Potential performance of a 0 h/1 h algorithm and a single cut-off measure of high-sensitivity troponin T in a diverse population: main results of the IN-HOPE study.

AIMS: Chest pain is a major cause of medical evaluation at emergency department (ED) and demands observation to exclude the diagnosis of acute myocardial infarction (AMI). High-sensitivity cardiac troponin assays used as isolated measure and by 0- and 1-h algorithms are accepted as a rule-in/rule-out strategy, but there is a lack of validation in specific populations. METHODS AND RESULTS: The IN-HOspital Program to systematizE Chest Pain Protocol (IN-HOPE study) is a multicentre study that prospectively included patients admitted to the ED due to suspected symptoms of AMI at 16 sites in Brazil. Medical decisions of all patients followed the standard approach of 0 h/3 h protocol, but, in addition, blood samples were also collected at 0 and 1 h and sent to a central laboratory (core lab) to measure high-sensitivity cardiac troponin T (hs-cTnT). To assess the theoretical performance of 0 h/1 h algorithm, troponin < 12 ng/L with a delta < 3 was considered rule-out while a value ≥ 52 or a delta ≥ 5 was considered a rule-in criterion (the remaining were considered as observation group). The main objective of the study was to assess, in a population managed by the 0 h/3 h protocol, the accuracy of 0 h/1 h algorithm overall and in groups with a higher probability of AMI. All patients were followed up for 30 days, and potential events were adjudicated. In addition to the prospective cohort, a retrospective analysis was performed assessing all patients with hs-cTnT measured during the year of 2021 but not included in the prospective cohort, regardless of the indication of the test. A total of 5.497 patients were included (583 in the prospective and 4.914 in the retrospective analysis). The prospective cohort had a mean age of 57.3 (± 14.8) and 45.6% of females with a mean HEART score of 4.0 ± 2.2. By the core lab analysis, 74.4% would be eligible for a rule-out approach (45.3% of them with a HEART score > 3) while 7.3% would fit the rule-in criteria. In this rule-out group, the negative predictive value for index AMI was 100% (99.1-100) overall and regardless of clinical scores. At 30 days, no death or AMI occurred in the rule-out group of both 0/1 and 0/3 h algorithms while 52.4% of the patients in the rule-in group (0 h/1 h) were considered as AMI by adjudication. In the observation group (grey zone) of 0 h/1 h algorithm, GRACE discriminated the risk of these patients better than HEART score. In the retrospective analysis, 1.091 patients had a troponin value of <5 ng/L and there were no cardiovascular deaths at 30 days in this group. Among all 4.914 patients, the 30-day risk of AMI or cardiovascular death increased according to the level of troponin: 0% in the group < 5 ng/L, 0.6% between 5 and 14 ng/L, 2.2% between 14 and 42 ng/L, 6.3% between 42 and 90 ng/L, and 7.7% in the level ≥ 90 ng/L. CONCLUSION: In this large multicentre study, a 0 h/1 h algorithm had the potential to classify as rule-in or rule-out in almost 80% of the patients. The rule-out protocol had high negative predictive value regardless of clinical risk scores. Categories of levels of hs-cTn T also showed good accuracy in discriminating risk of the patients with a very favourable prognosis for cardiovascular death in the group with value < 5 ng/L. CLINICALTRIALS.GOV: NCT04756362.

POST ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY PANCREATITIS PROPHYLAXIS: EVALUATION OF TWO DIFFERENT NSAID REGIMENS.

BACKGROUND: Endoscopic retrograde cholangiopancreatography is a widely used therapeutic modality for the pancreaticobiliary tree. However, it is responsible for the highest rates of complications among the endoscopic procedures, especially post-endoscopic retrograde cholangiopancreatography pancreatitis. The preventive methods include mechanical and pharmacological approaches, such as the use of non-steroidal anti-inflammatory drugs. OBJECTIVE: To compare the efficacy of two different strategies using non-steroidal anti-inflammatory drugs for the prevention of post-endoscopic retrograde cholangiopancreatography pancreatitis, and to clarify the uncertainty about the route of administration of non-steroidal anti-inflammatory drugs in the prevention of this complication. METHODS: This was a prospective trial. Two therapeutic groups were compared with a control group that was composed of patients who underwent endoscopic retrograde cholangiopancreatography, performed in the same service and by the same team in the period preceding the study (historical series), without the administration of any type of prophylaxis. The first group received 100 mg rectal diclofenac. The second group received 100 mg intravenous ketoprofen. Both groups were compared, separately and jointly, with the control group. RESULTS: Post-endoscopic retrograde cholangiopancreatography pancreatitis occurred in 4.39% (12/273) of the participants. In the group without prophylaxis, the incidence was 6.89% (10/145). Among those who received intravenous ketoprofen, the incidence was 2.56% (2/78). No cases of acute post-procedural pancreatitis were observed in the group that received rectal diclofenac (0/52). Although there was no statistical difference between the therapeutic groups when they were separately analyzed, a statistical difference in the prevention of post-procedural pancreatitis was observed when they were analyzed together (P=0.037). CONCLUSION: This study provides evidence for the efficacy of non-steroidal anti-inflammatory drugs in the prophylaxis of post-endoscopic retrograde cholangiopancreatography pancreatitis.

