Laparoscopic SpyGlass cholangioscopy evaluation during bilioenteric anastomosis for hepatolithiasis, a case report.

INTRODUCTION: Careful evaluation of intrahepatic injury of biliary tract diseases is crucial to assure proper management and estimate disease prognosis. Hepatholithiasis is a rare condition that can be associated to cholestatic liver diseases. Additional tools to improve diagnosis and patient care are of great interest specially if associated to decreased morbidity. Recently the spread of single-operator platforms of cholangioscopy brought this procedure back to scene. Our aim was to identify safety, feasibility and utility of SpyGlass cholangioscopy of biliary tract during laparoscopic hepaticojejunostomy. PRESENTATION OF CASE: A 53 years-old man with hepatolithiasis associated to choledolithiasis under treatment with ursodeoxycholic acid and fenofibrate for 8 months, was submitted to laparoscopic hepaticojejunostomy with cholangioscopy for biliary duct evaluation. Spyscope was inserted through a right lateral laparoscopic trocar entering the common bile duct. Examination of intra-hepatic bile ducts showed injury of right biliary. Few microcalculi were visualized. Left biliary ducts presented normal mucosa. Histopathological examination showed a chronic inflammatory process. During the procedure contrasted radiologic images were performed to assure Spyscope location. Following cholangioscopy evaluation, a Roux-en-Y hepaticojejunostomy was performed. To enlarge hepatic duct, a small longitudinal incision was made, and a PDS-5.0 running suture was used for bilioenteric anastomosis. Patient was discharged on postoperative day 6, with drain removal on day 20. CONCLUSION: SpyGlass cholangioscopy during laparoscopic hepaticojejunostomy is feasible leading to minimal additional invasion of the surgical. In this case the method was performed safely, providing detailed examination of injured biliary ducts, adding elements to determine disease prognosis and patient care.

Endoscopic ultrasound fine needle aspiration vs fine needle biopsy in solid lesions: A multi-center analysis.

BACKGROUND: While endoscopic ultrasound (EUS)-guided fine needle aspiration (FNA) is considered a preferred technique for tissue sampling for solid lesions, fine needle biopsy (FNB) has recently been developed. AIM: To compare the accuracy of FNB vs FNA in determining the diagnosis of solid lesions. METHODS: A retrospective, multi-center study of EUS-guided tissue sampling using FNA vs FNB needles. Measured outcomes included diagnostic test characteristics (i.e., sensitivity, specificity, accuracy), use of rapid on-site evaluation (ROSE), and adverse events. Subgroup analyses were performed by type of lesion and diagnostic yield with or without ROSE. A multivariable logistic regression was also performed. RESULTS: A total of 1168 patients with solid lesions (n = 468 FNA; n = 700 FNB) underwent EUS-guided sampling. Mean age was 65.02 ± 12.13 years. Overall, sensitivity, specificity and accuracy were superior for FNB vs FNA (84.70% vs 74.53%; 99.29% vs 96.62%; and 87.62% vs 81.55%, respectively; P < 0.001). On subgroup analyses, sensitivity, specificity, and accuracy of FNB alone were similar to FNA + ROSE [(81.66% vs 86.45%; P = 0.142), (100% vs 100%; P = 1.00) and (88.40% vs 85.43%; P = 0.320]. There were no difference in diagnostic yield of FNB alone vs FNB + ROSE (P > 0.05). Multivariate analysis showed no significant predictor for better accuracy. On subgroup analyses, FNB was superior to FNA for non-pancreatic lesions; however, there was no difference between the techniques among pancreatic lesions. One adverse event was reported in each group. CONCLUSION: FNB is superior to FNA with equivalent diagnostic test characteristics compared to FNA + ROSE in the diagnosis of non-pancreatic solid lesions. Our results suggest that EUS-FNB may eliminate the need of ROSE and should be employed as a first-line method in the diagnosis of solid lesions.

Evaluation of endoscopic ultrasound fine-needle aspiration versus fine-needle biopsy and impact of rapid on-site evaluation for pancreatic masses.

