II Brazilian consensus statement on endoscopic ultrasonography.

BACKGROUND AND OBJECTIVES: At the time of its introduction in the early 80s, endoscopic ultrasonography (EUS) was indicated for diagnostic purposes. Recently, EUS has been employed to assist or to be the main platform of complex therapeutic interventions. METHODS: From a series of relevant new topics in the literature and based on the need to complement the I Brazilian consensus on EUS, twenty experienced endosonographers identified and reviewed the pertinent literature in databases. The quality of evidence, strength of recommendations, and level of consensus were graded and voted on. RESULTS: Consensus was reached for eight relevant topics: treatment of gastric varices, staging of nonsmall cell lung cancer, biliary drainage, tissue sampling of subepithelial lesions (SELs), treatment of pancreatic fluid collections, tissue sampling of pancreatic solid lesions, celiac neurolysis, and evaluation of the incidental pancreatic cysts. CONCLUSIONS: There is a high level of evidence for staging of nonsmall cell lung cancer; biopsy of SELs as the safest method; unilateral and bilateral injection techniques are equivalent for EUS-guided celiac neurolysis, and in patients with visible ganglia, celiac ganglia neurolysis appears to lead to better results. There is a moderate level of evidence for: yield of tissue sampling of pancreatic solid lesions is not influenced by the needle shape, gauge, or employed aspiration technique; EUS-guided and percutaneous biliary drainage present similar clinical success and adverse event rates; plastic and metallic stents are equivalent in the EUS-guided treatment of pancreatic pseudocyst. There is a low level of evidence in the routine use of EUS-guided treatment of gastric varices.

Endoscopic management and prevention of migrated esophageal stents.

The use of self-expandable metallic stents has increased recently to palliate inoperable esophageal neoplasia and also in the management of benign strictures. Migration is one of the most common complications after stent placement and the endoscopist should be able to recognize and manage this situation. Several techniques for managing migrated stents have been described, as well as new techniques for preventing stent migration. Most stents have a "lasso" at the upper flange which facilitates stent repositioning or removal. An overtube, endoloop and large polypectomy snare may be useful for the retrieval of stents migrated into the stomach. External fixation of the stent with Shim's technique is efficient in preventing stent migration. Suturing the stent to the esophageal wall, new stent designs with larger flanges and double-layered stents are promising techniques to prevent stent migration but they warrant validation in a larger cohort of patients.

How variable are hydroxyproline determinations made in different samples of the same liver?

OBJECTIVES: The haphazard distribution of fibrous tissue can interfere with quantitative methods for evaluating hepatic fibrosis. Inter-sample variation may represent a crucial issue when hydroxyproline measurement is used to quantify fibrosis. A comparative study of the hydroxyproline levels in normal and fibrotic rats is herein reported. MATERIAL AND METHODS: Twelve normal and 20 Capillaria hepatica-infected Wistar rats were used. Two fragments of the liver (A and B) of each rat were taken from separate areas and hydroxyproline measurements were made. Calculated differences in hydroxyproline measurements between samples from the same liver were analyzed by BOOTSTRAP. RESULTS: Differences in normal rats varied from 0.026 to 1.85 micromol of HP/g, in ten rats, the difference was less than 0.50 micromol. In infected rats, it varied from 0.04 to 2.86 micromol HP/g. Differences higher than 0.69 micromol/g were significant for normal rats (p<0.05) and above 1.22 micromol/g (p<0.05) for fibrotic rats. CONCLUSIONS: Hydroxyproline ratio in a normal liver kept a fair degree of reproducibility. In the presence of hepatic fibrosis, the levels of hydroxyproline may vary significantly between samples from a single liver and may have limited value in quantifying the extent of fibrosis.

Capillaria hepatica in rats: focal parasitic hepatic lesions and septal fibrosis run independent courses.

Capillaria hepatica causes two main lesions in the liver of rats: multifocal chronic inflammation, directly related to the presence of disintegrating parasites and their eggs, and a process of systematized septal fibrosis. The comparative behavior of these two lesions was investigated in rats experimentally infected with 600 embryonated eggs, following either corticosteroid treatment or specific antigenic stimulation, in an attempt to understand the relationship between these two lesions, and the pathogenesis of septal fibrosis. The two treatments differently modified the morphological aspects of the focal parasitic-related lesions, but did not interfere with the presentation of diffuse septal fibrosis, although a mild decrease in the degree of fibrosis occurred in corticoid-treated animals. These findings indicate that although the two lesions are C. hepatica induced, they are under different pathogenetic control, the induction of septal fibrosis being triggered during early infection to follow an independent pathway.