Profilaxia da pancreatite pós-colangiopancreatografia retrógrada endoscópica: avaliação de dois regimes com AINEs diferentes / Post endoscopic retrograde cholangiopancreatography pancreatitis prophylaxis: evaluation of two different nsaid regimens

ABSTRACT BACKGROUND: Endoscopic retrograde cholangiopancreatography is a widely used therapeutic modality for the pancreaticobiliary tree. However, it is responsible for the highest rates of complications among the endoscopic procedures, especially post-endoscopic retrograde cholangiopancreatography pancreatitis. The preventive methods include mechanical and pharmacological approaches, such as the use of non-steroidal anti-inflammatory drugs. OBJECTIVE: To compare the efficacy of two different strategies using non-steroidal anti-inflammatory drugs for the prevention of post-endoscopic retrograde cholangiopancreatography pancreatitis, and to clarify the uncertainty about the route of administration of non-steroidal anti-inflammatory drugs in the prevention of this complication. METHODS: This was a prospective trial. Two therapeutic groups were compared with a control group that was composed of patients who underwent endoscopic retrograde cholangiopancreatography, performed in the same service and by the same team in the period preceding the study (historical series), without the administration of any type of prophylaxis. The first group received 100 mg rectal diclofenac. The second group received 100 mg intravenous ketoprofen. Both groups were compared, separately and jointly, with the control group. RESULTS: Post-endoscopic retrograde cholangiopancreatography pancreatitis occurred in 4.39% (12/273) of the participants. In the group without prophylaxis, the incidence was 6.89% (10/145). Among those who received intravenous ketoprofen, the incidence was 2.56% (2/78). No cases of acute post-procedural pancreatitis were observed in the group that received rectal diclofenac (0/52). Although there was no statistical difference between the therapeutic groups when they were separately analyzed, a statistical difference in the prevention of post-procedural pancreatitis was observed when they were analyzed together (P=0.037). CONCLUSION: This study provides evidence for the efficacy of non-steroidal anti-inflammatory drugs in the prophylaxis of post-endoscopic retrograde cholangiopancreatography pancreatitis.

RESUMO CONTEXTO: A colangiopancreatografia retrógrada endoscópica (CPRE) é uma modalidade terapêutica amplamente utilizada para vias biliopancreáticas, responsável pelas taxas mais elevadas de complicações entre os procedimentos endoscópicos, especialmente a pancreatite pós-CPRE (PPC). Os métodos preventivos incluem abordagens mecânicas e farmacológicas, entre elas, a utilização de antinflamatórios não esteroidais (AINEs). OBJETIVO: Comparar a eficácia de duas estratégias diferentes utilizando AINEs para a prevenção de PPC. Elucidar o cenário incerto sobre a via de administração do AINEs na prevenção da PPC. MÉTODOS - Ensaio clínico prospectivo. Duas estratégias terapêuticas foram comparadas a um grupo controle, composto por pacientes submetidos a CPRE no mesmo serviço e com a mesma equipe no período anterior ao estudo (série histórica), que não recebeu qualquer tipo de profilaxia. O primeiro grupo experimental recebeu 100 mg de diclofenaco via retal, o segundo grupo recebeu 100 mg de cetoprofeno endovenoso. Ambos os grupos foram comparados separadamente e em associação com o grupo de controle. RESULTADOS: A PPC ocorreu em 4,39% (12/273) dos participantes. No grupo sem profilaxia, esta incidência foi de 6,89% (10/145); entre os que receberam cetoprofeno endovenoso foi de 2,56% (2/78). Não houve casos de pancreatite aguda após o procedimento no grupo que recebeu diclofenaco via retal (0/52). Apesar de não haver diferença estatística entre estes grupos analisados separadamente, quando os dois grupos terapêuticos são analisados em conjunto estes apresentam diferenças estatísticas na prevenção da PPC (P=0,037). CONCLUSÃO: Este estudo foi capaz de corroborar a eficácia da utilização de AINEs para a profilaxia de pancreatite pós-CPRE.

Gastric intramural hematoma subsequent to thoracic aortic dissection: Case report and literature review.

INTRODUCTION: Intramural hematomas of the gastrointestinal tract are uncommom, usually located in the esophagus or duodenum, with idiophatic or secondary causes. We present a very rare case of gastric intramural hematoma caused by an unpublished etiology, with literature review. CASE PRESENTATION: An elderly woman suffered acute thoracic aorta dissection followed by gastric intramural hematoma, diagnosed through endoscopy and computed tomography angiography. The treatment included endovascular aortic repair and conservative management. DISCUSSION: The postulated mechanism for the bleeding in gastric intramural hematoma is shredding of terminal arteries at the point of penetration into the muscular layer with subsequent dissection of the muscularis propria from the submucosa. The most frequently cited risk factor is hemorrhagic diathesis/anticoagulant use and the main etiologies are trauma and post-interventional endoscopy. In the diagnosis work-up, computed tomography is the method of choice, usually associated with endoscopy. There is no standard of care for such rare condition. Thus, treatment may be cause-dependent, ranging from conservative to minimally invasive and/or surgery. CONCLUSIONS: Gastric intramural hematoma is a rare disorder with many causes and we described a new etiology for it. The computed tomography is the diagnostic modality of choice, with the aid of other examinations. The treatment comprises conservative measures, minimally invasive approach or most commonly surgery.

IVTH BRAZILIAN CONSENSUS CONFERENCE ON HELICOBACTER PYLORI INFECTION.

