An elderly patient's pancreatobiliary puzzle: unraveling diagnosis and treatment challenges.

Pancreatobiliary fistulas associated withntraductal Papillary Mucinous Neoplasm (IPMN) are rare and present therapeutic challenges. The authors describe the clinical course of an 81-year-old woman presenting with acute cholangitis, ultimately diagnosed with IPMN involving secondary ducts with focal high-grade dysplasia. Initial manifestations included elevated inflammatory markers, cholestasis, and imaging findings of a pancreatic lesion. Endoscopic retrograde cholangiopancreatography revealed dilation of both intrahepatic and extrahepatic bile ducts, along a cystic cluster originating from the pancreas, fistulizing into the common bile duct. Despite initial endoscopic interventions, recurrent cholestasis persisted. Subsequent multidisciplinary evaluation led to a cephalic duodenopancreatectomy. This case underscores the rarity of pancreatobiliary fistulas associated with IPMNs and the subsequent therapeutic challenges. The absence of standardized treatment algorithms for such intricate cases emphasizes the importance of individualized approaches. The fluoroscopy image displaying a cystic cluster originating from the pancreas and showing fistulization into the common bile duct is a rare image presented in our report, unique to this case.

Single-capsule bismuth-based quadruple therapy as a rescue therapy for Helicobacter pylori eradication.

INTRODUCTION: Helicobacter pylori (H. pylori) infection is highly prevalent in Portugal and its eradication is formally recommended. However, the indiscriminate use of antimicrobials has led to a drastic rise in antibiotic resistance, with the failure of traditional eradication schemes. A single-capsule bismuth-based quadruple therapy became recently available in Portugal. This study aims to evaluate the efficacy and safety of a bismuth-based quadruple therapy as a second-line or rescue therapy. PATIENTS AND METHODS: This was a multicentric study. All consecutive patients that were treated with bismuth-based quadruple therapy, as second-line or salvage treatment between July 2017 and April 2019 were enrolled. Their medical records were reviewed and clinical and laboratorial parameters, as well as data on treatment efficacy and adverse events were retrieved. Patients were also contacted by phone after treatment to confirm compliance, adverse events, and global satisfaction with this specific therapy. RESULTS: A total of 151 subjects were included (female-68.9%; mean age-56 ± 13.5 years). Patients were previously submitted to 212 eradication schemes (Median-1; 1-5; IQR:4): 33.5% triple clarithromycin-based, 25% sequential, 7.5% concomitant, 5.2% others, and in 28.8% it was not possible to know the previous eradication scheme(s) followed by the patient. The PPI of choice was esomeprazole (39.7%), followed by omeprazole (27.8%). Compliance was achieved in 93.4% and the overall eradication rate was 90.1% (95% CI: 84.6-94.2). Treatment-related adverse effects were experienced by 63 patients (41.7%; 95% CI: 34-49.7), being mild in 29, moderate in 19, and severe in 15. The main drawbacks of the treatment, from the patient's perspective, were the high price (47%) and the adverse effects (16.6%). Failure to eradicate H. pylori was correlated with the following: previous rifabutin-based scheme (0 vs. 100%; p = 0.010) and a higher number of previous treatment schemes (1.5 ± 0.7 vs. 2.3 ± 1.2; p < 0.001). CONCLUSION: In this South-European country a single-capsule bismuth-based quadruple therapy is an excellent option as a second-line or rescue therapy, with acceptable compliance and side effects.

Gastric heterotopia in the rectum: a rare entity with potential pitfalls.

Gastric heterotopia (GHT) is a medical condition where the gastric mucosa is found at a non-phyysiological part of the body. GHT can present itself anywhere in the gastrointestinal tract from the mouth to the anorectal area, as well as in the hepatobiliary system. However, it is relatively rare to find GHT in the rectum, with only around 50 documented cases reported in medical literature. We present the case of a 51-year-old man who underwent average-risk screening colonoscopy. He had no clinically significant comorbidities and was otherwise asymptomatic, with no family history. Notable findings included a pseudopolypoid lesion in the distal rectum, adjacent to the dentate line, measuring approximately 15 mm with regular-appearing mucosa under narrow-band-imaging. Biopsy specimens showed histological characteristics of oxyntic-type gastric mucosa without inflammation or dysplasia. GHT has the potential to progress to malignancy, although the rate of malignancy is currently unknown. Awareness of this entity is important given its frequency and potential for misdiagnosis.

