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Highlights • Massive gastric lipomatosis represent 5% of gastrointestinal tract lipomas and less than 1% of all gastric tumors. • Early diagnose and multidisciplinary follow up, is reflected is an adequate evolution. • Asymptomatic massive gastric lipomatosis, could be follow with endoscopy., Background Gastric lipomatosis (GL) is defined as a lipomatous lesion with diffuse infiltration of the submucosal layer by adipose tissue with multiple lesions and must be differentiated from gastrointestinal lipomas, which are solitary submucosal masses composed of well-differentiated adipose tissue surrounded by a fibrous capsule. GL are uncommon, represents 5 % of gastrointestinal tract lipomas and less than 1∼3 % of all gastric tumors. Case presentation A 65-year-old woman, who underwent non-operatively approach by Gastric lipomatosis. Non-specific gastrointestinal symptoms and endoscopic examination ruled out the possibility of mucosal ulceration or bleeding. Endoscopic ultrasonography and abdominal CT that confirmed gastric lipomatosis. Discussion Gastric lipomas are usually small, solitary and asymptomatic, and are hence often detected incidentally, surgical management in asymptomatic patients still be a in debate. Conclusion Non operative management in massive gastic lipomatosis is appropiate when the patient is asymptomatic without mucosal ulceration, regardless of the amount of gastric lipomas. Avoiding patient the morbidity of a total gastrectomy.

Introducción: Para la óptima realización de la ultrasonografía endobronquial (USEB) lineal es imprescindible que el paciente esté sedado para que se mantenga tranquilo, no tosa ni se mueva y el endoscopista trabaje cómodamente con un buen rendimiento de la exploración. Actualmente la técnica anestésica no está estandarizada y varía desde una anestesia general a una sedación. El objetivo del presente trabajo es conocer la dosificación, la seguridad y la satisfacción de la sedación endovenosa con propofol y remifentanilo e identificar los posibles factores predictivos de tos durante el procedimiento. Pacientes y métodos: Se estudió prospectivamente a los pacientes a quienes se realizó la USEB bajo sedación en un hospital de tercer nivel. Resultados: Se realizó la USEB a 90pacientes bajo sedación con remifentanilo y propofol, a una velocidad de infusión de 0,13 (0,09-0,17) ixgkg-¹ min^¹ y 2,34 (1,5-3,6) mgkg-¹ h_1, respectivamente. El 81% de los pacientes tosieron en algún momento de la exploración. En el 8% de los pacientes se interrumpió el procedimiento puntualmente por tos y desaturación. No se registraron complicaciones graves directamente relacionadas con la sedación. El nivel de satisfacción del neumólogo y del paciente con el procedimiento fue excelente o bueno en la mayoría de casos. No se observó relación estadísticamente significativa entre el número de episodios de tos durante la ecobroncoscopia y las variables test de la tos, ser tosedor habitual, hábito tabáquico o grado de severidad de la EPOC. Conclusiones: La sedación con remifentanilo y propofol realizada por un anestesiólogo permite realizar la USEB lineal en ventilación espontánea aunque con una elevada incidencia de tos y desaturación, siendo esta última la complicación más frecuente. No se encontraron factores predictivos de la tos durante el procedimiento. Introduction: Optimal linear endobronchial ultrasound (EBUS) outcomes require sedation to ensure that the patient remains calm, immobile, and does not cough, and so that the bronchoscopist can work comfortably. The choice of anesthesia techniques, on a spectrum ranging from general anesthesia to sedation, is not standardized. The aims of this study were to determine doses, safety and satisfaction for intravenous sedation with propofol and remifentanil, and identify potential predictors of coughing during the procedure, and determine patient and bronchoscopist satisfaction with the procedure. Patients and methods: The prospective study included patients undergoing EBUS under sedation in a tertiary hospital. Results: A total of 90 patients underwent EBUS under sedation with remifentanil and propofol, at infusion rates of 0,13 (0,09-0,17) g kg-¹ min^¹ and 2.34 (1.5-3.6) mg kg-¹ Lr¹, respectively. Just over four fifths of the patients (81%) coughed at some point during the ultrasound procedure. In 8% of patients the procedure was promptly discontinued due to coughing and desaturation. There were no major complications directly related to sedation. Bronchoscopists and patients rated their satisfaction with the procedure as excellent or good in most cases. There was no statistically significant relationship between the number of coughing episodes during the procedure and any of the following variables: positive cough test, a habitual cough, tobacco dependence, or severity of chronic obstructive pulmonary disease. Conclusions: Remifentanil and propofol administered by an anesthesiologist enabled spontaneously breathing patients to undergo linear EBUS, although with a high incidence of coughing and particularly desaturation. No predictors for coughing during EBUS were identified.

Fecal incontinence in adults The aim of this paper is to review the knowledge of this pathology by highlighting the clinical evolution, study and treatment. These different aspects need a multidisciplinary approach, because of their complex physiopathology, possible association with urinary incontinence and prolapse of the three compartments of the pelvis. The fecal incontinence (FI) constitutes a highly prevalent pathology that affects at least 2% of the population and up to 45% of the patients in nursing homes. This pathology can cause serious problems in physical, psychological, social, and economical levels. The clinical evaluation may identify or suspect the cause, and guide the study of FI. The initial treatment of the FI should always be medical one, often associa- ted to biofeedback and the surgical treatment should be only reserved for refractory FI. Sphincteroplasty is indicated by defi ned defaults of the external sphincter, with good initial results (at least 70%) that fall to 50% in 5 years. The artifi cial neosphincter and the dynamic graciloplasty represent an option for patient without suffi cient sphincter mass for a plasty. In the last few years new techniques have appear with promising re- sults, as the neuromodulation that uses electrodes in the sacral plexus or applied to the posterior tibial nerve. In conclusion the IF is a problem of large prevalence but kept in shadows because the patients tend to have reticence to declare it, and the doctors to inquire about. The focus should be multidisciplinary and the initial treatment must be medical one. The surgical treatment should be reserved for refractory FI.

