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Resumen Introduccion La reconstruccion esofagica es un proceso quirurgico tecnicamente muy complejo, gravado por una importante morbilidad. Clasicamente se han utilizado la gastroplastia y la coloplastia, aunque la yeyunoplastia ya fue descrita por Roux en 1907. Parece demostrado que la plastia de yeyuno libre es una muy buena opcion en el tratamiento de la enfermedad del esofago cervical, pero no esta tan claro el papel de la yeyunoplastia supercharged en la reconstruccion del esofago toracico. El objetivo de este estudio es el analisis de las reconstrucciones esofagicas realizadas en nuestra unidad y que precisaron de un injerto de yeyuno. Metodos Estudio retrospectivo de las reconstrucciones esofagicas realizadas con yeyunoplastias en nuestra unidad entre enero de 2011 y diciembre de 2019. Se analizan datos epidemiologicos, indicaciones, tecnica quirurgica y morbimortalidad. Resultados Se realizaron 67 procedimientos quirurgicos de reconstruccion esofagica compleja de los que 10 fueron yeyunoplastias: 5 yeyunos libres en esofago cervical y 5 supercharged en esofago toracico con abordaje transesternal. La morbilidad, mortalidad, estancia media y tiempo de retirada de la alimentacion enteral fueron menores en los yeyunos libres que en los supercharged. Conclusiones En nuestro grupo la yeyunoplastia supercharged es la ultima opcion para la reconstruccion del esofago toracico; el acceso por esternotomia media nos permite un excelente abordaje del mediastino anterior y los vasos mamarios internos. El yeyuno libre seria la primera eleccion —con indemnidad del resto de esofago— en la reconstruccion del esofago cervical.

Endoscopic balloon dilation (EBD) is the established endoscopic treatment for short strictures in Crohn's disease. Fully covered self-expandable metal stents (FCSEMS) have been used for endoscopic treatment of patients for whom EBD was unsuccessful. We aimed to determine the efficacy and safety of the two endoscopic treatments in patients with Crohn's disease with stenosis and compare the mean cost of both treatments.This multicentre, open-label, randomised trial was done in 19 tertiary and secondary hospitals in Spain. Patients with Crohn's disease with obstructive symptoms and predominantly fibrotic strictures of less than 10 cm in length were eligible for inclusion. We excluded patients with stenosis treated with SEMS or EBD in the previous year and stenosis not accessible to a colonoscope. Patients were randomly assigned (1:1) to receive either EBD (EBD group) or FCSEMS (FCSEMS group) using a digital en-block randomisation system (block size of four). In the EBD group, dilation was done with a CRE Boston Scientific (Marlborough, MA, USA) pneumatic balloon with the diameter set at the discretion of the endoscopist; a maximum of two sessions of dilation were allowed with a minimum interval of 15-30 days between them. In the FCSEMS group, a 20 mm diameter Taewoong (Gimpo-si, South Korea) fully covered metal stent was placed; stent length was set at the discretion of the endoscopist. The primary outcome was to assess the efficacy of the endoscopic treatment, defined by the proportion of patients free of a new therapeutic intervention (EBD, FCSEMS, or surgery) due to symptomatic recurrence at 1 year of follow-up. Patients were analysed according to the intention-to-treat principle. Adverse events were recorded for all the patients; events were considered associated to be with the procedure when a causal association was possible, probable, or definite. This trial is registered with ClinicalTrials.gov, NCT02395354.From Aug 28, 2013, to Oct 9, 2017, we assessed the eligibility of 99 patients, of whom 19 (19%) patients were excluded. Thus, 80 (81%) patients were randomly assigned to treatment: 39 (49%) patients to the FCSEMS group and 41 (51%) patients to the EBD group. 33 (80%) of 41 patients in the EBD group and 20 (51%) of 39 patients in the FCSEMS group were free of a new therapeutic intervention at 1 year (odds ratio [OR] 3·9 [95% CI 1·4-10·6]; p=0·0061). Two (3%) of 80 patients had severe adverse events (one [2%] patient in the EBD group and one [3%] patient in the FCSEMS group); both patients had perforations.EBD is more effective than FCSEMS for Crohn's disease strictures, with a good safety profile for both treatments.Spanish National Institute of Health, Foundation of Spanish Society of Digestive Endoscopy, Catalan Society of Gastroenterology, and Taweoong.