Hilar cholangiocarcinoma presenting with hematochezia due to metastases to the rectum.

An 84-year-old female, with history of endometrial and gallbladder adenocarcinomas, both submitted to curative surgeries, was admitted to the emergency room with obstructive jaundice. Computed tomography and subsequent magnetic resonance cholangiopancreatography revealed a common hepatic duct stenosis with intrahepatic biliary dilatation. She underwent percutaneous transhepatic cholangiography with successful biliary drainage. During the same admission, the patient experienced episodes of hematochezia. Rectosigmoidoscopy showed a 20 mm ulcer in the distal rectum and congestion of the rectal mucosa. Computed tomography revealed rectal wall circumferential thickening. Ulcer biopsies were compatible with a neoplasia of biliary origin.

Temperature Stability and Spectral Tuning of Long Period Fiber Gratings Fabricated by Femtosecond Laser Direct Writing.

Long period fiber gratings (LPFGs) were fabricated in a standard single mode fiber (SMF-28e) through femtosecond (fs) laser direct writing. LPFGs with longer and shorter periods were fabricated, which allows coupling from the fundamental core mode to lower and higher order asymmetric cladding modes (LP1,6 and LP1,12, respectively). For the grating periods of 182.7 and 192.5 µm, it was verified that the LP1,12 mode exhibits a TAP at approximately 1380 and 1448 nm in air and water, respectively. Characterization of the LPFGs subjected to high-temperature thermal treatment was accomplished. Fine-tuning of the resonance band's position and thermal stability up to 600 °C was shown. The temperature sensitivity was characterized for the gratings with different periods and for different temperature ranges. A maximum sensitivity of -180.73, and 179.29 pm/°C was obtained for the two resonances of the 182.7 µm TAP LPFG, in the range between 250 and 600 °C.

Esophagogastroduodenoscopy: how far should we go? A point of view.

N.A.

Plasmonic Optical Fiber Sensor Based on Double Step Growth of Gold Nano-Islands.

It is presented the fabrication and characterization of optical fiber sensors for refractive index measurement based on localized surface plasmon resonance (LSPR) with gold nano-islands obtained by single and by repeated thermal dewetting of gold thin films. Thin films of gold deposited on silica (SiO2) substrates and produced by different experimental conditions were analyzed by Scanning Electron Microscope/Dispersive X-ray Spectroscopy (SEM/EDS) and optical means, allowing identifying and characterizing the formation of nano-islands. The wavelength shift sensitivity to the surrounding refractive index of sensors produced by single and by repeated dewetting is compared. While for the single step dewetting, a wavelength shift sensitivity of ~60 nm/RIU was calculated, for the repeated dewetting, a value of ~186 nm/RIU was obtained, an increase of more than three times. It is expected that through changing the fabrication parameters and using other fiber sensor geometries, higher sensitivities may be achieved, allowing, in addition, for the possibility of tuning the plasmonic frequency.

Photonic Band Gap and Bactericide Performance of Amorphous Sol-Gel Titania: An Alternative to Crystalline TiO2.

In addition to its traditional application in white pigments, nanocrystalline titania (TiO2) has optoelectronic and photocatalytic properties (strongly dependent on crystallinity, particle size, and surface structure) that grant this naturally occurring oxide new technological applications. Sol-gel is one of the most widely used methods to synthesize TiO2 films and NPs, but the products obtained (mostly oxy-hydrated amorphous phases) require severe heat-treatments to promote crystallization, in which control over size and shape is difficult to achieve. In this work, we obtained new photocatalytic materials based on amorphous titania and measured their electronic band gap. Two case studies are reported that show the enormous potential of amorphous titania as bactericide or photocatalyst. In the first, amorphous sol-gel TiO2 thin films doped with N (TiO2−xNx, x = 0.75) were designed to exhibit a photonic band gap in the visible region. The identification of Ti-O-N and N-Ti-O bindings was achieved by XPS. The photonic band gaps were found to be 3.18 eV for a-TiO2 and 2.99 eV for N-doped a-TiO2. In the second study, amorphous titania and amine-functionalized amorphous titania nanoparticles were synthetized using a novel base-catalysed sol-gel methodology. All the synthesized amorphous TiO2 nanoparticles exhibit bactericide performance (E. coli, ASTME 2149-13).

Anaemia in Patients with Inflammatory Bowel Disease - A Nationwide Cross-Sectional Study.

