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Introduction: Diagnosing perihilar cholangiocarcinoma can be challenging. Previous studies suggest that the sensitivity of taking three cholangioscopy-guided biopsies is approximately 70%. We hypothesized that obtaining four or more biopsies might improve the sensitivity for diagnosing perihilar cholangiocarcinoma., Objective: To determine the acceptable number of cholangioscopy-guided biopsies to improve sensitivity for diagnosing perihilar cholangiocarcinoma., Methods: This retrospective study analyzed clinical records of adults with perihilar stenosis who underwent cholangioscopy-guided biopsies. Patients with gallbladder cancer or metastatic bile duct obstruction were excluded. Data were grouped based on the number of biopsies taken: Group A (1 to 3 biopsies), Group B (4 to 6 biopsies), and Group C (7 to 10 biopsies). Results from each group were compared against a composite standard, including clinical follow-up and/or biopsies performed by alternative methods., Results: The group that underwent 4 to 6 biopsies had a sensitivity of 77.4%, while the group with 7 to 10 had a sensitivity of 70.8%. The group with 1 to 3 biopsies had a sensitivity of 34.5%. Statistically significant differences were observed between the groups, with comparisons showing improved sensitivity in the 4 to 6 biopsy group versus the 1 to 3 biopsy group (χ² = 14.42, P = 0.0001), and the 7 to 10 biopsy group versus the 1 to 3 biopsy group (χ² = 6.56, P = 0.010)., Conclusions: Performing 4 to 6 cholangioscopy-guided biopsies significantly improves sensitivity for diagnosing perihilar cholangiocarcinoma compared to 1 to 3 biopsies. Further studies are needed to validate these findings.

Background: gastric cancer (GC) is a gastrointestinal (GI) neoplasia which often complicates with GI bleeding. It is uncertain if bleeding worsens mortality in this group of patients., Aims: to compare 30- and 90-day mortality in patients with unresectable GC (uGC) and tumor bleeding versus patients with the same neoplasia without bleeding., Methods: a retrospective analysis of patients with uGC, with and without tumor bleeding was performed. Survival analysis for 30- and 90-days mortality was performed using Cox regression. Logistic regression was used to identify risk factors associated with mortality and first bleeding episode., Results: 202 patients were included in the analysis (105 cases). Mortality at 90 days was 37.14 % for cases and 20.62 % for controls (p = 0.04). There was a significant difference in hazard ratio (HR) at 90 days for cases compared to controls (HR 1.95, 95 % CI 1.14-3.34, p = 0.02). Cases without palliative chemotherapy had the highest 90-days mortality (HR 5.43, 95 % CI 2.12-13.87, p < 0.01), compared to controls treated with chemotherapy. Predictors for first tumor bleeding were clinical stage IV (OR 2.93, 95 % CI 1.04-8.26, p = 0.04), Helicobacter pylori infection (OR 2.80, 95 % CI 1.35-5.80, p < 0.01) and histologic intestinal-subtype (OR 2.14, 95 % CI 1.07-4.30, p = 0.03)., Conclusions: tumor bleeding increases 90-days mortality in patients with uGC. Prevention of the first bleeding episode might improve outcome in these patients and the recognition of high-risk patients might help decision-making.

Objectives: Endoscopic ultrasound-guided tissue acquisition (EUS-TA) has been the most common method used for the preoperative cytopathological diagnosis of solid tumors of the pancreas. There are only a few reported cases about the role of endoscopic ultrasound-guided fine needle biopsy (EUS-FNB) in the pre-operative diagnosis of solid pseudopapillary neoplasms (SPN). This study aimed to evaluate the diagnostic yield of EUS-TA,including endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) andEUS-FNB, in patients with SPN., Methods: We performed a retrospective analysis of patients with EUS-TA for SPN diagnosis in 2 referral centers. The primary outcome was the diagnostic yield of EUS-TA compared to the surgical specimen., Results: Seventy-four patients with SPN of the pancreas were identified. Eighteen had a EUS-TA (10 EUS-FNB and 8 EUS-FNA). The median age of the patients was 31 years (IQR 21-38), and all patients were women. The most common presenting symptom was abdominal pain. Most of the tumors were in the head of the pancreas (9/18; 50%). The median tumor size by EUS was 4.5 cm (min-max 2-15 cm). The most common appearance on EUS was a solid lesion ( n  = 8/18, 44.4%). A definitive presurgical cytopathological diagnosis was obtained in 16/18 patients (88.8%) with EUS-TA. The sensitivity and positive predictive value of the EUS-TA were 94% each. One patient in the EUS-FNB group developed mild acute pancreatitis., Conclusion: The diagnostic yield of the EUS-TA in SPN is high. In most cases, the diagnosis was obtained with the first procedure. No differences in the diagnostic yield or AEs between EUS-FNA vs. EUS-FNB needles were seen.

