Objective We aimed to describe the presentation of papillary microcarcinoma (PTMC) and identify the clinical and histological features associated with persistence/recurrence in a Latin American cohort. Subjects and methods Retrospective study of PTMC patients who underwent total thyroidectomy, with or without radioactive iodine (RAI), and who were followed for at least 2 years. Risk of recurrence was estimated with ATA 2009 and 2015 classifications, and risk of mortality with 7th and 8th AJCC/TNM systems. Clinical data obtained during follow-up were used to detect structural and biochemical persistence/recurrence. Results We included 209 patients, predominantly female (90%), 44.5 ± 12.6 years old, 183 (88%) received RAI (90.4 ± 44.2 mCi), followed-up for a median of 4.4 years (range 2.0-7.8). The 7th and 8th AJCC/TNM system classified 89% and 95.2% of the patients as stage I, respectively. ATA 2009 and ATA 2015 classified 70.8% and 78.5% of the patients as low risk, respectively. Fifteen (7%) patients had persistence/recurrence during follow-up. In multivariate analysis, only lymph node metastasis was associated with persistence/recurrence (coefficient beta 4.0, p = 0.016; 95% CI 1.3-12.9). There were no PTMC related deaths. Conclusions Our series found no mortality and low rate of persistence/recurrence associated with PTMC. Lymph node metastasis was the only feature associated with recurrence in multivariate analysis. The updated ATA 2015 and 8th AJCC/TNM systems classified more PTMCs than previous classifications as low risk of recurrence and mortality, respectively.

MINSAL 2013 classifies appropriately DTC patients and estimates correctly their risk of persistence or recurrence.

Since its conception (1), endoscopic retrograde cholangio-pancreatography (ERCP) has been notorious due to the presence of complications. All steps in this technique entail a rate of undesired outcomes above that of the remaining endoscopy types (sedation, diagnosis, and therapeutic procedures), and every individual action is associated with a host of specific adverse effects, which seldom coincide with those in other steps and are often linked to individual patient characteristics. Even though ERCP represents a serious mechanical, chemical, hydrostatic, enzymatic, microbiological, and thermal insult in itself for the papilla, it is considered a relatively safe endoscopic procedure, once its potential to induce serious, life-threatening complications is assumed (2). In addition to training, ERCP requires a lot of cognitive effort on the performer's part: clinical judgement and decision making are essential items to confront the successive crossroads one is daily brought at by this technique. Factors such as the explorer's personality, restfulness, pressure level, and stress influence results obtained, as does the total amount of procedures performed (lifetime accumulation), current training level (daily practice), or simply time elapsed since the last similar case (3). On the other hand, ERCP is marked by an evaluation that is almost exclusively based on its complication rate, and many other axes exist that may influence a technique's results, such as the extent of technical success, extent and duration of beneficial effects, patient satisfaction, and cost. ERCP has evolved along the same lines as the rest of diagnostic and therapeutic modalities, mainly cholangioresonance and laparoscopic cholecystectomy, and its appropriate use has thus constantly changed. ERCP equipment and tools have also changed and improved, and retrospective studies face a mixture of cases, which hinders the assessment of risk factors for complication development. Such risk factors are specific for each complication and seldom overlap. This is in addition true for both patient-and explorer-dependent factors, as well as for post-ERCP care (4). A huge number of factors has been involved in the development of complications. Risk factors common to all complications include precut, combined or "rendezvous" access, difficult cannulation, and failed stone removal. All these are surrogate markers of simply a difficult ERCP and of the way in which each endoscopist or center faces it (4). Pancreatitis is the most common complication following ERCP. It is defined as the development or worsening of abdominal pain, with amylasemia rising above 3 times its normal value, within 24 hours after the procedure and requiring at least a 2-day stay in hospital, and represents a true scourge on a daily basis.