BACKGROUND: Anaemia is the most common complication in patients with inflammatory bowel disease (IBD). This study aims to assess the prevalence of anaemia in IBD patients and to know its characteristics with regard to the main IBD clinical features. METHODS: An observational cross-sectional multicentre study was conducted. We included all patients who had an appointment at the 15 participating centres during the period of 1 month, and who met the following selection criteria: age ≥18, diagnosis of IBD. Disease activity was evaluated by Harvey-Bradshaw Index (HBI) for Crohn's disease (CD), and by Simple Clinical Colitis Activity Index (SCCAI) for ulcerative colitis (UC). RESULTS: One thousand three hundred and thirteen patients, were included: 54.8% female, mean age 42.8 (interquartile range (25th-75th): 31-53 years), 59% had a diagnosis of CD, 39% of UC and 2% IBD unclassified. The median follow-up since diagnosis was 7 years. The ongoing treatment was aminosalicylates (63.1%), corticosteroids (11.6%), immunomodulators (36.4%) and anti-tumour necrosis factor (27.3%). Anaemia was identified in 244 patients, representing a prevalence of 18.6% (95% CI 16.6-20.9). A majority of cases (90%) have mild/moderate anaemia (mean haemoglobin 11.3 ± 0.8 g/dl). Anaemia was significantly higher in females (p = 0.006), but there were no differences between CDs (19.1%) and UCs (17.7%; p = 0.688). Anaemia was more frequent in patients with active disease (HBI >4; SCCAI >2) than in those in clinical remission (33.6 vs. 15.6%, p < 0.001) and in patients on steroids (36.8%) vs. other treatments (p < 0.001). Only 47% of patients with anaemia were under any specific treatment (oral iron 67%; intravenous iron 41%). CONCLUSION: Anaemia was more frequent in patients with active disease and in those on corticosteroids. The treatment of anaemia still seems undervalued, whereas more than half of anaemic patients were not receiving any specific treatment and the use of oral iron prevails contrarily to current recommendations.

Predictive value of rectal aberrant crypt foci for intraepithelial neoplasia in ulcerative colitis - a cross-sectional study.

BACKGROUND: Ulcerative colitis (UC) is associated with an increased risk of colorectal cancer (CRC). Aberrant crypt foci (ACF) are important biomarkers of sporadic CRC risk. Their correlation with the risk of intraepithelial neoplasia (IN) in UC remains unclear. AIMS: To assess whether ACF are a risk factor for IN in long-standing UC and to investigate any correlation between the clinico-epidemiological characteristics and prevalence/number of ACF in these patients. METHODS: Seventy-six patients with long-standing UC were prospectively screened by colonoscopy with chromoendoscopy-guided endomicroscopy. ACF were sought in the lower rectum. RESULTS: Eight INs were detected in seven (9.2%) patients. The ACF prevalence and mean number were 60.5% and 2.4 ± 2.8, respectively. The number of ACF was independently associated with the risk of having IN (odds ratio = 1.338; 95% confidence interval 1.030-1.738). ACF number revealed a good calibration (area under the receiver operating characteristic curve = 0.829) and discriminative ability (p = 0.205, Hosmer-Lemeshow test) for the prediction of synchronous IN. Patients with ≥3 ACF have a significantly higher prevalence of IN than patients with <3 ACF (22.6% vs. 0%, p = 0.001). Using this cut-off value, the performance of ACF in predicting the presence of IN was as follows: sensitivity = 100%, specificity = 65.2%, positive predictive value = 22.6%, and negative predictive value = 100%. Age >40 years, family history of CRC, and increased body mass index (BMI) were associated with a significantly higher number of ACF. CONCLUSION: Long-standing UC patients with ≥3 ACF have a significantly higher likelihood of having IN. Age >40 years, family history of CRC, and increased BMI have significant positive associations with the number of ACF.

NOD2 gene mutations in ulcerative colitis: useless or misunderstood?