The oblique-view echoendoscope is currently the sole tool for ultrasound-guided endoscopic procedures (EUS) in most hospital centers, despite its limitations like a lack of forward vision, issues with needle angle, and restricted accessory device size due to channel angulation. However, our study revealed no significant differences between the oblique and frontal endoscopes, except for minor variations in specific regions. For routine diagnostic studies, interchangeability between the devices is feasible. The anticipated advantages of the frontal device may emerge more prominently in future therapeutic procedures. This suggests that, while the oblique-view echoendoscope remains the primary tool, the frontal device holds potential for evolving roles in diagnostic and therapeutic interventions.

Background: Dysphagia is the most frequent symptom in patients diagnosed with esophageal cancer. Self-expanding metal stents (SEMS) are the current palliative treatment of choice for dysphagia in patients with non-curable esophageal cancer. This study aimed to evaluate the efficacy and adverse events (AEs) of different types of SEMS for palliation of dysphagia., Methods: We performed a retrospective cohort study of patients with advanced esophageal cancer and SEMS placement for dysphagia palliation in a tertiary care center. The primary outcome was the clinical success defined as an improvement in dysphagia (reduction of at least 2 points in the Mellow-Pinkas scoring system for dysphagia) after SEMS placement., Results: Between January 1999 and May 2020, 295 patients with esophageal cancer were identified. Among them, 75 had a SEMS placement for dysphagia palliation. The mean age of the patients was 61.3 years (standard deviation: 13.4), 69 patients (92%) were men, and the mean Mellow-Pinkas scoring for dysphagia pre- and post-SEMS placement were 3.1 and 1.4 (change from baseline -1.7), respectively. Technical success and clinical success were achieved in 98.6% and 58.9%, respectively. AEs were identified in 35/75 patients (46.7%), and SEMS migration was the most frequent AE in 22/75 patients (29.3%). There were no significant differences in improvement in dysphagia ( p  = 0.054), weight changes ( p  = 0.78), and AE ( p  = 0.73) among fully covered SEMS (fc-SEMS) and partially covered SEMS (pc-SEMS). The median follow-up was 89 days (interquartile range: 29-221)., Conclusion: SEMS placement was associated with a rapid improvement in dysphagia, high technical success, and a modest improvement in dysphagia with no major AE among fc-SEMS and pc-SEMS., Competing Interests: The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article., (© The Author(s), 2023.)

Introduction: endoscopic evaluation of the ampulla of Vater (AV), although routinely recommended, is not always possible due to its anatomic configuration, which can hide it from the visual field of the forward-viewing endoscope. Cap-assisted forward-viewing endoscopy has been proposed as a useful alternative to facilitate the examination of this structure., Objectives: to assess the efficacy of cap-assisted forward-viewing endoscopy for the complete evaluation of the AV. Secondary outcomes were to assess AV morphology, search and total procedure times and technique safety., Methods: a prospective, single-arm study. Patients who were selected for elective upper endoscopy were included. Patients with advanced neoplasia, modified anatomy, upper gastrointestinal stenosis or obstructions were excluded., Outcomes: ninety patients were included, 36 males (40 %) and 54 females (60 %). Fifteen percent had a history of hereditary colon cancer syndrome. Technical success of cap-assisted, forward-viewing endoscopy was 98.8 %. AV was classified as type 1 (classic) in 49.4 %, type 2 (small) in 16.8 %, type 3 (protruding) in 11.2 % and type 4 (ridged) in 22.4 %. The mean search time was 37.7 seconds (s) (SD ± 31.6) and the total procedure time was 487.4 s (SD ± 206.2). No adverse events were reported., Conclusions: cap-assisted forward-viewing endoscopy is an effective and safe technique for the complete visualization and morphologic characterization of the ampulla of Vater.