Significant progress has been obtained since the III Brazilian Consensus Conference on H. pylori infection held in 2012, in Bento Gonçalves, Brazil, and justify a fourth meeting to establish updated guidelines on the current management of H. pylori infection. Therefore, the Núcleo Brasileiro para Estudo do Helicobacter pylori e Microbiota (NBEHPM), association linked to Brazilian Federation of Gastroenterology (FBG) held its fourth meeting again in Bento Gonçalves, RS, Brazil, on August 25-27, 2017. Twenty-six delegates, including gastroenterologists, endoscopists, and pathologists from the five regions of Brazil as well as one international guest from the United States, participated in the meeting. The participants were invited based on their knowledge and contribution to the study of H. pylori infection. The meeting sought to review different aspects of treatment for infection; establish a correlation between infection, dyspepsia, intestinal microbiota changes, and other disorders with a special emphasis on gastric cancer; and reassess the epidemiological and diagnostic aspects of H. pylori infection. Participants were allocated into four groups as follows: 1) Epidemiology and Diagnosis, 2) Dyspepsia, intestinal microbiota and other afections, 3) Gastric Cancer, and, 4) Treatment. Before the consensus meeting, participants received a topic to be discussed and prepared a document containing a recent literature review and statements that should be discussed and eventually modified during the face-to-face meeting. All statements were evaluated in two rounds of voting. Initially, each participant discussed the document and statements with his group for possible modifications and voting. Subsequently, during a second voting in a plenary session in the presence of all participants, the statements were voted upon and eventually modified. The participants could vote using five alternatives: 1) strongly agree; 2) partially agree; 3) undecided; 4) disagree; and 5) strongly disagree. The adopted consensus index was that 80% of the participants responded that they strongly or partially agreed with each statement. The recommendations reported are intended to provide the most current and relevant evidences to management of H. pylori infection in adult population in Brazil.

ERCP PERFORMANCE IN A TERTIARY BRAZILIAN CENTER: FOCUS ON NEW RISK FACTORS, COMPLICATIONS AND QUALITY INDICATORS.

BACKGROUND: ERCP can lead to complications, which can be prevented by the recognition of risk factors. AIM: To identify these risk factors, with quality evaluation. METHODS: Retrospective study in a Brazilian hospital in 194 patients, excluding surgically altered anatomy. RESULTS: 211 ERCPs were performed: 97.6% were therapeutic, 83.4% were started by trainees, with deep cannulation rate of 89.6%. Precut was needed in 16.6% of the ERCPs and classic sphincterotomy in 67.3%, with 75.4% of ductal clearance at single session and 8.0% of technical failure. Inacessible papillas ocurred in 2.5% of cases. There were 2.5% of late complications and 16% of early complications. Multivariate analysis identified six predictors for early complications: fistulotomy precut (OR=3.4, p=0.010), difficult cannulation (OR=21.5, p=0.002), attending's procedural time (OR=2.4, p=0.020), choledocholithiasis (adjusted OR=1.8, p=0.015), cannulation time (adjusted OR=3.2, p=0.018) and ERCP duration (adjusted OR=2.7, p=0.041). CONCLUSION: Six risk factors for post-ERCP complications were identified. ERCP duration and cannulation time are suggested as new potential quality indicators.

Endoscopic polymer injection and endoluminal plication in treatment of gastroesophageal reflux disease: evaluation of long-term results.

BACKGROUND AND STUDY AIMS: Us of proton pump inhibitors (PPIs) has made endoscopic treatment of gastroesophageal reflux disease (GERD) more efficient, with reduction in morbidity and complications. However, some patients persist with symptoms despite medical treatment and some are not compliant with it or cannot afford it for financial reasons, and thus they require non-pharmacological therapeutic options such as surgical fundoplication. Surgery may be effective in the short term, but there is related morbidity and concern about its long-term efficacy. The possibility of minimally invasive endoluminal surgeries has resulted in interest in and development of newly endoscopic devices. Good short-term results with surgical fundoplication lack of studies of is with long follow-up justify our interest in this study. The aim of this study was to investigate the efficacy of endoscopic polymer injection and endoluminal full-thickness plication in the long-term control of GERD. PATIENTS AND METHODS: Forty-seven patients with GERD who underwent an endoscopic procedure were followed up for 60 months and evaluated for total response (RT), partial response (RP) and no response (SR) to endoscopic treatment with reintroduction of PPIs. RESULTS: Twenty-one patients received polymer injection (G0) and 26 endoluminal plication (G1). The number of patients with no response to endoscopic treatment with reintroduction of PPIs increased in time for both techniques (G0 P  = 0.006; G1 P  < 0.001). There was symptomatic improvement up to 12 months, with progressive loss of this trending up to 60 months in G0 and G1 ( P  < 0.001). Health-related quality of life score (GERD-HRQL) demonstrated TR in G0 and G1 at 1, 3, 6 and 12 months. The 60-month analysis showed an increased number of patients with SR in both groups. The quality of life assessment (SF-36) showed benefit in G0 up to 3 months. G0 showed a higher rate of complications. There were no deaths. There was healing of esophagitis at 3 months in 45 % of patients in G0 and 40 % in G1. There was no improvement in manometric or pH findings. CONCLUSION: Endoscopic therapies were ineffective in controlling GERD in the long term.

Intragastric balloons in high-risk obese patients in a Brazilian center: initial experience.