PURPOSE: NOD2 mutations have been linked to an increased risk of Crohn's disease and to some of its phenotypes. The association between NOD2 mutations and susceptibility to ulcerative colitis (UC) remains somewhat controversial and potential correlations between these mutations and UC phenotype have not been studied. AIM: To assess whether NOD2 mutations are a risk factor for UC in Portugal and if there are any genotype-phenotype correlations in these patients. METHODS: The three main NOD2 mutations were searched in 200 patients with UC and in 202 healthy controls. RESULTS: NOD2 mutations were present in 28 patients with UC (14.0 %) and in 27 controls (13.4 %) (p = 0.853). Mutation carriers were more likely to receive steroids during the first year of disease than non-carriers (54.2 % vs. 29.6 %, p = 0.018) and among these patients the need for intravenous administration was more frequent in those with the R702W polymorphism (90.0 % vs. 45.5 %, p = 0.014). In patients with severe colitis admitted for intravenous steroids, a greater proportion of mutation carriers was considered intravenous-steroid refractory and required salvage therapy (90.0 % vs. 38.1 %, p = 0.004). Patients with NOD2 mutation were submitted to colectomy more frequently than non-carriers (17.9 % vs. 4.1 %. p = 0.015). No correlation with the need for immunosuppressants/immunomodulators was found. CONCLUSIONS: In the Portuguese population, NOD2 mutations do not increase the risk of UC but are associated with a more aggressive course including greater need of steroids in the first year, increased incidence of intravenous-steroid refractoriness and a higher colectomy rate.

Infective Endocarditis After Endoscopic Stricture Dilation in Crohn's Disease.

Stricture formation is common in Crohn's disease, and endoscopic intervention plays an increasingly important role in managing these strictures. A 61-year-old man with biological aortic prosthesis and a 30-year history of ileocolonic stricturing Crohn's disease, managed with azathioprine and infliximab, presented with marked occlusive symptoms. Colonoscopy revealed a descending colon stricture, prompting endoscopic balloon dilation. At the time of the procedure, no prophylactic antibiotic was given. Subsequently, he developed Streptococcus gallolyticus endocarditis, necessitating aortic valve replacement. The authors present a case of late Streptococcus gallolyticus endocarditis associated with endoscopic balloon dilation of a Crohn-related colonic stricture.

Assessing climate change and health provisions among staff in higher education institutions: A preliminary investigation.

Climate change can have direct and indirect effects on human health. Direct effects can include an increase in extreme weather events, such as heatwaves and floods, as well as an increase in the spread of vector-borne and infectious diseases, which may lead to a set of health problems and diseases. Indirect effects can include changes in air quality, water availability, and food production and distribution. These changes can lead to an increase in respiratory problems, malnutrition, and increased food insecurity. There is a perceived need to investigate the extent to which Higher Education Institutions (HEIs) are engaged in efforts to foster a greater understanding of the connections between climate change and health. In this context, this preliminary investigation offers an overview of the relationships between climate change and health. By means of a survey among teaching staff and researchers at HEIs from 42 countries across all continents working on the connection between climate change and health. The study has investigated the extent to which current provisions for education and training on the connection between climate change and health are being considered and how current needs in terms of policy development, research, and training are being met. A series of case studies illustrate how universities worldwide are actively developing strategies and implementing measures to address climate change and health. The study concludes by providing specific recommendations aimed at facilitating the handling of issues related to climate change and health in a higher education context.

Long-term chorioretinal changes after photodynamic therapy for chronic central serous chorioretinopathy.

PURPOSE: To evaluate morphological and functional chorioretinal changes 5 years after standard photodynamic therapy (PDT) for chronic central serous chorioretinopathy (CSC). METHODS: A retrospective, nonrandomized study, including patients with chronic CSC treated with standard PDT and followed for at least 60 months. All patients underwent a complete ophthalmological examination, and the location and number of treatments were registered. Five or more years after treatment, subfoveal and non-subfoveal treated areas were evaluated with Spectralis optical coherence tomography and microperimetry. RESULTS: Seventeen eyes of 15 patients were included, with mean age of 48.3 ± 8.4 years and a mean follow-up of 80.6 ± 12.4 months (range from 62 to 104 months). All eyes had neurosensory detachment (NSD) at baseline. Treatment was performed under the fovea in 58.8 % and in a non-foveal area in 41.2 % of the eyes. At the final visit all eyes had resolution of the NSD, with a statistical significant reduction in central macular thickness (p = 0.005) and preserved neuroretinal thickness (p = 0.839). There was a statistical difference between initial and final BCVA (p < 0.001) and a mean gain of 8.4 ± 7.8 letters. Subfoveal morphological changes in external limiting membrane (ELM) and in photoreceptor inner and outer segment junction (IS/OS) were correlated with final BCVA (p = 0.015 and p = 0.014 respectively), but not with the variation of BCVA. There was a statistical correlation between morphological changes in IS/OS line and retinal sensitivity in the central 12° and 2° (p = 0.003 and p = 0.002 respectively). The morphological changes in the subfoveal layers were not dependent on treatment location (p = 0.154, p = 0.644, and p = 1.0 for ELM, IS/OS line, and retinal pigment epithelium respectively). Subfoveal final mean choroidal thickness was 295.1 ± 68.7 µm, and showed no statistical difference from the normal population (p = 0.633). CONCLUSIONS: Morphological and functional chorioretinal changes, observed 5 or more years after standard PDT for chronic CSC, were not correlated with the location of treatment, neither with the progression of visual acuity or with the location of treatment, and are more likely to be related to the disease itself than with the treatment provided.