Introduction and Objectives: Self-expanding metallic stents (SEMS) are the ideal treatment for malignant gastric outlet obstruction (MGOO) in patients with a short life expectancy, but stent dysfunction is frequent. The primary aim of our study was to identify the predictive factors of SEMS dysfunction in MGOO and the secondary aim was to determine the technical success, clinical success, and nutritional impact after SEMS placement., Material and Methods: A retrospective, longitudinal study was conducted at the gastrointestinal endoscopy department of the Instituto Nacional de Cancerología in Mexico City. Patients diagnosed with MGOO that underwent SEMS placement within the time frame of January 2015 to May 2018 were included. We utilized the gastric outlet obstruction scoring system (GOOSS) to determine clinical success and SEMS dysfunction., Results: The study included 43 patients, technical success was 97.7% (n=42), and clinical success was 88.3% (n=38). SEMS dysfunction presented in 30.2% (n=13) of the patients, occurring in<6 months after placement in 53.8% (n=7) of them. In the univariate analysis, the histologic subtype, diffuse gastric adenocarcinoma (p=0.02) and the use of uncovered SEMS (p=0.02) were the variables associated with dysfunction. Albumin levels and body mass index did not increase after SEMS placement. Medical follow-up was a mean 5.8 months (1-24 months)., Conclusions: SEMS demonstrated adequate technical and clinical efficacy in the treatment of MGOO. SEMS dysfunction was frequent and diffuse type gastric cancer and uncovered SEMS appeared to be dysfunction predictors., (Copyright © 2020 Asociación Mexicana de Gastroenterología. Publicado por Masson Doyma México S.A. All rights reserved.)

Introduction and Aims: Malignant dysphagia is difficulty swallowing resulting from esophageal obstruction due to cancer. The goal of palliative treatment is to reduce the dysphagia and improve oral dietary intake. Self-expandable metallic stents are the current treatment of choice, given that they enable the immediate restoration of oral intake. The aim of the present study was to describe the results of using totally covered and partially covered esophageal stents for palliating esophageal cancer., Materials and Methods: A retrospective study was conducted on patients with inoperable esophageal cancer treated with self-expandable metallic stents. The 2 groups formed were: group A, which consisted of patients with a fully covered self-expandable stent (SX-ELLA ® ), and group B, which was made up of patients with a partially covered self-expandable stent (Ultraflex ® )., Results: Of the 69-patient total, 50 were included in the study. Group A had 19 men and 2 women and their mean age was 63.6 years (range 41-84). Technical success was achieved in 100% (n=21) of the cases and clinical success in 90.4% (n=19). Group B had 24 men and 5 women and their mean age was 67.5 years (range 43-92). Technical success was achieved in 100% (n=29) of the cases and clinical success in 89.6% (n=26). Complications were similar in both groups (33.3 vs. 51.7%)., Conclusion: There was no difference between the 2 types of stent for the palliative treatment of esophageal cancer with respect to technical success, clinical success, or complications., (Copyright © 2018 Asociación Mexicana de Gastroenterología. Publicado por Masson Doyma México S.A. All rights reserved.)