More than 10 years ago I wondered whether argon plasma coagulation (APC) would prove revolutionary for therapeutic endoscopy (1). Now, time has settled the question. We now know that APC sources are essential in all endoscopy units around the world, but their use is basically restricted to hemostatic procedures. Ablative applications have been relegated to mere "touch-ups" to finish off other techniques, which today anew seem revolutionary.APC has also evolved, and second-generation sources are now available that provide several application modes: forced, pulsed, and precise, with various coagulation effects (2).The forced modality is characterized by continuous monopolar current, which is delivered to the target tissue through a conductive flow of ionized argon gas (argon plasma), and represents the energy dispensed by present-day sources. In pulsed mode discontinuous current is delivered to provide one of two effects: effect one with higher intensity current and longer pauses, and effect two with a higher number of lower-energy pulses. Finally, with the precise mode argon plasma may be regulated using an electronic setup regardless of system impedance and target distance, provided the latter is shorter than 5 mm (3). The effectiveness of second-generation APC is 50% higher than that of original generators (4).The primary benefit attributed to argon plasma is its capability to cause limited damage in superficial layers, since current moves from treated, dried-up areas with a higher resistance to untreated areas with a lower resistance, with this drift protecting patients from potential perforation by deep burns (5,6). In contrast, more recent studies in experimental models show significant damage to the muscularis propria with severity increasing with dispensed energy amount, pulse duration, and target area; the layer is hit by 86% of 40W shots or 69% of applications longer than 5 seconds using both traditional (7) or second-generation sources (8), the latter requiring greater caution given their increased energetic yield by nearly 50%.Obviously, continuous gas flow during delivery results in gastrointestinal tract distension and patient discomfort, an adverse effect that may be easily countered by repeat aspirations during therapy pauses.The most devastating, feared effect is no doubt a deflagration of inflammable gases within the colon. This is why patients scheduled to undergo argon plasma therapy must be fully prepared in an anterograde manner using a sugar-free solution regardless of the target area for APC. Just because actinic proctitis is the condition to be treated, as is the case with Tormo et al. (9), it does not mean that full preparation (using phosphates in our case) to prevent gases from exploding may be overlooked.Argon plasma coagulator -"primum non nocere"

As a result of the development of endoscopic equipment, we endoscopists have played an increasingly relevant role in the diagnosis and management of esophageal, gastric, duodenal, colonic, biliary, and pancreatic conditions. The small bowel seemed out of reach, much too far from our entry doors -the mouth and the anus. The paradigm regarding this frustrating situation was obscure upper gastrointestinal bleeding. Up to 5% of patients with gastrointestinal bleeding were -and still are in many cases-repeatedly explored, admitted, and operated upon to no avail, with patients forced to cope with morbidity as inherent not only to their condition but also to such unfruitful examinations (1-3).The advent of early push enteroscopes hardly advanced 50 to 90 cm (4) into the winding, distensible jejunum. With just these few centimeters, however, we increased diagnostic yield from 8 to 35%. But we were still far removed from reaching the average 6.7 m of small bowel (5), even more so if we consider that average length beyond Treitz's angle, as reached in some enteroscopy series, was shorter than 25 cm (6). Radiographic explorations using a barium contrast material, including enteroclysis, are also of little help. Bleeding in excess of 0.5 cc/min is required for Tc 99m -labeled red blood cell scans to have a yield above 20%, and anyway this exploration will not appropriately locate the bleeding point so that lesions may be identified during surgery (7). Arteriography, while allowing therapeutical measures, requires active bleeding during the procedure, and may be aggravated by serious complications (8).We had to reach further then. First to describe and perform a total enteroscopy was Hiratsuka in 1971 (9), using the ropeaway procedure, only to be followed shortly afterwards by Tada (10), who reported on another total exploration using a sonde enteroscope. Both methods were time-consuming and costly in terms of complications, and thus did not become widespread; intraoperative enteroscopy remained the gold standard in the diagnosis and management of small-bowel conditions (1). With this, diagnostic accuracy increases to 75% (11) but surgical morbidity and the common development of postoperative ileus advise that this examination be restricted to patients with obscure intestinal bleeding as a last option.The next step came a short time ago. The capsule designed and marketed by Given Imaging allows a direct, painless view of virtually the whole small bowel using a small, wireless device. The capsule currently in use is 11 mm in diameter and 26 mm in length, acquires 2 images per second, and captures and transmits around 50,000 pictures to an external recorder during its 8-hour battery life. Images are sent from this recorder to a workstation where they are reviewed by the examiner following their conversion into a video format. The capsule is minimally uncomfortable for the patient, who may be explored while out of hospital on an ambulatory Small bowel: the last frontier

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