Testicular Seminoma Presenting as Gastrointestinal Bleeding: A Rare Cause of Metastatic Disease in the Stomach.

Introduction: Gastric metastases are quite infrequent. When arising from testicular germ cell tumors, gastric metastases are usually associated with nonseminomas. Case Report: A 45-year-old man presented with upper gastrointestinal bleeding, severe anemia, and elevated lactate dehydrogenase. Endoscopy revealed three atypical-looking gastric ulcers. Abdominal computed tomography showed an extensive heterogeneous retroperitoneal mass and a smaller one in the pelvis. Biopsies of both the ulcers and the retroperitoneal mass revealed a highly proliferative neoplasia of unknown origin. While the diagnostic work up was taking place, the patient complained of a testicular mass which was resected, after suspicious findings in the ultrasound. Histopathologic findings revealed a testicular seminoma. Revision of previous biopsies was compatible with metastatic seminoma to the stomach and the retroperitoneum. Discussion/Conclusion: Gastric metastasis arising from testicular seminoma is quite infrequent and usually diagnosed after the primary tumor is known. We report a rare case of a testicular seminoma presenting as upper gastrointestinal bleeding due to gastric metastases. This case highlights the importance of detailed anamnesis and physical examination in the differential diagnosis of atypical gastric ulcers with initial inconclusive work up and emphasizes an unusual manifestation of a germ cell malignancy.

Introdução: As metástases gástricas são bastante infrequentes. Quando são secundárias a tumores testiculares, geralmente as metástases gástricas associam-se a nãoseminomas. Caso Clínico: Um homem de 45 anos recorreu ao serviço de urgência por quadro de hemorragia digestiva alta, tendo-se detetado uma anemia grave e elevação da lactato desidrogenase. A endoscopia revelou três úlceras gástricas de aspeto atípico. A tomografia computorizada abdominal mostrou uma extensa massa heterogénea retroperitoneal e outra de menores dimensões na cavidade pélvica. Foram realizadas biópsias das úlceras gástricas e da massa retroperitoneal, sendo compatíveis com uma neoplasia altamente proliferativa de origem indeterminada. Durante a investigação etiológica, o doente referiu a deteção de uma massa testicular. Esta foi ressecada após a realização de ecografia com achados suspeitos. A histologia fez o diagnóstico de um seminoma testicular. A revisão das biópsias prévias foi compatível com metastização gástrica e retroperitoneal do seminoma. Discussão/Conclusão: A metastização gástrica com origem em seminomas do testículo é infrequente e geralmente é detetada após o diagnóstico do tumor primário. Apresenta-se um caso raro de manifestação inaugural de um seminoma testicular como hemorragia digestiva alta devido a metástases gástricas. Este caso evidencia a importância de uma anamnese e um exame objetivo detalhados no diagnóstico diferencial de úlceras gástricas atípicas com investigação inicial negativa, salientando também uma manifestação infrequente de uma neoplasia de células germinativas.

Isolation of Flaviviruses and Alphaviruses with Encephalitogenic Potential Diagnosed by Evandro Chagas Institute (Pará, Brazil) in the Period of 1954-2022: Six Decades of Discoveries.