Background and Objective: Drainage with metallic stents is the treatment of choice in malignant obstructive jaundice. Technical and clinical success with metallic stents is obtained in over 90% and 80% of cases, respectively. There are self-expandable metallic stents designed to increase permeability. The aim of this study was to describe the results obtained with totally covered self-expandable and uncovered self-expandable metallic stents in the palliative treatment of malignant biliary obstruction., Patients and Methods: Sixty eight patients with malignant obstructive jaundice secondary to pancreatobiliary or metastatic disease not amenable to surgery were retrospectively included. Two groups were created: group A (covered self-expandable metallic stents) (n = 22) and group B (uncovered self-expandable metallic stents) (n = 46)., Results: Serum total bilirubin, direct bilirubin, alkaline phosphatase and gamma glutamyl transferase levels decreased in both groups and no statistically significant difference was detected (p = 0.800, p = 0.190, p = 0.743, p = 0.521). Migration was greater with covered stents but it was not statistically significant either (p = 0.101). Obstruction was greater in the group with uncovered stents but it was not statistically significant either (p = 0.476)., Conclusion: There are no differences when using covered self-expandable stents or uncovered self-expandable stents in terms of technical and clinical success or complications in the palliative treatment of malignant obstructive jaundice.

Background: gastric cancer patients are first diagnosed with an unresectable tumor in up to 40% of cases. Gastric outlet obstruction causes nausea, vomiting, dehydration and malnutrition. The aim of the study was to compare self-expanding metal stents to antrectomy and Roux-en Y gastrojejunostomy for palliation of obstructive adenocarcinoma of the gastric antrum., Methods: retrospective study in patients with obstructing cancer of the gastric antrum. Patients were divided into two groups: group A, underwent endoscopic placement of self-expanding metal stents and group B underwent surgical treatment with antrectomy and Roux-en Y gastrojejunostomy. Collected data included: age, gender, performance status (Karnofsky's score), body mass index, histopathology, clinical stage (TNM classification), technical and clinical success of the procedure, time to oral intake, in-hospital stay, reintervention rate, and complications related to the treatment and survival., Results: a total of 39 patients with gastric adenocarcinoma were included, 21 male and 18 female. Nineteen patients were assigned to group A and 20 patients to group B. There were no statistically significant differences between groups in regards to age, body mass index, Karnofsky's score and clinical stage. The technical and clinical success was similar for both groups. There was a statistically significant difference between groups favoring self-expanding metal stent in time to oral intake (1 ± 0 vs. 4.9 ± 0.6 days, p = 0.0001) and in-hospital stay (0.94 ± 1.18 vs. 7.8 ± 7.7 days, p = 0.0005). We did not find statistically significant differences with regards to long-term survival., Conclusions: in patients with malignant gastric outlet obstruction due to gastric cancer, endoscopic palliation with self-expanding metal stents provide a shorter interval to oral intake, shorter in-hospital stay and lower rate of complications.

Background: chronic radiation proctopathy (CRP) is associated with recurrent rectal bleeding and transfusional requirements. Argon plasma coagulation (APC) and hyperbaric oxygen therapy (HOT) have been shown to be effective in the control of CRP. No prospective comparisons have been reported between these treatments., Aim: the aim was to evaluate the effectiveness, safety and impact on tissue toxicity of APC compared to HOT in patients with CRP., Material and Methods: a prospective study for evaluating treatment response was conducted. Patients with cervical cancer and CRP with rectal bleeding were recruited. They had not received previous treatment. Collected data included: demographics, previous radiation dosage, duration and severity of rectal bleeding. Hemoglobin, transfusional requirements, and tissue toxicity (SOMA LENT questionnaire) at baseline and at 1, 2, and 3 months follow up were recorded., Results: thirty-one patients were included, 14 in the APC group and 17 in the HOT group. No response was noted in 13 and 18% of patients in the APC and HOT group respectively (p = NS). At the 1 and 2 months follow-up, the APC group showed a significantly better response in terms of transfusional requirements (0.6 vs. 3.4 and 0.7 vs. 2.5) and tissue toxicity score (5.3 vs. 8.6 and 3.8 vs. 7.248). After 3 months, both groups showed further improvement in all parameters without significant differences between them., Conclusions: APC and HOT were effective, safe and decreased the tissue toxicity scores in patients with CRP. However, response rate was higher and faster in the APC group.

