesion (some cases slight changes in color or in the surface, a location that is difficult to detect, except in retro view); elements associated with the endoscopic technique (lesions hidden underneath gastric contents, non-systematic visualization, not enough time for exploration); and early access to the procedure (long waiting lists, lack of clinic or epidemiology screening criteria, lack of risk-stratification looking for pre-malignant lesions to establish endoscopic follow-up). Know and act upon the mentioned factors is a path that has proven to improve EGC diagnosis and therefore, improve prognosis.

Detectar y tratar el cáncer gástrico (CG) en una etapa inicial constituye la estrategia más efectiva para mejorar el pronóstico de esta patología. Pacientes con CG incipiente (CGI), definido como el que compromete sólo la mucosa y la submucosa, tienen un muy buen pronóstico a largo plazo y si se cumplen algunos criterios, el tratamiento endoscópico es curativo. Desgraciadamente el diagnóstico de CGI es infrecuente en todo el mundo, a excepción de algunos países asiáticos donde más de la mitad de los tumores se diagnostican en esta etapa. En Japón la principal vía por la que se realiza este diagnóstico precoz es mediante el tamizaje oportunista, es decir, la endoscopia que se realiza de manera cotidiana por diferentes motivos. Dentro de los factores que afectan la capacidad diagnóstica de la endoscopia destacan: las características de la lesión (algunos casos con discretos cambios de color o superficie, ubicación habitualmente en áreas de mejor visualización en retrovisión); factores asociados a la técnica endoscópica (contenido gástrico que puede ocultar lesiones, visualización no sistemática, tiempo insuficiente de exploración); y el acceso oportuno a ella (largas listas de espera, falta de criterios de selección clínicos o epidemiológicos, falta de estratificación del riesgo mediante la búsqueda de lesiones premalignas para definir intervalos de seguimiento endoscópico). Conocer y actuar sobre los factores descritos es un camino que ha demostrado su utilidad en mejorar el diagnóstico del CGI y así mejorar su pronóstico.

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BACKGROUND AND OBJECTIVES: The introduction of propofol (2,6-diisopropylphenol) as a sedative agent has transformed the area of sedation for endoscopic procedures. However, a major drawback of sedation with the use of propofol is its high incidence of injection pain. The most widely used technique in reducing propofol injection pain is through the association of other drugs. The aim of this study was to evaluate the effect of remifentanil-propofol combination on the incidence of propofol injection pain and its influence on the total dose of propofol required for sedation in upper digestive tract endoscopy (UDE) diagnostic tests. METHOD: One hundred and five patients undergoing upper digestive tract endoscopy were evaluated and randomly divided into 3 groups of 35 patients each. The Control Group received propofol alone; Study-group 1 received remifentanil at a fixed dose of 0.2 mg/kg combined with propofol; Study-group 2 received remifentanil at a fixed dose of 0.3 mg/kg combined with propofol. The incidence of propofol injection pain and the total dose of propofol required for the test were evaluated. The sample was very similar regarding age, weight, height, sex, and physical status. Statistical analysis was performed according to the nature of the evaluated data. Student'st-test was used to compare the mean of age, weight, height (cm), and dose (mg/kg) variables between groups. The χ2 test was used to compare sex, physical status, and propofol injection pain between groups. The significance level was a < 0.05. RESULTS: There was significant statistical difference between the study groups and the control group regarding the parameters of propofol injection pain and total dose of propofol (mg/kg) used. However, there were no statistical differences between the two study groups for these parameters. CONCLUSION: We conclude that the use of remifentanil at doses of 0.2 mg/kg and 0.3 mg/kg was effective for reducing both the propofol injection pain and the total dose of propofol used.