OBJECTIVE: to assess the short-term efficacy, tolerance and complications in high-risk morbidly obese patients treated with an intragastric balloon as a bridge for surgery. METHODS: we conducted a post-hoc analysis study in a Brazilian teaching hospital from 2010 to 2014, with 23 adult patients with a BMI of 48kg/m2, who received a single intragastric air or liquid balloon. We defined efficacy as 10% excess weight loss, and complications, as adverse events consequent to the intragastric balloon diagnosed after the initial accommodative period. We expressed the anthropometric results as means ± standard deviation, comparing the groups with paired T / Student's T tests, when appropriate, with p<0.05 considered statistically significant. RESULTS: the balloons were effective in 91.3% of the patients, remained in situ for an average of 5.5 months and most of them (65.2%) were air-filled, with a mean excess weight loss of 23.7kg±9.7 (excess weight loss 21.7%±8.9) and mean BMI reduction of 8.3kg/m2±3.3. Complications (17.3%) included abdominal discomfort, balloon deflation and late intolerance, without severe cases. Most of the participants (82.7%) did not experience adverse effects. We removed the intragastric balloons in time, without intercurrences, and 52.2% of these patients underwent bariatric surgery within one month. CONCLUSION: in our center, intragastric balloons can be successfully used as an initial weight loss procedure, with good tolerance and acceptable complications rates.

Intragastric balloons in high-risk obese patients in a Brazilian center: initial experience / Balões intragástricos em obesos de alto risco em um centro brasileiro: experiência inicial

ABSTRACT Objective: to assess the short-term efficacy, tolerance and complications in high-risk morbidly obese patients treated with an intragastric balloon as a bridge for surgery. Methods: we conducted a post-hoc analysis study in a Brazilian teaching hospital from 2010 to 2014, with 23 adult patients with a BMI of 48kg/m2, who received a single intragastric air or liquid balloon. We defined efficacy as 10% excess weight loss, and complications, as adverse events consequent to the intragastric balloon diagnosed after the initial accommodative period. We expressed the anthropometric results as means ± standard deviation, comparing the groups with paired T / Student's T tests, when appropriate, with p<0.05 considered statistically significant. Results: the balloons were effective in 91.3% of the patients, remained in situ for an average of 5.5 months and most of them (65.2%) were air-filled, with a mean excess weight loss of 23.7kg±9.7 (excess weight loss 21.7%±8.9) and mean BMI reduction of 8.3kg/m2±3.3. Complications (17.3%) included abdominal discomfort, balloon deflation and late intolerance, without severe cases. Most of the participants (82.7%) did not experience adverse effects. We removed the intragastric balloons in time, without intercurrences, and 52.2% of these patients underwent bariatric surgery within one month. Conclusion: in our center, intragastric balloons can be successfully used as an initial weight loss procedure, with good tolerance and acceptable complications rates.

RESUMO Objetivo: identificar a eficácia em curto prazo, a tolerância e as complicações em obesos mórbidos de alto risco, tratados com balão intragástrico como ponte para cirurgia. Métodos: estudo de análise post-hoc em um hospital acadêmico brasileiro durante o período de 2010 a 2014, de 23 pacientes adultos com IMC de 48kg/m2 que receberam um único balão intragástrico de ar ou líquido. Eficácia foi definida como perda de excesso de peso de 10%, e complicações como eventos adversos consequentes ao balão intragástrico diagnosticados após o período acomodativo inicial. Expressaram-se os resultados antropométricos com média ± desvio padrão, comparando os grupos com testes T Pareado / T de Student, quando apropriado, com p<0,05 considerado estatisticamente significante. Resultados: os balões foram efetivos em 91,3% dos pacientes, permaneceram in situ por em média 5,5 meses e a maioria deles (65,2%) era de ar, com perda média de excesso peso de 23,7kg±9,7 (perda de excesso de peso de 21,7%±8,9) e redução média de IMC de 8,3kg/m2±3,3. As complicações (17,3%) compreenderam desconforto abdominal, deflação do balão e intolerância tardia, sem casos graves. A maioria dos participantes (82,7%) não experimentou efeitos adversos, seus balões intragástricos foram extraídos em tempo, sem intercorrências e 52,2% desses pacientes submeteram-se à cirurgia bariátrica no intervalo de um mês. Conclusão: no nosso centro, balões intragástricos podem ser usados com sucesso como procedimento inicial de perda ponderal, com boa tolerância e taxas aceitáveis de complicações.

Ercp performance in a tertiary brazilian center: focus on new risk factors, complications and quality indicators / Performance de cpre em centro terciário brasileiro: foco em novos fatores de risco, complicações e indicadores de qualidade

ABSTRACT Background: ERCP can lead to complications, which can be prevented by the recognition of risk factors. Aim: To identify these risk factors, with quality evaluation. Methods: Retrospective study in a Brazilian hospital in 194 patients, excluding surgically altered anatomy. Results: 211 ERCPs were performed: 97.6% were therapeutic, 83.4% were started by trainees, with deep cannulation rate of 89.6%. Precut was needed in 16.6% of the ERCPs and classic sphincterotomy in 67.3%, with 75.4% of ductal clearance at single session and 8.0% of technical failure. Inacessible papillas ocurred in 2.5% of cases. There were 2.5% of late complications and 16% of early complications. Multivariate analysis identified six predictors for early complications: fistulotomy precut (OR=3.4, p=0.010), difficult cannulation (OR=21.5, p=0.002), attending's procedural time (OR=2.4, p=0.020), choledocholithiasis (adjusted OR=1.8, p=0.015), cannulation time (adjusted OR=3.2, p=0.018) and ERCP duration (adjusted OR=2.7, p=0.041). Conclusion: Six risk factors for post-ERCP complications were identified. ERCP duration and cannulation time are suggested as new potential quality indicators.

