Underwater versus conventional EMR for nonpedunculated colorectal lesions: a randomized clinical trial.

BACKGROUND AND AIMS: Conventional endoscopic mucosal resection (CEMR) is the standard modality for removing nonpedunculated colorectal lesions. Underwater endoscopic mucosal resection (UEMR) has emerged as an alternative method. There are few comparative studies between these techniques, especially evaluating recurrence. Therefore, the purpose of this trial was to compare CEMR and UEMR for the resection of colorectal lesions with respect to efficacy, safety, and recurrence rate. METHODS: This was a randomized controlled trial of UEMR versus CEMR for naïve and nonpedunculated lesions measuring between 10 and 40 mm. The primary outcome was adenoma recurrence at 6 months after the resection. Secondary outcomes were rates of technical success, en bloc resection, and adverse events. Block randomization was used to assign patients. Tattooing was performed to facilitate localization of the scars and eventual recurrences. Endoscopic follow-up was scheduled at 6 months after the procedure. The sites of resections were examined with white-light imaging, narrow-band imaging (NBI), and conventional chromoscopy with indigo carmine followed by biopsies. RESULTS: One hundred five patients with 120 lesions were included, with a mean size of 17.5 ± 7.1 (SD) mm. Sixty-one lesions were resected by UEMR and 59 by CEMR. The groups were similar at baseline regarding age, sex, average size, and histologic type. Lesions in the proximal colon in the CEMR group corresponded to 83% and in the UEMR group to 67.8% (P = .073). There was no difference between groups regarding success rate (1 failure in each group) and en bloc resection rate (60.6% UEMR vs 54.2% CEMR, P = .48). Intraprocedural bleeding was observed in 5 CEMRs (8.5%) and 2 UEMRs (3.3%) (P = .27). There was no perforation or delayed hemorrhage in either groups. Recurrence rate was higher in the CEMR arm (15%) than in the UEMR arm (2%) (P = .031). Therefore, the relative risk of 6-month recurrence rate in the CEMR group was 7.5-fold higher (95% CI, 0.98-58.20), with a number needed to treat of 7.7 (95% CI, 40.33-4.22). The higher recurrence rate in the CEMR group persisted only for lesions measuring 21 to 40 mm (35.7% vs 0%; P = .04). CONCLUSION: This study demonstrated that UEMR was associated with a lower adenoma recurrence rate than was CEMR. Both endoscopic techniques were effective and had similar rates of adverse events for the treatment of nonpedunculated colorectal lesions.

Stents for benign and malignant esophageal strictures.

This paper presents commentaries on endotherapy for esophageal perforation/leaks; treatment of esophageal perforation; whether esophageal stents should be used for treating benign esophageal strictures; what determines the optimal stenting period in benign esophageal strictures/leaks; how to choose an esophageal stent; how a new fistula secondary to an esophageal stent should be treated; which strategy should be adopted when a fistula of a cervical anastomosis occurs; intralesional steroids for refractory esophageal strictures; balloon and bougie dilators for esophageal strictures and predictors of response to dilation; whether refractory strictures from different etiologies respond differently to endotherapy; surgical therapy of benign esophageal strictures; and whether stenoses following severe esophageal burns should be treated by esophageal resection or esophageal bypass.

Estesioneuroblastoma / Esthesioneuroblastoma

O estesioneuroblastoma é uma neoplasia maligna incomum, que tem origem no epitélio olfatório e corresponde de 4% a 6% dos tumores malignos dos seios paranasais. A última grande revisão sobre esses tumores mostra que, desde sua descoberta, há oitenta anos, menos de mil casos foram publicados na literatura mundial. As manifestações clínicas usuais constituem-se por anosmia, obstrução nasal e epistaxe. Devido às características microscópicas serem bastante variadas e inespecíficas, é importante que o diagnóstico seja bem estabelecido pela histoquímica e imunoistoquímica, pois disso dependerá o prognóstico do paciente. Por se tratar de uma doença rara, ainda não há consenso quanto ao melhor tipo de tratamento, mas os relatos de casos bem sucedidos incluíram tratamento multidisciplinar com quimioterapia, ressecção cirúrgica e radioterapia. Em um período de seis anos (janeiro/ 2000 a janeiro/2006), ocorreram quatro casos no serviço do Hospital e Maternidade Celso Pierro, que são aqui reportados

Esthesioneuroblastoma is an uncommon malignant neoplasm that arises from the olfactory epithelium and corresponds to 4% - 6% of all malignant tumors in the paranasal sinuses. The last extensive review on these tumors reveals that less than one thousand cases have been published in the literature since its discovery eighty years ago. The common clinical manifestations are anosmia, nasal obstruction and epistaxis. Since its microscopic characteristics vary greatly and are unspecific, a precise diagnosis using histochemical and immunohistochemical techniques cannot be overemphasized as the patient?s prognosis depends on the diagnosis. As it is a rare disease, there is no consensus regarding the best treatment, but reports of cases treated successfully cite a multidisciplinary approach, which includes chemotherapy, surgical resection and radiation therapy. Our service has treated four cases over a period of six years (January 2000 - January 2006) that are reported here