Viruses with encephalitogenic potential can cause neurological conditions of clinical and epidemiological importance, such as Saint Louis encephalitis virus, Venezuelan equine encephalitis virus, Eastern equine encephalitis virus, Western equine encephalitis virus, Dengue virus, Zika virus, Chikungunya virus, Mayaro virus and West Nile virus. The objective of the present study was to determine the number of arboviruses with neuroinvasive potential isolated in Brazil that corresponds to the collection of viral samples belonging to the Department of Arbovirology and Hemorrhagic Fevers, Evandro Chagas Institute (SAARB/IEC) of the Laboratory Network of National Reference for Arbovirus Diagnosis from 1954 to 2022. In the analyzed period, a total of 1,347 arbovirus samples with encephalitogenic potential were isolated from mice; 5,065 human samples were isolated exclusively by cell culture; and 676 viruses were isolated from mosquitoes. The emergence of new arboviruses may be responsible for diseases still unknown to humans, making the Amazon region a hotspot for infectious diseases due to its fauna and flora species characteristics. The detection of circulating arboviruses with the potential to cause neuroinvasive diseases is constant, which justifies the continuation of active epidemiological surveillance work that offers adequate support to the public health system regarding the virological diagnosis of circulating arboviruses in Brazil.

Phylogeography of dengue virus serotype 4, Brazil, 2010-2011.

Dengue virus serotype 4 (DENV-4) reemerged in Roraima State, Brazil, 28 years after it was last detected in the country in 1982. To study the origin and evolution of this reemergence, full-length sequences were obtained for 16 DENV-4 isolates from northern (Roraima, Amazonas, Pará States) and northeastern (Bahia State) Brazil during the 2010 and 2011 dengue virus seasons and for an isolate from the 1982 epidemic in Roraima. Spatiotemporal dynamics of DENV-4 introductions in Brazil were applied to envelope genes and full genomes by using Bayesian phylogeographic analyses. An introduction of genotype I into Brazil from Southeast Asia was confirmed, and full genome phylogeographic analyses revealed multiple introductions of DENV-4 genotype II in Brazil, providing evidence for >3 introductions of this genotype within the last decade: 2 from Venezuela to Roraima and 1 from Colombia to Amazonas. The phylogeographic analysis of full genome data has demonstrated the origins of DENV-4 throughout Brazil.

Appropriateness of Endoscopic Procedures: A Prospective, Multicenter Study.

INTRODUCTION: Advances in endoscopy and open-access systems led to an increase in endoscopic procedures. However, overuse of endoscopy has been consistently reported. This study aims to assess the appropriateness of esophagogastroduodenoscopy (EGD) and colonoscopy referral in the private and public setting. PATIENTS AND METHODS: We conducted a prospective, multicenter study at 2 public and 5 private endoscopy units. Patients scheduled for elective EGD or colonoscopy were enrolled. Clinical data and endoscopy findings were recorded. Appropriateness of endoscopy was defined according to the American Society for Gastrointestinal Endoscopy guidelines (for EGD) and the European Panel on Appropriateness of Gastrointestinal Endoscopy II (for colonoscopy). RESULTS: Regarding EGD: 215 patients enrolled (43.7% were males) with a mean age of 61.0 ± 15.1 years; 54.0% (n = 116) were in public hospitals. Referral by a gastroenterologist was made for 34.9% (n = 75). Appropriate indications were made for 62.3% (n = 134): 42.4% in private versus 79.3% in public endoscopy units (odds ratio [OR] 5.20; 95% confidence interval [CI] 2.85-9.49; p < 0.01). Rate of appropriate EGD was 74.7% for gastroenterologist referral and 56.1% for other specialties (OR 2.31; 95% CI 1.24-4.28; p < 0.01). Diagnostic yield for relevant findings was 47.9%. No association between indication appropriateness, gastroenterologist referral, and relevant endoscopic findings was found. Regarding colonoscopy: 287 patients enrolled (49.1% were males) with a mean age of 60.4 ± 14.4 years; 48.1% (n = 138) were in public hospitals. Referral by a gastroenterologist was made for 20.6% (n = 59). Appropriate indications were made for 70.0% (n = 201): 53.0% in private vs. 88.4% in public endoscopy units (OR 6.75; 95% CI 3.66-12.47; p < 0.01). Diagnostic yield was 57.1%. Relevant endoscopic diagnosis was associated with indication: 63.2% in the appropriate vs. 43.0% in the nonappropriate indication group (p < 0.05). DISCUSSION: A significant percentage of endoscopies, mainly in the private setting, were performed without an appropriate indication. This influenced the diagnostic yield. The use of adequate criteria is fundamental for the rational use of an open-access system.