Background: Dysphagia is a common problem after surgical stenosis (5% to 55%) and can be refractory to conventional endoscopic treatment in 22% of cases. It has been proposed that electro-incision is an alternative and effective treatment., Objective: To evaluate the effectiveness of electro-incision with the insulation-tipped diathermic Knife-2 (IT-Knife-2) in the treatment of dysphagia produced by surgical anastomotic strictures., Methods: Longitudinal and case-series study from August 2009 to June 2010. Eight consecutive patients with anastomotic stricture-associated dysphagia and naive to endoscopic treatment were included. We performed three or more radiated cuts in the stricture until passage of the gastroscope was achieved with IT-Knife-2 and electrocautery (ERBE IC 200) with a 70-100 W energy cut-off and 25 W coagulation. We carried out measurements at baseline and 15 days after the intervention, evaluating the dysphagia by the Atkinson grading scale and endoscopic changes., Results: The majority of patients were at clinical stage IV with an Eastern Cooperative Oncology Group score of 1 - 3 and Karnofsky between 40 and 90. At the time of endoscopic diagnosis, patients had dysphagia grade II and III. Strictures in all of the cases were short in length and had a diameter of minor than 5 mm. At 15 days of the intervention, no patient demonstrated dysphagia (p = 0.0013) and the anastomotic diameters was more than 9.5 mm and without evidence of stenosis (p = 0.0001). None of our patients presented postincisional complications., Conclusions: Electro-incision with IT-Knife-2 is effective as primary treatment for the relief of benign dysphagia associated with postsurgical anastomotic stenosis."

Introduction: Endoscopy is the better test to detect premalignant lesions, but its main problem is the sampling error., Objectives: To evaluate the diagnostic usefulness of endoscopic biopsies using narrow band imaging (NBI) vs. chromoendoscopy for diagnosing gastric intestinal metaplasia., Methods: Forty one patients were studied with conventional endoscopy, NBI magnification endoscopy and chromoendoscopy (3% acetic acid, 0.6% indigo carmine) for examination of gastric antrum. Biopsies were taken randomly from the antrum, body and incisura angularis. Additional biopsies were taken from areas with villous or crypt pattern according to NBI and chromoendoscopy examination (targeted biopsies)., Results: 240 biopsies were taken, 205 randomized biopsies and 35 targeted biopsies. Intestinal metaplasia was found in 25 randomized biopsies and 9 directed samples (12% vs. 25.7%). The NBI and chromoendoscopy had sensitivity of 70% vs. 77%, specificity of 97% vs. 98%, with diagnostic accuracy of 96% vs. 97%, respectively. Random biopsies and targeted biopsies had a sensitivity of 91% vs. 74%, specificity of 51% vs. 95%, and diagnostic accuracy of 93% vs. 86%, respectively. The intra-observer variability showed a k value of 0.86 (range 0.74 to 0.99)., Conclusion: Targeted biopsies are more specific than random biopsies to detect gastric intestinal metaplasia. NBI and chromoendoscopy may be used similarly to guide biopsies.

Introduction: Fecal occult blood tests (FOBT) (biochemical or immunological) are based on the fact that most of the polyps or cancers bleed. Anemia due to iron deficiency is a wellknown sign for colorectal cancer (CRC). Ferritin is frequently used to select candidates for colonoscopy., Objective: To determine and compare the diagnostic value of immunological fecal occult blood test vs. ferritin for the detection of colorectal neoplasia (cancer or polyps) in high-risk patients., Methods: A transversal prospective study at National Cancer Institute, Mexico City, in consecutive asymptomatic subjects at high risk for CRC was performed, comparing two tests (immunological against serum ferritin) with colonoscopy plus histopathology. Both tests were performed in a blindly fashion previous to colonoscopy., Results: Fifty patients were included in the study; twenty-eight patients had colorectal neoplasia (21 CRC, 7 adenomas). All immunologic tests for fecaloccult blood were positive in patients with colorectal lesions (sensitivity, 98%). There was no difference between the mean ferritin levels in patients with CRC or adenomas vs. those with negative colonoscopy (p = 0.58). The cutoff point where significant relationship between serum ferritin levels and colon lesions was established was ?46 ng/mL. In anemic patients with serum ferritin levels <46 ng/mL, the test had a sensitivity 53%, specificity 86%, positive predictive value 83%, and negative predictive value of 59% (p = 0.003)., Conclusions: The immunological FOBT is a better diagnostic tool than serum ferritin for screening of colonic neoplasms.