JUSTIFICATIVA E OBJETIVOS: A introdução do propofol (2,6-di-isopropilfenol) como agente sedativo tem transformado a área da sedação para procedimentos endoscópicos. Entretanto, um grande inconveniente da sedação com o uso do propofol é sua alta incidência de dor à injeção. A técnica mais usada na redução da dor à injeção do propofol tem sido a associação com outros fármacos. O objetivo deste estudo foi avaliar a repercussão da associação do remifentanil com o propofol na incidência de dor à injeção de propofol e a influência na dose total de propofol necessária para sedação em endoscopia digestória alta (EDA) diagnóstica. MÉTODO: Foram avaliados 105 pacientes, submetidos à EDA diagnóstica e divididos aleatoriamente em três grupos de 35. O Grupo Controle foi sedado apenas com propofol. O Grupo de Estudo 1 foi sedado com remifentanil em dose fixa de 0,2 µg/kg associado ao propofol. E o Grupo de Estudo 2 foi sedado com remifentanil em dose fixa de 0,3 µg/kg associado ao propofol. Foram avaliadas a incidência de dor à injeção de propofol e a dose de propofol necessária para o exame. A amostra se mostrou bastante similar em relação às variáveis idade, peso, altura, sexo e estado físico. De acordo com a natureza dos dados estudados, procedeu-se ao tratamento estatístico julgado adequado. Usou-se o teste t para comparação, entre os grupos analisados, das médias das variáveis idade, peso, altura (cm) e dose (mg/kg). Foi usado o teste ?2 para comparação, entre os grupos analisados, das variáveis sexo, estado físico e dor à injeção de propofol. O nível de significância adotado foi a < 0,05. RESULTADO: Houve diferença estatística significativa entre os grupos de estudo e o grupo controle tanto no parâmetro dor à injeção de propofol quanto no parâmetro dose de propofol usada (mg/kg). Entretanto, não houve diferenças estatísticas entre os dois grupos de estudo para esses parâmetros. CONCLUSÃO: O uso do remifentanil nas doses de 0,2 µg/kg e de 0,3 µg/kg mostrou-se efetivo tanto sobre o parâmetro redução da dor à injeção de propofol quanto sobre o parâmetro dose de propofol usada.

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BACKGROUND AND OBJECTIVES: The introduction of propofol (2,6-diisopropylphenol) as a sedative agent has transformed the area of sedation for endoscopic procedures. However, a major drawback of sedation with the use of propofol is its high incidence of injection pain. The most widely used technique in reducing propofol injection pain is through the association of other drugs. The aim of this study was to evaluate the effect of remifentanil-propofol combination on the incidence of propofol injection pain and its influence on the total dose of propofol required for sedation in upper digestive tract endoscopy (UDE) diagnostic tests. METHOD: One hundred and five patients undergoing upper digestive tract endoscopy were evaluated and randomly divided into 3 groups of 35 patients each. The Control Group received propofol alone; Study-group 1 received remifentanil at a fixed dose of 0.2mg/kg combined with propofol; Study-group 2 received remifentanil at a fixed dose of 0.3mg/kg combined with propofol. The incidence of propofol injection pain and the total dose of propofol required for the test were evaluated. The sample was very similar regarding age, weight, height, sex, and physical status. Statistical analysis was performed according to the nature of the evaluated data. Student's t-test was used to compare the mean of age, weight, height (cm), and dose (mg/kg) variables between groups. The χ(2) test was used to compare sex, physical status, and propofol injection pain between groups. The significance level was α<0.05. RESULTS: There was significant statistical difference between the study groups and the control group regarding the parameters of propofol injection pain and total dose of propofol (mg/kg) used. However, there were no statistical differences between the two study groups for these parameters. CONCLUSION: We conclude that the use of remifentanil at doses of 0.2mg/kg and 0.3mg/kg was effective for reducing both the propofol injection pain and the total dose of propofol used.

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BACKGROUND AND OBJECTIVES: The introduction of propofol (2,6-diisopropylphenol) as a sedative agent has transformed the area of sedation for endoscopic procedures. However, a major drawback of sedation with the use of propofol is its high incidence of injection pain. The most widely used technique in reducing propofol injection pain is through the association of other drugs. The aim of this study was to evaluate the effect of remifentanil-propofol combination on the incidence of propofol injection pain and its influence on the total dose of propofol required for sedation in upper digestive tract endoscopy (UDE) diagnostic tests. METHOD: One hundred and five patients undergoing upper digestive tract endoscopy were evaluated and randomly divided into 3 groups of 35 patients each. The Control Group received propofol alone; Study-group 1 received remifentanil at a fixed dose of 0.2mg/kg combined with propofol; Study-group 2 received remifentanil at a fixed dose of 0.3mg/kg combined with propofol. The incidence of propofol injection pain and the total dose of propofol required for the test were evaluated. The sample was very similar regarding age, weight, height, sex, and physical status. Statistical analysis was performed according to the nature of the evaluated data. Student's t-test was used to compare the mean of age, weight, height (cm), and dose (mg/kg) variables between groups. The ℵ(2) test was used to compare sex, physical status, and propofol injection pain between groups. The significance level was α < 0.05. RESULTS: There was significant statistical difference between the study groups and the control group regarding the parameters of propofol injection pain and total dose of propofol (mg/kg) used. However, there were no statistical differences between the two study groups for these parameters. CONCLUSION: We conclude that the use of remifentanil at doses of 0.2mg/kg and 0.3mg/kg was effective for reducing both the propofol injection pain and the total dose of propofol used.