Technique Video Video 1 EUS-guided biliary rendezvous as an emergent rescue after a failed choledochoduodenostomy using a lumen-apposing metal stent.

Introduction The need for fluoroscopy guidance in patients undergoing endoscopic ultrasound-guided transmural drainage (EUS-TMD) of peripancreatic fluid collections (PFCs) remains unclear. Aims The aim of this study was to compare general outcomes of EUS-TMD of PFCs under fluoroscopy (F) vs fluoroless (FL). Methods This is a comparative study with a retrospective analysis of a prospective and consecutive inclusion database at a tertiary centre, from 2009 to 2015. All patients were symptomatic pseudocyst (PSC) and walled-off pancreatic necrosis (WON). Two groups were assigned depending on availability of fluoroscopy. The groups were heterogeneous in terms of their demographic characteristics, PFCs and procedure. The main outcome measures included technical and clinical success, incidences, adverse events (AEs), and follow-up. Results Fifty EUS-TMD of PFCs from 86 EUS-guided drainages were included during the study period. Group F included 26 procedures, PSC 69.2%, WON 30.8%, metal stents 61.5% (46.1% lumen-apposing stent) and plastic stents 38.5%. Group FL included 24 procedures, PSC 37.5%, WON 62.5%, and metal stents 95.8% (lumen-apposing stents). Technical success was 100% in both groups, and clinical success was similar (F 88.5%, FL 87.5%). Technical incidences and intra-procedure AEs were only described in group F (7.6% and 11.5%, respectively) and none in group FL. Procedure time was less in group FL (8 min, p = 0.0341). Conclusions Fluoroless in the EUS-TMD of PFCs does not involve more technical incidences or intra-procedure AEs. Technical and clinical success was similar in the two groups.

Endoscopic ultrasound (EUS) and endoscopic retrograde cholangiopancreatography (ERCP) have much in common, including their main indications (biliopancreatic disorders), powerful therapeutic capacities and a steep learning curve. Over the years they have evolved from novel diagnostic procedures to interventional therapeutic techniques, but along different paths (different scopes or devices and endoscopists specializing exclusively in one or the other technique). However, EUS has gradually developed into a therapeutic technique that requires skills in the use of ERCP devices and stents, leading some ERCP specialists to explore the therapeutic potential of EUS. The corresponding literature, which has grown exponentially, includes recent experiments on combining the two techniques, which have gradually come to be used in routine care in a number of centers, with positive technical, clinical and financial outcomes. We review EUS and ERCP as individual or combined procedures for managing biliopancreatic disorders.

Background and Aims When ERCP fails, EUS-guided interventional techniques may be an alternative. The aim of this study was to evaluate the general outcomes and safety of EUS-guided methylene blue cholangiopancreatography in patients with failed ERCP in benign biliopancreatic diseases. Methods Patients with benign biliopancreatic diseases and failed ERCP were included. EUS-guided cholangiopancreatography plus injection of methylene blue was performed, and then ERCP using coloring agent flow as an indicator of papilla orifice was performed. Procedures were prospectively collected in this observational, single-center study. Technical success, clinical success, and adverse events were analyzed retrospectively. Results Eleven patients were included (10 choledocholithiasis, 1 pancreatic stricture). The main reason for failed ERCP was an unidentifiable papilla. EUS-guided ductal access with cholangiopancreatography and papilla orifice identification was obtained in all cases. Technical success and clinical success rates of 91% were achieved, with successful biliopancreatic drainage in 10 patients. Adverse events included 1 peripancreatic abscess attributed to a precut, which was successfully treated. No adverse events were related to the first EUS-guided stage. Conclusion EUS-guided cholangiopancreatography with methylene blue injection seems to be a feasible and helpful technique for treatment in patients with benign biliopancreatic diseases with previous failed ERCP because of an undetectable papilla.

The incidence of acute pancreatitis (AP) is increasing. AP is one of the gastrointestinal diseases that most frequently requires hospital admission in affected individuals. In the last few years, considerable scientific evidence has led to substantial changes in the medical and surgical treatment of this disease. New knowledge of the physiopathology of AP indicates that its severity is influenced by its systemic effects (organ failure), especially if the disease is persistent, and also by local complications (fluid collections or necrosis), especially if these become infected. Treatment should be personalized and depends on the patient's clinical status, the location of the necrosis, and disease stage.