Background: Simulators have been used as a training method; they allow training, skill development, standardization of techniques and the performance of a greater number of risk-free procedures. Endoscopic submucosal dissection (ESD) is the standard treatment for early gastric cancer since it allows en bloc resection of larger lesions however requires longer procedure time and has more complications than endoscopic mucosal resection., Objective: To evaluate the use of biological inanimate simulators in endoscopic training for the development of skills required for ESD., Methods: Experimental design using a biological inanimate simulator to evaluate the development of endoscopic skills. Five trained endoscopists with knowledge of the ESD technique, but without previous experience were selected. Technical success, complication rate and procedure time were evaluated. Each participant performed a self-evaluation., Results: 18 lesions of 10-20 mm in diameter were dissected, with a mean area of 2.64 ± 2 cm2 and a mean procedure time of 21.08 ± 14.01 minutes (5.48 - 48.61). Self-evaluation and instructor's evaluation showed a strong positive correlation. There was no correlation between lesion size and procedure time. There was one perforation (5.8%), which was successfully managed with one endoclip. Complications such as bleeding could not be assed., Conclusions: The use of inanimate biological simulators allows training in complex endoscopic procedures such as ESD with a wide safety margin. Lesion size did not correlate with procedure time. It is necessary to increase the number of procedures to improve the learning curve. This simulator does not allow evaluation of complications other than perforations.

Background: Dilatation of the intercellular spaces by electron microscopy has been considered as an early morphological marker of tissue injury in gastroesophageal reflux disease. The degree of dilatation in Barret's esophagus in currently unknown., Objectives: To determine the frequency of dilated intervellular spaces in Barrett's esophagus., Material and Methods: Cross-sectional and prospective analysis of consecutive patients with gastroesophageal reflux disease. We selected symptomatic patients > 18 years and both sexes. Patients with recent PPI use (< 14 days), H-2 antagonists, NSAID's or previous upper GI tract surgery were excluded. VARIABLES INCLUDED: Clinical-demographic data, Carlsson-Dent score, conventional endoscopy findings, pH-metry results (in non-erosive) and normal mucosal biopsies at 2 and 5 cm above the squamocolumnar junction. Dilation of intercellular spaces was measured by electron microscopy., Statistics: Chi square test with a significance level 0.05 was calculated. The following four groups were compared: a) non-erosive reflux disease (n = 14); b) erosive esophagitis (n = 5); c) Barrett's esophagus (n = 13); and d) healthy controls (n = 5)., Results: the dilation of intervellular spaces was increasingly greater form non-erosive revlux to Barrett's esophagus and higher in biopsies taken at 5 cm than at 2 cm of the squamous columnar junction (2.72 +/- 1.35 vs. 1.71 +/- 0.48 microg) (p = 0.001). There was no difference between biopsies at 2 and 5 cm in the order groups., Conclusion: dilation of intercellular spaces was greater in Barrett s esophagus than in the other groups and higher at 5 cm from the squamocolumnar junction.

Self-expandable prostheses have gained in popularity for palliation tumors of the gastrointestinal tract. We present four cases of patients with gastric adenocarcinoma who were palliated by self-expandable metallic prostheses. Two patients had undergone total gastrectomy with esophago-jejunal anastomosis. In one there was recurrent cancer in the anastomosis and the other had non-malignant stenosis. The remaining two patients had unresectable tumors. Correct placement of prostheses was possible in all cases; however, maintenance of adequate hydration and acceptable nutritional status per orem was possible only in three of four patients. In all cases there was temporary slight pain, in one, slight hemorrhage, and in one the prosthesis migrated and it was necessary to withdraw it surgically. Although these are only a few cases, we can say that self-expandable prostheses are a promising alternative to palliate gastric cancer.