INTRODUÇÃO: O avanço em endoscopia digestiva e a existência de sistemas open-acess levaram a um aumento quantitativo de endoscopias. Porém, a sobreutilização da endoscopia tem sido reportada na literatura. Este estudo tem como objetivo aferir prospectivamente as indicações para endoscopia digestiva alta (EDA) e endoscopia digestiva baixa (EDB) em unidades de saúde públicas e privadas. DOENTES E MÉTODOS: Estudo prospetivo, multicêntrico, que incluiu doentes submetidos a endoscopia digestiva alta (EDA) ou baixa (EDB) com intuito não terapêutico em 2 unidades hospitalares públicas e 5 unidades privadas. Adequabilidade da indicação definida pelas recomendações da American Society for Gastrointestinal Endoscopy (EDA) e do European Panel on Appropriateness of Gastrointestinal Endoscopy II (EDB). RESULTADOS: EDA: Incluídos 215 doentes (masculino ­ 43.7%; idade média ­ 61.0 ± 15.11 anos), 54.0% (n = 116) em unidades hospitalares públicas. Referenciação por gastrenterologista em 34.9% (n = 75). Indicação considerada adequada em 62.3% (n = 134): 42.4% em unidades privadas versus 79.3% em unidades públicas (odds ratio [OR] 5.20, 95% confidence interval [CI] 2.85­9.49, p < 0.01). Indicação adequada em 74.7% com referenciação por gastrenterologista versus 56.1% por não-gastrenterologista (OR 2.31, 95% CI 1.24­4.28; p < 0.01). Identificados achados endoscópicos relevantes em 47.9%. EDB: Incluídos 287 doentes (masculino ­ 49.1%; idade média ­ 60.4 ± 14.4 anos), 48,1% (n = 138) em unidades públicas. Referenciação por gastrenterologista em 20.6% (n = 59). A indicação foi considerada adequada em 70.0% (n = 201): 53.0% em unidade privada versus 88.4% em unidade pública (OR 6.75, 95% CI 3.66­12.47; p < 0.01). Achados endoscópicos relevantes em 57.1%: 77.7% (n = 129) em exames com indicação adequada vs 22.3% (n = 37) sem indicação adequada (p < 0.05). CONCLUSÕES: Neste estudo, uma percentagem significativa dos procedimentos endoscópicos foi realizada sem indicação apropriada, especialmente no sector privado, o que influenciou a rentabilidade diagnóstica. A prescrição tendo por base critérios definidos é fundamental para o uso racional de um sistema de acesso livre.

Adenoma Recurrence after Endoscopic Piecemeal Mucosal Resection of Colorectal Flat Lesions: Applicability of the Sydney EMR Recurrence Tool in a Non-Tertiary Centre.

Introduction: Endoscopic mucosal resection (EMR) is the treatment of choice for non-invasive colorectal flat lesions. When endoscopic piecemeal mucosal resection (EPMR) is performed, endoscopic surveillance is necessary due to the risk of recurrence. The Sydney EMR Recurrence Tool (SERT) is a 0-4 scale that classifies lesions according to size, occurrence of intraprocedural bleeding (IPB) and presence of high-grade dysplasia (HGD). Our goal is to evaluate the applicability of SERT in predicting adenoma recurrence (AR) after EPMR. Methods: This is a retrospective single-centre study with inclusion of lateral spreading lesions ≥20 mm, consecutively resected by EPMR from March 2010 to February 2018, with at least 1 endoscopic re-evaluation. Results: A total of 181 lesions were included, corresponding to 174 patients with a mean age of 68 years and male gender predominance (61%; n = 106). The most frequent location was the ascending colon (34%; n = 62). Lesions were assessed according to Paris Classification (PC): 0-IIa: 39% (n = 71); 0-IIb: 24% (n = 43); 0-IIa + Is: 23% (n = 42); 0-IIa + IIb: 6% (n = 11); 0-IIa + IIc: 2% (n = 3). The mean size of the lesions was 33 ± 11 mm, with 25 (14%) being ≥40 mm. IPB occurred in 9 cases (5%), and 44 lesions (24%) displayed HGD. Sixty-six lesions (36.5%) were classified as SMSA (size, morphology, site, and access score) level 4. Adjunctive therapy with argon plasma coagulation (APC) was used in 37% (n = 67) of cases. The 6-month AR rate was 16% (n = 29). According to SERT groups, the AR rate was: SERT 0: 12% (14/120); SERT 1: 17% (6/35); SERT 2: 25% (3/12); SERT 3: 30% (3/10); SERT 4: 75% (3/4). Two of the three SERT variables (size ≥40 mm and IPB) were associated with recurrence at 6 months (p < 0.05). HGD and the remaining tested variables (age, gender, localization, accessibility, PC, use of APC/biopsy forceps and occurrence of delayed bleeding) were not associated with AR. SERT 0 lesions showed an inferior risk of 6-month AR (adjusted OR = 2.62; p = 0.035), with a negative predictive value of 88%. SMSA correlated with SERT (p < 0.001) and SMSA level 4 was associated with 6-month AR (p = 0.007). Lesions classified both as SERT 0 and SMSA level <4 had the lowest 6-month recurrence rate (9.2%). The 24-month recurrence rate was 23% (n = 41). When applying the Kaplan-Meier method, cumulative recurrence was significantly lower in SERT 0 lesions (p = 0.006, log-rank test). Discussion/Conclusion: Resection of flat colorectal lesions by EPMR has a considerable risk of recurrence, mostly in SERT 1-4 lesions. SERT 0 lesions, especially with SMSA level <4, show a lower risk of recurrent adenoma, which might allow longer intervals to first endoscopic surveillance in the future.