Background and study aims Endoscopic ultrasound (EUS)-guided fine needle aspiration (FNA) is traditionally considered a first-line strategy for diagnosing pancreatic lesions; however, given less than ideal accuracy rates, fine-needle biopsy (FNB) has been recently developed to yield histological tissue. The aim of this study was to compare diagnostic yield and safety between EUS-FNA and EUS-FNB in sampling of pancreatic masses. Patients and methods This was a multicenter retrospective study to evaluate efficacy and safety of EUS-FNA and EUS-FNB for pancreatic lesions. Baseline characteristics including sensitivity, specificity, and accuracy, were evaluated. Rapid on-site evaluation (ROSE) diagnostic adequacy, cell-block accuracy, and adverse events were analyzed. Subgroup analyses comparing FNA versus FNB route of tissue acquisition and comparison between methods with or without ROSE were performed. Multivariable logistic regression was also performed. Results A total of 574 patients (n = 194 FNA, n = 380 FNB) were included. Overall sensitivity, specificity, and accuracy of FNB versus FNA were similar [(89.09 % versus 85.62 %; P  = 0.229), (98.04 % versus 96.88 %; P  = 0.387), and 90.29 % versus 87.50 %; P  = 0.307)]. Number of passes for ROSE adequacy and cell-block accuracy were comparable for FNA versus FNB [(3.06 ±â€Š1.62 versus 3.04 ±â€Š1.88; P  = 0.11) and (3.08 ±â€Š1.63 versus 3.35 ±â€Š2.02; P  = 0.137)]. FNA + ROSE was superior to FNA alone regarding sensitivity and accuracy [91.96 % versus 70.83 %; P  < 0.001) and (91.80 % versus 80.28 %; P  = 0.020)]. Sensitivity of FNB + ROSE and FNB alone were superior to FNA alone [(92.17 % versus 70.83 %; P  < 0.001) and (87.44 % versus 70.83 %; P  < 0.001)]. There was no difference in sensitivity though improved accuracy between FNA + ROSE versus FNB alone [(91.96 % versus 87.44 %; P  = 0.193) and (91.80 % versus 80.72 %; P  = 0.006)]. FNB + ROSE was more accurate than FNA + ROSE (93.13 % versus 91.80 % ; P  = 0.001). Multivariate analysis showed ROSE was a significant predictor of accuracy [OR 2.60 (95 % CI, 1.41-4.79)]. One adverse event occurred after FNB resulting in patient death. Conclusion EUS-FNB allowed for more consistent cell-block evaluation as compared to EUS-FNA. EUS-FNA + ROSE was found to have a similar sensitivity to EUS-FNB alone suggesting a reduced need for ROSE as part of the standard algorithm of pancreatic sampling. While FNB alone produced similar diagnostic findings to EUS-FNA + ROSE, FNB + ROSE still was noted to increase diagnostic yield. This finding may favor a unique role for FNB + ROSE, suggesting it may be useful in cases when previous EUS-guided sampling may have been indeterminate.

Efficacy and Safety of Endoscopic Sleeve Gastroplasty at Mid Term in the Management of Overweight and Obese Patients: a Systematic Review and Meta-Analysis.

BACKGROUND: Endoscopic sleeve gastroplasty (ESG) has emerged as a promising technique in endoscopic bariatric and metabolic therapies (EBMTs). We aimed to perform a systematic review and meta-analysis to provide an update on its efficacy and safety. METHODS: This is a systematic review and meta-analysis was performed following the PRISMA guidelines. MEDLINE, Cochrane, EMBASE, and LILACS were searched to identify the studies related to ESG. RESULTS: Eleven studies with a total of 2170 patients were included. The average BMI pre-ESG was 35.78 kg/m2. Pooled mean %TWL observed at 6, 12, and 18 months was 15.3%, 16.1%, and 16.8% respectively. Pooled mean %EWL at 6, 12, and 18 months was 55.8%, 60%, and 73% respectively. No procedure-related mortality was reported. CONCLUSION: ESG is a safe and effective procedure for primary obesity therapy with promising short- and mid-term results.

Narrow-band imaging for scar (NBI-SCAR) classification: from conception to multicenter validation.

BACKGROUND AND AIMS: Surveillance post-endoscopic resection (ER) currently warrants biopsy samples from the resection site scar in most cases, although clinical practice is variable. A classification with standard criteria for scars has not yet been established. We aimed to create and validate a novel classification for post-ER scars by using specific criteria based on advanced imaging. METHODS: Key endoscopic features for scars with and without recurrence were (1) dark brown color, elongated/branched pit pattern, and dense capillary pattern and (2) whitish, pale appearance, round/slightly large pits, and irregular sparse vessels. Scars were first assessed with high-definition white-light endoscopy (HD-WLE) followed by interrogation with narrow-band imaging (NBI). Scars with at least 2 concordant characteristics were diagnosed with "high confidence" for NBI for scar (NBI-SCAR) classification. The final endoscopic predictions were correlated with histopathology. The primary outcome was the difference in sensitivity between NBI-SCAR and HD-WLE predictions. Secondary outcomes included the validation of our findings in 6 different endoscopy settings (Australia, United States, Japan, Brazil, Singapore, and Malaysia). The validation took place in 2 sessions separated by 2 to 3 weeks, each with 10 one-minute videos of post-ER scars on underwater NBI with dual focus. Inter-rater and intrarater reliability were calculated with Fleiss' free-marginal kappa and Bennett et al. S score, respectively. RESULTS: One hundred scars from 82 patients were included. Ninety-five scars were accurately predicted with high confidence by NBI-SCAR in the exploratory phase. NBI-SCAR sensitivity was significantly higher compared with HD-WLE (100% vs 73.7%, P < .05). In the validation phase, similar results were found for endoscopists who routinely perform colonoscopies and use NBI (sensitivity of 96.4%). The inter-rater and intrarater reliability throughout all centers were, respectively, substantial (κ = .61) and moderate (average S = .52) for this subset. CONCLUSIONS: NBI-SCAR has a high sensitivity and negative predictive value for excluding recurrence for endoscopists experienced in colonoscopy and NBI. In this setting, this approach may help to accurately evaluate or resect scars and potentially mitigate the burden of unnecessary biopsy samples.