RESUMO Racional: A CPRE está associada a complicações, que podem ser prevenidas pelo reconhecimento de fatores de risco. Objetivo: Identificar tais fatores em nosso meio, com avaliação de qualidade. Métodos: Estudo retrospectivo em 194 pacientes de um hospital brasileiro, excluindo-se anatomia cirurgicamente alterada. Resultados: Executaram-se 211 CPREs: 97.6% foram terapêuticas, 83.4% iniciadas pelos residentes, com 89.6% de taxa de canulação profunda. Pré-corte foi necessário em 16.6% das CPREs e papilotomia clássica em 67.3%, com esvaziamento ductal de 74.5% em única sessão e 8.0% de falha técnica. Papilas inacessíveis ocorreram em 2.5% dos casos. Houve complicações tardias (2.5%) e precoces (16%). Em análise multivariada, identificaram-se seis preditores para complicações precoces: fistulotomia (RC=3.4, p=0.010), canulação difícil (RC=21.5, p=0.002), tempo do preceptor no procedimento (RC=2.4, p=0.020), coledocolitíase (RC ajustada=1.8, p=0.015), tempo de canulação (RC ajustada=3.2, p=0.018) e duração da CPRE (RC ajustada=2.7, p=0.041). Conclusão: Identificaram-se seis fatores para complicações pós-CPRE, sugerindo-se duração da CPRE e tempo de canulação como novos potenciais indicadores de qualidade.

Estudo prospectivo para tratamento de acalasia pela técnica de miotomia endoscópica POEM (Peroral Endoscopic Myotomy) / Prospective study of POEM: Peroral Endoscopy Myotomy in the treatment of esophageal achalasia

Miotomia endoscópica por via oral (POEM) foi recentemente descrita em humanos como tratamento para a acalasia. Este conceito tem evoluído a partir de desenvolvimentos na cirurgia endoscópica transluminal por orifícios (NOTES) e com potencial para se tornar uma importante opção terapêutica para o tratamento de megaesôfago. Neste estudo prospectivo descrevemos nossa abordagem com o POEM e a experiência inicial para o tratamento de pacientes com acalasia. Três pacientes com distúrbios da motilidade esofágica foram submetidos ao POEM. Este procedimento endoscópico consiste em uma incisão na mucosa do esôfago, formando um túnel submucoso até cárdia para divisão seletiva das fibras circulares do esfíncter inferior do esôfago (EIE). Essa entrada na mucosa é fechada por clipes hemostáticos endoscópicos. Todos os pacientes tiveram esofagogramas e manometrias esofágicas no pré e pós-operatório para acompanhamento clínico, comparativo, em 3 meses. Todos os três pacientes foram submetidos com sucesso ao tratamento POEM, e a miotomia tinha um comprimento médio de 13 cm. O tempo operatório variou 115-120 minutos. A permanência no hospital foi de 4 dias. Nossa experiência inicial com o procedimento POEM demonstra sua segurança operacional, sendo considerados bons os resultados clínicos iniciais. Embora os dados de avaliação a longo prazo devam ser estudados, o POEM poderia se tornar o tratamento de escolha para acalasia.

Peroral endoscopic myotomy (POEM) has recently been described in humans as a treatment for achalasia. This concept has evolved from developments in natural orifice translumenal endoscopic surgery (NOTES) and has the potential to become an important therapeutic option. We describe our approach as well as our initial clinical experience as part of an ongoing study treating achalasia patients with POEM. Three patients with esophageal motility disorders were enrolled in and underwent POEM. This completely endoscopic procedure involved a mid esophageal mucosal incision, a submucosal tunnel onto the gastric cardia, and selective division of the circular and sling fibers at the lower esophageal sphincter. The mucosal entry was closed by conventional hemostatic clips. All patients had postoperative esophagograms before discharge and initial clinical follow-up 3 weeks postoperatively. All (3 of 3) patients successfully underwent POEM treatment. After the procedure, smooth passage of the endoscope through the gastroesophageal junction was observed in all patients. Operative time ranged from 120 to 240 minutes. No leaks were detected in the swallow studies and mean length of stay was 4 days. No clinical complications were observed, and at the initial follow-up, all patients reported dysphagia relief without reflux symptoms. Our initial experience with the POEM procedure demonstrates its operative safety, and early clinical results have shown good results. Although further evaluation and long-term data are mandatory, POEM could become the treatment of choice for symptomatic achalasia.

Aortic disease in the young: genetic aneurysm syndromes, connective tissue disorders, and familial aortic aneurysms and dissections.

There are many genetic syndromes associated with the aortic aneurysmal disease which include Marfan syndrome (MFS), Ehlers-Danlos syndrome (EDS), Loeys-Dietz syndrome (LDS), familial thoracic aortic aneurysms and dissections (TAAD), bicuspid aortic valve disease (BAV), and autosomal dominant polycystic kidney disease (ADPKD). In the absence of familial history and other clinical findings, the proportion of thoracic and abdominal aortic aneurysms and dissections resulting from a genetic predisposition is still unknown. In this study, we propose the review of the current genetic knowledge in the aortic disease, observing, in the results that the causative genes and molecular pathways involved in the pathophysiology of aortic aneurysm disease remain undiscovered and continue to be an area of intensive research.

