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Ámbito
- Esta guía debe ser usada en todos los establecimientos del seguro social del Perú (EsSalud), según lo correspondiente a su nivel de atención.
Población y alcance
- Pacientes adultos (≥18 años) con sospecha de cáncer gástrico y con cáncer gástrico limitado a intermucosa/submucosa.
Autores
Expertos clínicos:
- Garcia Delgado, César Alberto
- Mestanza Rivas Plata, Ana Lucía
- Velásquez Chamochumbi, Hermes
- Rojas Chihuán, Flor de María Zenobia
- Méndez Mejía, Karem Elizabeth
- Cerna León, Jorge
- Rivas Urquizo, Carlos Alberto
- Núñez Paredes, Iveth Virgnia
- Aliaga Macha, Carlos Hugo
- Cuevas Muñoz, Nelson
- Philco Salas, Manuel
- Portanova Ramírez, Michel
Metodólogos:
- Balbin Ramón, Graciela Josefína
- Canelo Aybar, Carlos Gilberto
- Posso Rivera, Margarita
- Niño de Guzmán Quispe, Ena
Coordinadores:
- Timaná Ruiz, Raúl Alonso
Metodología
Resumen de la metodología:
- Conformación del GEG: La Dirección de Guías de Práctica Clínica, Farmacovigilancia y Tecnovigilancia, del Instituto de Evaluación de Tecnologías en Salud e Investigación (IETSI) del Seguro Social del Perú (EsSalud), conformó un grupo elaborador de la guía (GEG), que incluyó médicos especialistas y metodólogos.
- Planteamiento de preguntas clínicas: En concordancia con los objetivos y alcances de esta GPC, se formularon las preguntas clínicas.
- Búsqueda de la evidencia para cada pregunta: Para cada pregunta clínica, se realizaron búsquedas de revisiones sistemáticas (publicadas como artículos científicos o guías de práctica clínica). De no encontrar revisiones de calidad, se buscaron estudios primarios, cuyo riesgo de sesgo fue evaluado usando herramientas estandarizadas.
- Evaluación de la certeza de la evidencia: Para graduar la certeza de la evidencia, se siguió la metodología Grading of Recommendations Assessment, Development, and Evaluation (GRADE), y se usaron tablas de Summary of Findings (SoF).
- Formulación de las recomendaciones: El GEG revisó la evidencia recolectada para cada una de las preguntas clínicas en reuniones periódicas, en las que formuló las recomendaciones usando la metodología GRADE, otorgándole una fuerza a cada una. Para ello, se tuvo en consideración los beneficios y daños de las opciones, valores y preferencias de los pacientes, aceptabilidad, factibilidad, equidad y uso de recursos. Estos criterios fueron presentados y discutidos, tomando una decisión por consenso o mayoría simple. Asimismo, el GEG emitió puntos de buenas prácticas clínicas (BPC) sin una evaluación formal de la evidencia, y mayormente en base a su experiencia clínica.
- Revisión externa: La presente GPC fue revisada en reuniones con profesionales representantes de otras instituciones, tomadores de decisiones, y expertos externos.
Flujogramas que resumen el contenido de la GPC
Flujograma del manejo
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1. Eficacia y seguridad del tratamiento para la erradicación de Helicobacter pylori
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Recomendación 1:
Se recomienda el tratamiento de erradicación para Helicobacter Pylori para la prevención de lesiones gástricas malignas. (Recomendación fuerte a favor, certeza moderada de la evidencia)
2. Cromoendoscopía virtual comparada con la endoscopía luz blanca
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Recomendación 1:
Se recomienda el uso de la cromoendoscopía virtual en comparación a la endoscopia de luz blanca para el diagnóstico de cáncer gástrico temprano. (Recomendación fuerte a favor, certeza moderada de la evidencia)
BPC 1:
Mientras se desarrolle la implementación de la cromoendoscopía virtual se recomienda continuar con las técnicas diagnósticas habituales incluyendo la endoscopía convencional con luz blanca, entre otras, al considerarse que cuentan con nivel de precisión diagnóstica aceptable.
3. Métodos de la tomografía computarizada versus la resonancia magnética para estadiaje
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Recomendación 1:
No se recomienda el uso de la resonancia magnética para el estadiaje loco-regional de los pacientes con cáncer gástrico temprano. (Recomendación fuerte en contra, certeza baja de la evidencia)
4. Ultrasonografía endoscópica versus la tomografía axial computarizada en el estadiaje
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Recomendación 1:
Se sugiere el uso de la ultrasonografía endoscópica para el estadiaje loco-regional de los pacientes con cáncer gástrico temprano en los establecimientos en los que se encuentre disponibles. (Recomendación condicional a favor, certeza baja de la evidencia)
BPC 1:
En tanto se desarrolle la implementación de la ultrasonografía endoscópica se recomienda realizar la tomografía espiral multicorte, y en lo preferible incorporar el protocolo de hidrotem, para el estadiaje loco-regional de los pacientes con cáncer gástrico temprano.
5. Resonancia magnética versus la ultrasonografía endoscópica en el estadiaje
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En base a las dos recomendaciones anteriores se decidió no discutir esta comparación dado que la ultrasonografía endoscópica es el método de elección frente a la resonancia magnética.
6. Eficacia y seguridad de la resección mucosa endoscópica frente a la disección submucosa endoscópica
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Recomendación 1:
Se recomienda la disección submucosa para el manejo endoscópico del cáncer gástrico temprano como parte del manejo multidisciplinario del cáncer gástrico temprano. (Recomendación condicional a favor, certeza baja de la evidencia)
7. Eficacia y seguridad del tratamiento endoscópico frente al tratamiento quirúrgico
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Recomendación 1:
Se recomienda el tratamiento endoscópico frente al quirúrgico en pacientes con cáncer gástrico temprano siguiendo los estándares internacionales. (Recomendación condicional a favor, certeza baja de la evidencia)
BCP 1:
Use la resección endoscópica para el tratamiento de las lesiones neoplásicas gástricas superficiales que presentan un riesgo muy bajo de metástasis ganglionares.
BCP 2:
Use la resección endoscópica mucosa para lesiones menores de 10-15 mm con una probabilidad muy baja de histología avanzada (Paris 0-IIa). Mientras que la disección endoscópica submucosa sería el tratamiento de elección para la mayoría de las lesiones neoplásicas gástricas superficiales.
BCP 3:
La resección endoscópica debe realizarse cuando la probabilidad de metástasis en los ganglios linfáticos es extremadamente baja y el tamaño y el sitio de la lesión son susceptibles de resección en bloque.
8. Eficacia y seguridad del seguimiento endoscópico en los pacientes adultos con lesiones gástricas premalignas
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Recomendación 1:
Se recomienda un programa de seguimiento de lesiones premalignas gástricas a través de la endoscopía digestiva alta, el cual debe ser monitorizado permanentemente para sustentar su efectividad y seguridad. (Recomendación fuerte a favor, certeza baja de la evidencia)
BPC 1:
El tiempo de seguimiento de lesiones premalignas gástricas a través de la endoscopía digestiva alta debe de ser hasta los 10 años.
9. Eficacia y seguridad del seguimiento endoscópico en los pacientes adultos post-resección endoscópica de cáncer
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Recomendación 1:
Se recomienda un programa de seguimiento endoscópico posterior a la resección endoscópica en pacientes con Ca gástrico temprano. (Recomendación fuerte a favor, certeza baja de la evidencia)
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