The Effectiveness of Endoscopic Gastroplasty for Obesity Treatment According to FDA Thresholds: Systematic Review and Meta-Analysis Based on Randomized Controlled Trials.

Endoscopic bariatric therapies (EBTs) are promising alternatives to conventional surgery for obesity. The aim of this study is to compare efficacy and safety through a systematic review and meta-analysis of the endoscopic gastroplasty techniques versus conservative treatment. We searched MEDLINE, EMBASE, Cochrane CENTRAL, Lilacs/Bireme. Randomized controlled trials (RCTs) enrolling obese patients comparing endoscopic gastroplasty to sham or diet/exercise were considered eligible. Among 6014 records, three RCTs were selected for meta-analysis. The total sample was 459 patients (312 EBTs vs 147 control). Mean total body weight loss in the intervention group (IG) was 4.8% higher than the control group (CG) at 12 months (p = 0.01). The IG responder rate was 44.31% at 12 months. Therefore, the endoscopic gastroplasty is more effective than conservative therapies but do not achieve FDA thresholds.

Dissecação e Capacitação de Habilidades eCompetências Gerais na Formação Médica / Dissection and Training of Skills and General Competences in Medical Education

Relacionar o ensino e a aprendizagem da disciplinade Dissecação na Anatomia Topográfica com a capacitaçãodas habilidades gerais instituídas pelas Diretrizes CurricularesNacionais dos Cursos de Medicina: atenção à saúde, tomadade decisões, comunicação, liderança, administração egerenciamento, e educação permanente. Materiais eMétodos: Trata-se de um estudo seccional que envolveuuma população de 270 alunos do curso de Medicina daFaculdade de Medicina Nova Esperança e da UniversidadeFederal da Paraíba, ambas em João Pessoa - PB. A amostrafoi selecionada aleatoriamente e incluiu 132 graduandos, queresponderam a um questionário estruturado desenvolvidopelos autores. Resultados: Não houve diferença significativaquanto ao sexo dos alunos entrevistados, tendo sido a médiade idade de 21,7 anos. Dos 132 graduandos, houve o relatode que, frequente ou muito frequentemente, ocorreu odesenvolvimento de: capacidade de tomar decisões – 57,2%,liderança – 57,7%; administração e gerenciamento – 74,3%,comunicação – 87,1%, educação continuada – 76,0%,atenção à saúde – 59,8%. Conclusão: A dissecação temimportância na capacitação das habilidades gerais no ensinode Anatomia Topográfica e, portanto, pode contribuir com aformação do perfil do profissional médico preconizado pelasDiretrizes Curriculares Nacionais dos Cursos de Medicina...

To associate teaching and learning in the subjectDissection within the field of topographical anatomy withthe training of general skills established by the NationalCurriculum Guidelines for Medical Courses: health care,decision making, communication, leadership, administrationand management, and continuing education. Material andMethods: This was a cross-sectional study involving apopulation of 270 students of Medicine, Nova EsperançaFaculty of Medicine and the Federal University of Paraíba,both in the city of Joao Pessoa - PB. The sample wascomposed of 132 undergraduates randomly selected, whoanswered a structured questionnaire developed by theauthors. Results: There was no significant difference in thegender of the students interviewed, which had mean age of21.7 years. Of the 132 undergraduate students, often orvery often, there was the development of: decision-makingabilities – 57.2%, leadership qualities - 57.7%; administrationand management - 74.3%, communication – 87.1%, continuingeducation - 76.0%, health care attention - 59.8%. Conclusion:Anatomic dissection is important in the training of generalskills in the teaching of Topographical Anatomy and hencecan contribute to the formation of the medical profilerecommended by the National Curriculum Guidelines forMedical Courses...