Introduction Surgery is the accepted treatment for infected acute pancreatitis, although mortality remains high. As an alternative, a staged management has been proposed to improve results. Initial percutaneous drainage could allow surgery to be postponed, and improve postoperative results. Few centers in Spain have published their results of surgery for acute pancreatitis. Objective To review the results obtained after surgical treatment of acute pancreatitis during a period of 12 years, focusing on postoperative mortality. Materials and methods We have reviewed the experience in the surgical treatment of severe acute pancreatitis (SAP) at Bellvitge University Hospital from 1999 to 2011. To analyze the results, 2 periods were considered, before and after 2005. A descriptive and analytical study of risk factors for postoperative mortality was performed. Results A total of 143 patients were operated on for SAP, and necrosectomy or debridement of pancreatic and/or peripancreatic necrosis was performed, or exploratory laparotomy in cases of massive intestinal ischemia. Postoperative mortality was 25%. Risk factors were advanced age (over 65 years), the presence of organ failure, sterility of the intraoperative simple, and early surgery ( Conclusions Pancreatic infection can appear at any moment in the evolution of the disease, even in early stages. Surgery for SAP has a high mortality rate, and its delay is a factor to be considered in order to improve results.

Resumen Introduccion La cirugia es el tratamiento aceptado en la pancreatitis aguda infectada, aunque la mortalidad sigue siendo elevada. Como alternativa, el manejo en etapas se ha propuesto como alternativa para mejorar los resultados. El drenaje percutaneo inicial permitiria demorar la cirugia, y mejorar los resultados postoperatorios. Pocos centros a nivel nacional han publicado sus resultados tras la cirugia por pancreatitis aguda. Objetivo Revisar los resultados obtenidos tras el tratamiento quirurgico de pancreatitis aguda durante un periodo de 12 anos, con especial interes en la mortalidad postoperatoria. Material y metodos Hemos recogido la experiencia en el tratamiento quirurgico de la pancreatitis aguda grave (PAG) en el Hospital Universitari de Bellvitge desde 1999 hasta 2011. Para analizar los resultados, consideramos 2 periodos de estudio, anterior y posterior a 2005. Realizamos un estudio descriptivo y un analisis de factores de riesgo de mortalidad postoperatoria. Resultados Se ha intervenido a 143 pacientes por PAG, realizandose necrosectomia o desbridamiento de necrosis pancreatica o peripancreatica, o laparotomia exploradora en caso de hallar isquemia intestinal masiva. La mortalidad postoperatoria ha sido del 25%. Los factores de riesgo fueron la edad avanzada (superior a 65 anos), la presencia de fallo organico, la esterilidad de la muestra intraoperatoria obtenida y la cirugia precoz ( Conclusiones La infeccion pancreatica puede aparecer en cualquier momento de la evolucion de la enfermedad, incluso en fases tempranas. La cirugia en PAG comporta una elevada mortalidad, y la demora de la misma es un factor a tener en cuenta para mejorar los resultados.

Background EUS-guided cholangiopancreatography (ESCP) allows transmural access to biliopancreatic ducts when ERCP fails. Data regarding technical details, safety, and outcomes of ESCP are still unknown. Objective To evaluate outcomes of ESCP in community and referral centers at the initial development phase of this procedure, to identify the ESCP stages with higher risk of failure, and to evaluate the influence on outcomes of factors related to the endoscopist. Design Multicenter retrospective study. Setting Public health system hospitals with experience in ESCP in Spain. Patients A total of 125 patients underwent ESCP in 19 hospitals, with an experience of Intervention ESCP. Main Outcome Measurements Technical success and complication rates in the initial phase of implantation of ESCP are described. The influence of technical characteristics and endoscopist features on outcomes was analyzed. Results A total of 125 patients from 19 hospitals were included. Biliary ESCP was performed in 106 patients and pancreatic ESCP was performed in 19. Technical success was achieved in 84 patients (67.2%) followed by clinical success in 79 (63.2%). Complications occurred in 29 patients (23.2%). Unsuccessful manipulation of the guidewire was responsible for 68.2% of technical failures, and 58.6% of complications were related to problems with the transmural fistula. Limitations Retrospective study. Conclusion Outcomes of ESCP during its implantation stage reached a technical success rate of 67.2%, with a complication rate of 23.2%. Intraductal manipulation of the guidewire seems to be the most difficult stage of the procedure.