Paralisia de Bell subsequente a ritidoplastia / Bell’s palsy subsequent to rhytidectomy

A paralisia facial periférica é uma entidade que pode deixar sequelas estéticase funcionais importantes nos pacientes. De acordo com a literatura, a paralisia de Bell (PB) é a causa mais comum, representando de 50 a 80% dos casos. Porém deve ser considerada como diagnóstico de exclusão. Estima-se uma prevalência ligeiramente maior entre as mulheres e sua incidência é bimodal, com picos na terceira e oitava décadas de vida. A maioria dos pacientes evolui para a recuperação dentro de algumas semanas, embora seja comum uma piora do quadro nas primeiras 48 horas. O tratamento deve ser realizado no sentido de prevenir complicações e as condutas medicamentosas não estão consagradas. Como fatores de risco para a PB têm sido relatados hipertensão arterial, diabete mellitus, gravidez, puerpério e infecção pelo vírus herpes tipo I. Embora existam vários fatores de risco associados à PB, em relação à cirurgia de face-lifting existe apenas um caso relatado na literatura. Relato do Caso: No presente estudo, os autores descrevem o segundo caso de paralisia de Bell após a cirurgia de face-lifting.

The peripheral facial palsy is a disease that can leave significant aestheticaland functional sequelae in patients. According to medical literature, Bell’s palsy (BP) is the most common cause, representing from 50 to 80% of the cases. However, it must be considered as an exclusion diagnosis. A slightly higher prevalence is estimated in women and its incidence is bimodal with peaks in the third and eighth life decades. Most patients recover within weeks, though a worsening degree may be common in the first 48 hours. Treatment must be performed to prevent complications and the medical procedures are not universally accepted. The following have been mentioned as BP risk factors: arterial hypertension, mellitus diabetes, pregnancy, puerperium and infection caused by type I herpesvirus. Although there are several BP associated risk factors, regarding face-lifting surgery there is only one reported case in medical literature. Case Report: In the present study, the authors describe the second case of Bell’s palsy after face-lifting surgery.

Cervicoplastia ampliada para correção de alterações cervicais / Expanded cervicoplasty to correction of cervical changes

INTRODUÇÃO: A cervicoplastia é considerada parte importante na cirurgia do rejuvenescimento facial. Apesar das diversas técnicas já descritas, a busca pelo tratamento ideal ainda persiste. As dificuldades aumentam nos casos considerados complexos, em que a flacidez excessiva de pele e a ptose muscular pronunciada prejudicam a manutenção dos resultados a longo prazo. OBJETIVOS: No intuito de discutir as opções técnicas disponíveis para a cervicoplastia e apresentar a rotina cirúrgica utilizada pelo autor - com ênfase no tratamento ampliado sobre o músculo platisma - é que este estudo foi delineado. MÉTODO: Dezoito pacientes foram submetidos ao round lifting associado à confecção de retalhos musculares de platisma, na linha médio-cervical, e à retirada parcial da gordura subplatismal. Os pacientes foram acompanhados por 12 meses e o resultado pós-operatório tardio foi avaliado por cinco cirurgiões plásticos da SBCP. RESULTADOS: Quatro pacientes foram excluídos do estudo por não retornarem para o acompanhamento pós-operatório tardio. Dos 14 pacientes avaliados, 7 (50 por cento) tiveram o resultado classificado como excelente, 5 (35,7 por cento) como moderado e 2 (14,3 por cento) como fraco. Nenhum paciente teve o resultado classificado como perfeito ou ruim. CONCLUSÃO: A cervicoplastia ampliada proporcionou a obtenção de resultados satisfatórios, mesmo em casos difíceis. Acreditamos que a técnica é uma alternativa válida para o cirurgião plástico, podendo contribuir para que obtenhamos um resultado pós-operatório agradável, natural e mantido com o tempo.

INTRODUCTION: Cervicoplasty is considered an important part of facial surgery. Despite the various techniques already described, the search for optimal treatment still persists, especially in complex or difficult cases, where the skin excess and the muscular ptosis affect the maintenance of long-term results. OBJECTIVE: This study was designed to discuss the technical options available to cervicoplasty and present the routine used by the author - with emphasis on platisma muscle extended treatment. METHOD: Eighteen patients were submitted to "Round Lifting" associated with a platisma muscle flap in cervical mid-line and partial removal of subplatismal fat. The patients were followed for 12 months and late postoperative outcome was evaluated by five of SBCP plastic surgeons. RESULTS: Four patients were excluded for not returning for follow-up. Of the 14 patients evaluated, 7 (50 percent) patients had an excellent result, 5 (35.7 percent) patients moderate and 2 (14.3 percent) weak. No patient had the result classified as perfect or poor. CONCLUSION: The expanded cervicoplasty described here provided great results, even in difficult cases. We believe that the technique is a valid alternative to the plastic surgeon, which can help you obtain a pleasing postoperative result, natural and maintained over time.

[Undetected surgical glove perforation during emergency procedures]. / Perfurações não detectadas de luvas em procedimentos de urgência.

OBJECTIVE: Gloves are the most important barriers that protect hospital personnel and patients. Unfortunately, glove perforation rates reach up to 78% in high risk procedures. The purpose of this prospective study was to evaluate the glove perforation rate in emergency procedures carried out in the Emergency Service of 'Santa Casa de São Paulo', School of Medicine. METHODS: The study analyzed all gloves used in the emergency room during a 2 months period. Gloves were tested immediately after the surgical procedure using the approved standardized water leak method. RESULTS: A total of 252 surgical gloves used by residents in 42 surgical procedures and 2361 gloves used in emergency procedures were tested for the presence of punctures by the water insuflation method. Forty one (16.3%) of the gloves tested showed at least one puncture, 18 (33%) in traumatic emergencies. The overall perforation rate in the emergency room was 7,3%. CONCLUSION: We concluded that the incidence of punctures in gloves during surgical procedures was high, and occurred mostly with surgeons.