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La hemorragia de vías digestivas altas (HVDA) es una emergencia habitual; su etiología más común es laúlcera péptica. La restauración del volumen intravascular y la presión arterial son la prioridad del manejo previo al identificar la causa del sangrado. La esofagogastroduodenoscopia (EGD) debe realizarse luego de lareanimación inicial, así como lograrse la estabilización hemodinámica, para identifi car la causa del sangradoy dar el tratamiento necesario. Se realiza un estudio sobre el evento en un hospital de referencia de tercernivel, en Cundinamarca, Colombia.Materiales y métodos: Estudio descriptivo retrospectivo; datos obtenidos de la historia clínica electrónica de pacientes adultos que consultaron por urgencias en el Hospital Universitario de la Samaritana (HUS) por HVDA, diagnosticada por hematemesis, melenas, rectorragia o anemia, y a quienes se les realizó EGDdurante el periodo abril de 2010-abril de 2011. Resultados: Se atendió a 385 pacientes a lo largo del período de estudio; se excluyó a 100 de ellos,debido a hemorragia secundaria a várices esofágicas, historia clínica incompleta y hemorragia digestivabaja, para un total de 285 pacientes analizados. Conclusiones: La mayoría de la población atendida en el Hospital Universitario de La Samaritana (HUS)por HVDA son adultos mayores de 60 años. La úlcera péptica sigue siendo el diagnóstico más común asociadoal uso de AINE y ASA. La mortalidad es comparable a la de las regencias internacionales.

Upper gastrointestinal tract bleeding is a common emergency whose most common etiology is a peptic ulcer.Restoration of intravascular volume and blood pressure management are priorities before identifyingthe cause of bleeding. After initial resuscitation and after hemodynamic stabilization has been achieved, anesophagogastroduodenoscopy (EGD) should be performed to identify the cause of bleeding and determinethe treatment needed. This is a study performed at a third level referral hospital in Cundinamarca, Colombia.Materials and Methods: This is a retrospective study of data from electronic medical records of adult patients admitted to the emergency room of the Hospital Universitario de la Samaritana (HUS) because of uppergastrointestinal tract bleeding which ahd been diagnosed because of hematemesis, melena, rectal bleedingand/or anemia. Patients all underwent EGD between April 2010 and April 2011.Results: 385 patients with upper gastrointestinal tract bleeding were seen during the study period, but 100were excluded because of bleeding secondary esophageal varices, incomplete clinical histories and lowergastrointestinal bleeding. A total of 285 patients were included. 69.1 % were older than 60 years, 73.3 % hadhypertension, 55.1 % reported use of infl ammatory drugs (NSAIDs) and aspirin (ASA), 19.6 % reported previous bleeding episodes, and 17.9 % had hemodynamic instability. 63 patients (22.1 %) required endoscopichemostasis, and 32 (11.2 %) experienced rebleeding. Overall mortality reported was 13.1 % of which 55.3 %were men. Mortality attributable to gastrointestinal bleeding was 3.1 %.Conclusions: The majority of patients served by the HUS with upper GI bleeding are adults over 60 years.Peptic ulcers remain the most common diagnosis associated with the use of NSAIDs and ASA. The mortalityrate is comparable to international standards.

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La gastrostomía endoscópica percutánea: PEG o GEP, es una técnica ampliamente difundida. Con una adecuada metodología de colocación y seguimiento tiene pocas complicaciones tanto en el peri-procedimiento como en el seguimiento a largo plazo. Se describen en cifras bajas, retiro accidental, infección, desgaste, migración al tejido sub-cutáneo, entre otras. Presentamos el caso de una paciente con sonda varios meses que acude con Hemorragia Digestiva a la Emergencia de nuestra Institución.

PEG or Percutaneous endoscopic gastrostomy is a well known and widely used procedure. With adequate methodology of instrumentation and follow up it has very low rate of complications directly related or non-related to the procedure. Such complications include accidental retirement, wound infection, deterioration of tube, migration to sub-cutaneous tissue and others. We present a case in which a patient with long history of PEG shows up at our ER with melena (upper GI bleeding).

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