OBJETIVO: Avaliar o desempenho diagnóstico da citologia obtida pela CPER, aquele obtido pela EE-PAAF e a concordância entre patologistas gerais (PG) e especialistas (PE) em pacientes com estenose biliar. MÉTODOS: Incluímos pacientes com estenose biliar identificados pela CPER. A EE-PAAF foi realizada apenas em áreas com efeito de massa ou da parede espessada do ducto biliar. O padrão-ouro foi a cirurgia, histologia e/ou o seguimento. As amostras teciduais foram consideradas: malignas, suspeitas, atípicas, insuficientes ou benignas. Os espécimes obtidos por cada método foi interpretado (cego) por um PG e outro PE. RESULTADO: 46 pacientes foram incluídos (37 malignos e 9 benignos). O diagnóstico final foi de tumor pancreático (26), biliar (11), pancreatite crônica (8) e estenose inflamatória do ducto biliar (1). Sensibilidade e acurácia da CPER foram 43,2% e 52,2% para o PG e 51,4% e 58,7% para o PE. Sensibilidade e acurácia da EE-PAAF foi 52,8% e 58,5% para o PG e 69,4% e 73,2% para o PE. A combinação entre a CPER e EE-PAAF demonstrou maior sensibilidade e acurácia para ambos PG (64,9% e 69,6%) e PE (83,8% e 84,8%), respectivamente. CONCLUSÃO: A citologia obtida pelo escovado da via biliar durante a CPER e as amostras teciduais colhidas pela EE-PAAF tem rendimento semelhante para o diagnóstico das estenoses biliares. No entanto, a combinação dos métodos resulta em uma maior acurácia. Além disso, espera-se que a interpretação das amostras ocorra com maior precisão pelo PE se comparado ao PG. OBJECTIVE: To evaluate and to compare the diagnostic yield of ERCP brush cytology (ERCP) and EUS-FNA in patients with biliary strictures and evaluates the agreement between general pathologists (GP) and expert GI pathologists (GIP) in the final diagnosis of biliary strictures. METHODS: Patients with biliary strictures documented by ERCP were included. Brush cytology was performed and during EUS, only visible mass lesions or localized bile duct wall thickening were aspirated. The gold standard method for diagnosis was surgical histology and/or follow-up. Tissue sampling results were: malignant, suspicious, atypical, insufficiently or benign. Specimens were interpreted by GP and GIP, blinded for prior tests results. RESULTS: 46 patients were included. Final diagnosis was malignancy in 37 (26 pancreatic - 11 biliary) and benign in 9 (8 chronic pancreatitis - 1 common bile duct inflammatory stricture). Sensitivity and accuracy for ERCP brush cytology were 43.2% and 52.2% for GP and 51.4% and 58.7% for GIP. Sensitivity and accuracy for EUS-FNA were 52.8% and 58.5%, respectively for GP and 69.4% e 73.2% for GIP. In comparison, the combination of brush cytology and EUS-FNA demonstrated higher sensitivity and accuracy for both GP (64.9% and 69.6%, respectively) and GIP (83.8% and 84.8%, respectively) and improved agreement with final diagnosis for both (mostly for GIP). CONCLUSION: Both, ERCP brush cytology and EUS-FNA has a similar yield for the diagnosis of biliary strictures. However, the combination of these methods results in an improved diagnostic accuracy. In addition, GIP might be expected to interpret specimens with greater accuracy than GP.

Introducción: La endosonografía anorrectal (EAR) es una alternativa diagnóstica en las patologías anorrectales. Objetivo: Analizar las principales indicaciones y resultados de la EAR. Material y método: Estudio prospectivo, descriptivo desarrollado entre Noviembre 1999 hasta Septiembre 2004. Se correlacionó el informe de la EAR con los hallazgos quirúrgicos y resultados de biopsias. Análisis mediante concordancia. Resultados: En el período mencionado se realizaron 1000 EAR, (62% mujeres, edad promedio 55 años). Las indicaciones fueron etapificación y seguimiento de cáncer rectal (CR) en 279 pacientes, otros tumores 119, incontinencia fecal (IF) en 336, fístulas perianales en 137, dolor anal (DA) en 73, y otras indicaciones en 56 pacientes. En la etapificación del CR la concordancia general para la profundidad tumoral y compromiso linfonodal fue 81,6% y 67,8%, respectivamente. En el estudio de IF, la EAR resultó normal en el 17%, se informó interrupción de ambos esfínteres en 16% de los pacientes, interrupción del esfínter anal externo en el 65% y del esfínter anal interno aislado en el 2%. En 30 pacientes operados por IF en nuestra institución, hubo 100% de concordancia entre hallazgos endosonográficos e intraoperatorios. En el estudio por fístulas perianales, 10,2% normales, 64,2% confirmaron la fístula, 13,1% evidenció una colección y en el 12,5% otros diagnósticos. En el estudio por DA, 36 EAR fueron normales y en 37 se evidenció alguna alteración (50,7%). Conclusión: Las indicaciones más frecuentes fueron el estudio de pacientes con incontinencia fecal y etapificación del cáncer de recto. Existe adecuada concordancia entre hallazgos endosonográficos y quirúrgicos