International consensus guidelines for surgical resection of mucinous neoplasms cannot be applied to all cystic lesions of the pancreas.

BACKGROUND & AIMS: International consensus guidelines, aimed at predicting malignancy, are available for surgical resection of mucinous cysts but not for other cystic lesions of the pancreas. We sought to determine whether the consensus guidelines can be applied to all cystic lesions of the pancreas. METHODS: We identified all patients who underwent surgical resection of pancreatic cysts from 2001-2007. Pathology analyses of surgical specimens served as the reference standard. Surgical resection criteria proposed by the Sendai Guidelines and 5 modifications of these criteria were tested to determine their accuracy for diagnosis of malignant cysts. RESULTS: Patients with cystic lesions of the pancreas (n = 154; mean age, 59.8 years; 64% women) underwent resection and met prespecified study criteria. Twenty-one patients had a malignancy. The classification cyst size > or = 3 cm had an accuracy of 56%, negative predictive value of 84%, and identified only 57% of the malignant cysts. The classification cyst size > or = 3 cm or cyst with main pancreatic duct > or = 10 mm had an accuracy of 55%, negative predictive value of 86%, and identified 66% of malignant cysts. The modified criterion of cyst size > or = 3 cm or cyst with main pancreatic duct > 3 mm had an accuracy of 48%, negative predictive value of 94%, and identified 91% (19/21) of the malignancies. Cyst size (odds ratio, 1.05) and pancreatic duct dilation > 3 mm (odds ratio, 10.5) were strong and independent predictors of malignancy. CONCLUSIONS: When applied to all cystic lesions of the pancreas, the international consensus criteria cause some malignant cysts to be missed. Modified criteria could identify most malignant cysts, although overall accuracy remains low.

Infliximab to treat severe ulcerative colitis.

A 48-year-old female with severe ulcerative colitis refractory to conventional therapy was referred to our facility for management. The patient showed extensive ulcerative colitis since the age of 20 years and had failed therapy with 5-aminosalicylic acid agents and azathioprine. The disease remained active despite treatment with steroids and cyclosporine. The clinical and endoscopic parameters were consistent with severe disease. Infectious precipitants were ruled out. Given the severity of the disease and in order to avoid a colectomy, we started the patient on infliximab therapy. A dramatic clinical and endoscopic response was observed and she remained in remission at the end of a 1-year follow-up period. We discuss findings in the literature regarding the use of infliximab therapy in patients with ulcerative colitis who have failed steroids and cyclosporine.

Comparison of carcinoembryonic antigen and molecular analysis in pancreatic cyst fluid.

BACKGROUND: Pancreatic-cyst fluid carcinoembryonic antigen (CEA) levels and molecular analysis are useful diagnostic tests in differentiating mucinous from nonmucinous cysts. OBJECTIVE: To assess agreement between CEA and molecular analysis for differentiating mucinous from nonmucinous cysts. DESIGN: Retrospective analysis. SETTING: Academic medical center. METHODS: Patients who underwent EUS-guided FNA for evaluation of pancreatic cysts were identified. The following information was used to designate a cyst mucinous: the CEA criterion was CEA level >or=192 ng/mL and the molecular analysis criteria were DNA quantity >or=40 ng/microL and/or k-ras 2-point mutation and/or >or=2 allelic imbalance mutations. Pathologic analysis of cysts served as the criterion standard. RESULTS: From 2006 to 2007, 100 patients met the study criteria. The average age of the patients was 63 years, 65% were women, and 30% were symptomatic. The mean diameter of pancreatic cysts was 2.5 cm. The median CEA value was 83 ng/mL (range 1-50,000 ng/mL), the mean DNA content was 16 ng/microL (range 1-212 ng/microL), 11% had K-ras mutations, and 43% had >or=2 allelic imbalance mutations. When using prespecified criteria, there was poor agreement between CEA and molecular analysis for the classification of mucinous cysts (kappa = 0.2). Poor agreement existed between CEA and DNA quantity (Spearman correlation = 0.2; P = .1), K-ras mutation (kappa = 0.3), and >or=2 allelic imbalance mutations (kappa = 0.1). Of the 19 patients for whom a final pathologic diagnosis was available, CEA had a sensitivity of 82% compared with 77% for molecular analysis. When CEA and molecular analysis were combined, 100% sensitivity was achieved. LIMITATIONS: Retrospective analysis and small sample size. CONCLUSION: There was poor agreement between CEA levels and molecular analysis for diagnosis of mucinous cysts. Diagnostic sensitivity was improved when results of CEA levels and molecular analysis were combined.