Resumen Introduccion El tratamiento de la coledocolitiasis asociada a colelitiasis es controvertido. Los costes hospitalarios podrian ser un factor decisivo para elegir entre las distintas opciones terapeuticas. Objetivos Comparar la eficacia y los costes de 2 alternativas en el tratamiento de la coledocolitiasis: 1) Un-tiempo: colecistectomia y exploracion de la via biliar por laparoscopia y 2) Dos-tiempos: colangiopancreatografia retrograda endoscopica y colecistectomia laparoscopica secuencial. Material y metodos Estudio observacional, retrospectivo de 49 pacientes con coledocolitiasis y vesicula in situ, tratados de forma consecutiva y simultanea durante 2 anos, mediante una de las 2 estrategias. Se compararon las complicaciones postoperatorias, estancia, numero de procedimientos por paciente, conversion a laparotomia, eficacia en la extraccion de calculos y costes hospitalarios. Resultados No hubo diferencias en cuanto a caracteristicas clinicas y morbilidad de los pacientes. La estancia postoperatoria media para el grupo Un-tiempo fue menor que para el grupo Dos-tiempos. Tres pacientes del grupo Dos-tiempos requirieron conversion a laparotomia. La mediana de costes por paciente fue menor para la estrategia en Un-tiempo, representando un ahorro global de 37.173 € durante el periodo estudiado. Conclusiones Entre las 2 opciones terapeuticas, no se han encontrado diferencias significativas en cuanto a la eficacia, ni la morbimortalidad postoperatorias, pero si desde el punto de vista de la estancia y los costes hospitalarios. El manejo de los pacientes con coledocolitiasis en un solo tiempo represento un ahorro de 3 dias de estancia y 1.008 € por paciente.

Introduction Since 2006, the results of MAGIC trial demonstrated that a perioperative regimen of Epirrubicin-cisplatin-5FU (ECF) decreases tumour size and stage, with significantly improvement in overall survival (OS) and progression-free survival (PFS). However, the survival rate of patients (pts) with locally advanced resectable gastric cancer (LARGC) remains poor. Our aim was to identify prognostic factors and their correlation with a more aggressive disease in our area. Methods We retrospectively reviewed 65 pts with LARGC who were planned to receive perioperative chemotherapy followed by surgery at our institution, between May 2008 and February 2012. We analysed the correlation between mOS and recurrence free survival (RFS) with patient characteristics, sex and age, and some tumour characteristics, as histology, tumour localization, both clinical and pathological stage, and tumour regression rate (TRR). OS and RFS was analysed using Kaplan-Meier curves and the differences with Log-Rank test. Results 16 women and 49 men were analysed, with a median age of 63 years (range 38-78). 41% pts had a diffuse type, 49% an intestinal type and 10% a mixt type adenocarcinoma. 30% of tumours were proximal and 70% were distal. There were clinically 1.6% stage I, 49.2% stage II and 49.2% stage III pts. 58 pts (98%) completed 3 cycles of neoadjuvant chemotherapy. 42 pts received ECF, whereas 23 pts received other schemes (13 pts carboplatin+5FU, 8 pts cisplatin+5FU, 2 pts other combinations). Radiological downstaging was observed in 59% pts. 40 total gastrectomy, 14 partial gastrectomy and 9 Ivor-Lewis were conducted. There was 1 pt who underwent a palliative derivation. We found 1 surgery-related death. Adjuvant chemotherapy was delivered in 45 pts. There were pathologically 22% stage I, 47% stage II, 22% stage III and 9% stage IV pts. Pathological downstaging in terms of TRR (RG1+RG2+RG3) was obtained in 42% pts, achieving 3 complete responses (RG1). 4 pts had marked regression (RG2) and 19 pts had 10-50% viable tumour remaining (RG3), meanwhile 36 pts did not respond (RG4). The median follow-up of the whole group was 24 months. We did not reach nor the mOS neither the mRFS, given that 70% pts were alive after 2 years. 2 year OS was 72% (95 CI, 60.3%-83.6%) and 2 year RFS was 52.5% (95 CI, 39.8%-65.3%). Age Conclusion Preoperative chemotherapy contributes to pathological downstaging and histologic tumour regression in less than 50% pts. Age>60 years, minor pathological downstaging and tumour regression rate have been objectively correlated to poor outcomes. New patient and tumour characteristics must be identified as prognostic and predictive factors. The development of targeted therapies should provide new possibilities in the treatment of LARGC.