Introdução: A mucosectomia endoscópica é a terapêutica de eleição nas lesões colorretais planas não invasivas e, quando fragmentada, obriga a vigilância endoscópica, dado o risco de recorrência. O Sydney Endoscopic Mucosal Resection Recurrence Tool (SERT) é uma escala de 0 a 4 que classifica as lesões em função da dimensão, ocorrência de hemorragia imediata na sua excisão (HI) e presença de displasia de alto grau (DAG). Pretende-se avaliar a aplicabilidade do SERT na predição de adenoma recorrente (AR) após mucosectomia fragmentada. Métodos: Estudo retrospetivo unicêntrico com inclusão de todas as lesões planas ≥20 mm excisadas por mucosectomia fragmentada, entre Março/2010 e Fevereiro/2018, com pelo menos uma vigilância endoscópica. Resultados: Incluídas 181 lesões, correspondentes a 174 doentes com idade média de 68 anos e predomínio do sexo masculino (61%; n = 106). A localização mais frequente foi o cólon ascendente (34%; n = 62). As lesões foram avaliadas segundo a classificação de Paris (CP): 0-IIa: 39% (n = 71); 0-IIb: 24% (n = 43); 0-IIa + Is: 23% (n = 42); 0-IIa + IIb: 6% (n = 11); 0-IIa + IIc: 2% (n = 3). O tamanho médio foi 33 ± 11 mm, tendo 25 (14%) dimensões ≥40 mm. Verificou-se HI em 9 casos (5%) e DAG em 44 (24%). O nível SMSA (size, morphology, site, and access score) foi 4 em 66 lesões (36.5%). Realizou-se terapêutica com árgon plasma (APC) em 37% (n = 67) dos casos.A taxa de AR aos 6 meses foi: SERT 0: 12% (14/120); SERT 1: 17% (6/35); SERT 2: 25% (3/12); SERT 3: 30% (3/10); SERT 4: 75% (3/4); global: 16% (29/181). O AR aos 6 meses associou-se à dimensão ≥40 mm e à HI (p < 0.05). A DAG não mostrou relação com a recorrência, assim como a idade, sexo, localização, acessibilidade, CP, terapêutica adju-adjuvante (APC/pinça de biópsias) e ocorrência de hemorragia tardia. As lesões SERT 0 apresentaram menor risco de AR aos 6 meses (OR ajustado = 2.62; p = 0.035), com um valor preditivo negativo de 88%. O SMSA correlacionou-se com o SERT (p < 0.001), estando o nível SMSA 4 associado à recorrência aos 6 meses (p = 0.007). As lesões classificadas como SERT 0 e nível SMSA <4 apresentaram a menor taxa de AR (9.2%). A taxa de recorrência aos 24 meses foi 23% (n = 41). Aplicando o método de Kaplan Meier, a recorrência cumulativa foi menor nas lesões SERT 0 (p = 0.006, teste log-rank). Discussão/Conclusão: A excisão de lesões planas por mucosectomia fragmentada apresenta uma taxa de recorrência considerável, sobretudo em lesões SERT 1­4. As lesões SERT 0, particularmente se nível SMSA <4, apresentam menor risco de recidiva, o que poderá possibilitar um prolongamento do intervalo até à primeira vigilância endoscópica.