Principais achados de colonoscopias realizadas em caráter de urgência e eletivas / Main finding on emergency and electie colonoscopies

Desde 1960 houve grande avanço tecnológico na observação do aparelho digestivo com o advento dos endoscópiosflexíveis, usados inicialmente para o trato digestivo superior e posteriormente também para o inferior, permitindo diagnósticos mais precisos e realização do tratamento em alguns casos. Mesmo em situações de urgência a colonoscopia pode ser utilizada como primeira escolha podendo ser diagnóstica e terapêutica. OBJETIVO: O presente estudo teve por objetivo avaliar quais foram os resultados principais das colonoscopias realizadas no Setor de Endoscopia Digestiva do Hospital Regional de Mato Grosso do Sul. MATERIAIS E MÉTODOS: Foram estudados 290 pacientes submetidos à colonoscopia no Serviço de EndoscopiaDigestiva do Hospital Regional do Mato Grosso do Sul, no período de novembro de 2006 a agosto de 2007. Foram analisadas as seguintes variáveis: sexo, idade, caráter de indicação do exame (urgência e eletiva) e diagnóstico. RESULTADOS: A idade média foi de 52 anos, variando de 15 a 92 anos. A maioria dos pacientes era do sexo feminino (56,5%). Dos 290 exames realizados no período foram constatados 48,5% (n=141) de colonoscopias com diagnóstico normal. Dentre os anormais houve uma prevalência de doença diverticular dos colos (n=56), seguido de pólipos (n=37), doenças inflamatórias (n=31), neoplasias (n=18) e angiodisplasia (n=7). Os pólipos apresentaram uma maior concentração em colo sigmóide (n=18) seguido pelo colo descendente e reto. Asdoenças inflamatórias apresentaram como diagnóstico colonoscópio, colite actínica (n=11) seguida por retite actínica (n=7) e retite inespecífica (n=7). Houve um maior número de procedimentos oriundos do ambulatório (73%) em contraste com internados(20%) e provenientes do Pronto Socorro (7%). CONCLUSÃO: A doença diverticular e os pólipos foram os diagnósticos preponderantes, pois a maior indicação foi a hemorragia digestiva...

Since 1960 it there was a great technological breakthrough, including the observation of the digestive system with the advent of flexible endoscopy. Initially used to the upper digestive tract and subsequently to the colon, allowing more accurate diagnoses and, in some cases, the complete treatment. Even in urgency situations, colonoscopy can be used as first choice and work as a diagnostic tool or eve the therapeutic procedure. AIM: This study analyzed the results of colonoscopy held in the Digestive Endoscopy unit at the Hospital Regional Rosa Pedrossian in Mato Grosso do Sul. MATERIALS AND METHODS: It was performed a colonoscopy in 290 patients at the unit of Digestive Endoscopy in the Hospital Regional of Mato Grosso do Sul, in during november 2006 until august 2007. The results were analyzed and verified the following variables: sex, age, solicitation as elective or emergency and diagnosis. RESULTS: The age of the patients ranged from 15 to 92 years old and the mean age was 52 years. Most of the patients were female (56.5%). The colonoscopy tests showed that 48.5% (n=141) were normal. Among the abnormal there were a prevalence of colon diverticulum (n = 56), followed by polyps (n = 37), inflammatory diseases (n = 31), cancer (n = 18) and angiodisplasy (n = 7). Polyps most usual place were in colorectal sigmoid (n = 18) followed by colorectal downward and rectum. The inflammatory diseases were shown as actinic colitis (n = 11) followed by actinic proctitte (n = 7) and nonspecific proctite (n = 7). There was a higherprevalence of procedures from the ambulatory 73%, interns 20% and from the emergency room 7%. CONCLUSION: The predominant diagnosis was diverticulum disease, followed by polyps. Digestive hemorrhage was the main signal noticed by the doctors who asked for the exam. With a high incidence of polyps, and mostly in sigmoid, just evidenced the how important the retosigmoidoscopy is...

Revised duplex criteria and outcomes for renal stents and stent grafts following endovascular repair of juxtarenal and thoracoabdominal aneurysms.

OBJECTIVES: To assess outcomes and develop duplex scan criteria that will reliably determine the luminal status of covered and uncovered renal stents following fenestrated and branched endovascular repair. METHODS: A prospective database of patients treated with fenestrated and branched endografts between 2001 and 2006 was reviewed. All patients with evidence of renal artery pathology including duplex scan assessed peak systolic velocity (PSV) <50 or >200 cm/s, renal aortic ratio (RAR) >3.5, elevation of the serum creatinine >30%, computed tomography (CT) evidence of renal stenosis underwent further analyses including medical chart review, and a review of CT and duplex scan imaging data. Correlations of ultrasound scan, CT, angiographic, and clinical outcomes were conducted and receiver operator curve (ROC) analysis was performed. Freedom from stenosis or occlusion was determined by Kaplan-Meier analysis with differences assessed by log rank tests. RESULTS: A total of 518 renal arteries were treated with uncovered or covered renal stents (287 patients). Mean follow-up was 25 months. The estimated freedom from stenosis at 12, 24, and 36 months were 95% (95% confidence interval [CI] 93-98), 92% (89-96), and 89% (85-93) for uncovered stents, and 98% (96-100), 97% (95-100), and 95% (91-100) for covered stents (log rank P = .04). Secondary interventions were performed in 20% of the patients who developed stenoses. Only one of the detected stenoses that was not treated with a secondary intervention progressed to occlusion. Duplex scan criteria derived from ROC analysis correlating with curved planar reconstruction (CPR) from axial imaging data calculated a 60-99% in-stent stenosis to be associated with a PSV >280 cm/s or RAR >4.5. Occlusions were best identified by a mid renal artery PSV <57 cm/s in conjunction with an RAR <1.2. CONCLUSION: Revised ultrasound scan criteria have been developed to improve the sensitivity and specificity of non-invasive interrogation of renal stents following endovascular aneurysm repair (EVAR). Covered renal stents are associated with a lower incidence of in-stent stenosis and are thus recommended over uncovered stents for use in fenestrated or branched endografts.