RECOMMENDATIONS FOR INVASIVE PROCEDURES IN PATIENTS WITH DISEASES OF THE LIVER AND BILIARY TRACT: REPORT OF A JOINT MEETING OF THE BRAZILIAN SOCIETY OF HEPATOLOGY (SBH), BRAZILIAN SOCIETY OF DIGESTIVE ENDOSCOPY (SOBED) AND BRAZILIAN SOCIETY OF INTERVENTIONAL RADIOLOGY AND ENDOVASCULAR SURGERY (SOBRICE).

Liver and biliary tract diseases are common causes of morbidity and mortality worldwide. Invasive procedures are usually performed in those patients with hepatobiliary diseases for both diagnostic and therapeutic purposes. Defining proper indications and restraints of commonly used techniques is crucial for proper patient selection, maximizing positive results and limiting complications. In 2018, the Brazilian Society of Hepato-logy (SBH) in cooperation with the Brazilian Society of Interventional Radiology and Endovascular surgery (SOBRICE) and the Brazilian Society of Digestive Endoscopy (SOBED) sponsored a joint single-topic meeting on invasive procedures in patients with hepatobiliary diseases. This paper summarizes the proceedings of the aforementioned meeting. It is intended to guide clinicians, gastroenterologists, hepatologists, radiologists, and endoscopists for the proper use of invasive procedures for management of patients with hepatobiliary diseases.

Peristomal infection in percutaneous endoscopic gastrostomy (PEG): a comparative study of two gastropexy techniques in a before-and-after design.

INTRODUCTION: Percutaneous endoscopic gastrostomy (PEG) performed using the Pull technique is associated with a high rate of surgical infections. When PEG is performed using the Introducer technique, a lower rate of infection is seen. However, this technique can pose technical difficulties during gastropexy. Gastropexy using two straight needles, our initial method, causes the snare to be in contact with the sterile suture. We have recently used an original gastropexy technique performed with a long curved needle in which there is no contamination of the sterile suture. The aim of this study is to compare the rates of infection observed with these two methods of gastropexy. METHODS: The Introducer technique was performed in all patients with two different gastropexy techniques used during two separate, consecutive periods. Antibiotic prophylaxis was not used during either procedure. Any surgical infections were treated with local wound care and/or antibiotic therapy with treatment based on the severity of the infection. The surgical infection rates in each group were compared. RESULTS: Group I consisted of 142 patients who underwent gastropexy with two straight needles, and group II consisted of 435 patients on whom gastropexy was performed with a curved needle. The infection rates found in groups I and II were 2.8% and 0.2%, respectively (P = 0.03). CONCLUSIONS: Gastropexy performed with a curved needle was associated with a lower rate of infection when compared to gastropexy performed with two straight needles.

Initial experience in Brazil with endoscopic submucosal dissection for early gastric cancer using insulation-tipped knife: a safety and feasibility study.

BACKGROUND: Endoscopic resection is an adequate treatment for subgroups of patients with early gastric cancer. Endoscopic submucosal dissection (ESD) represents a recent advance and leads to good results when adequately indicated. There is great experience with this technique in Japan and it is gaining acceptance among Western endoscopists. We present the first gastric ESD series performed in Brazil. METHODS: Patients with well-differentiated adenocarcinomas macroscopically classified as early cancer, less than 30 mm with no ulcer or scar, were included. ESD was performed with an insulated-tip knife and electrosurgical unit with endocut mode. Clinicopathological aspects and morbidity were evaluated. The study was approved by the local ethics committee and informed consent was obtained from all participant subjects. RESULTS: From October 2005 to July 2007, 160 patients received surgical treatment for gastric cancer; 44 patients (27.5%) had early gastric cancer. In this latter group, 15 procedures (ESD) were performed in 12 patients. The mean size of the lesions was 16.8 mm. Almost half of the lesions were located in the proximal third of the stomach and the mean elapsed time for the procedure was 140 min. In 80% of the cases resection was en bloc and 80% of the resections were considered curative. We had three perforations, which were managed clinically, and no bleeding. CONCLUSION: When adequately indicated, ESD is a safe and feasible technique.

Endoscopic mucosal resection of early gastric cancer: initial experience with two technical variants.

BACKGROUND: When performed in carefully selected cases, the endoscopic treatment of early gastric cancer yields results which are comparable to the conventional surgical treatment, but with lower morbidity and mortality and better quality of life. Several technical options to perform endoscopic mucosal resection have been described and there is a large amount of accumulated experience with this procedure in eastern countries. In western countries, particularly in Brazil, technical limitations associated with the small number of cases of early gastric cancer reflect the little experience with this therapeutic mode. AIM: This study was carried out in order to assess the indications, pathological results and morbidity of a series of endoscopic mucosal resections using two technical variants in addition to investigating the safety and feasibility of the method. METHODS: Individuals with well-differentiated early gastric adenocarcinomas with up to 30 mm in diameter without scar or ulcer underwent endoscopic treatment. Two variants of the strip biopsy technique were used. The pathological study assessed the depth of the vertical invasion, lateral and basal margins as well as angio-lymphatic invasion. RESULTS: Thirteen tumors in 12 patients were resected between June 2002 and August 2005. The most common macroscopic types were IIa and IIa + IIc. Tumor size ranged from 10 to 30 mm (mean = 16.5 mm). En bloc resection was carried out in nine patients. Angio-lymphatic invasion was not observed; however, submucosal invasion was found in two cases. In four cases, the lateral margin was involved. Perforation occurred in two patients who then received conservative treatment. CONCLUSION: The relatively small series presented here suggests that the method is safe and feasible. Appropriate patient selection is the most important criteria. Long follow-up is required after treatment due to the risk of relapse.

Endoscopic mucosal resection of early gastric cancer: initial experience with two technical variants

BACKGROUND: When performed in carefully selected cases, the endoscopic treatment of early gastric cancer yields results which are comparable to the conventional surgical treatment, but with lower morbidity and mortality and better quality of life. Several technical options to perform endoscopic mucosal resection have been described and there is a large amount of accumulated experience with this procedure in eastern countries. In western countries, particularly in Brazil, technical limitations associated with the small number of cases of early gastric cancer reflect the little experience with this therapeutic mode. AIM: This study was carried out in order to assess the indications, pathological results and morbidity of a series of endoscopic mucosal resections using two technical variants in addition to investigating the safety and feasibility of the method. METHODS: Individuals with well-differentiated early gastric adenocarcinomas with up to 30 mm in diameter without scar or ulcer underwent endoscopic treatment. Two variants of the strip biopsy technique were used. The pathological study assessed the depth of the vertical invasion, lateral and basal margins as well as angio-lymphatic invasion. RESULTS: Thirteen tumors in 12 patients were resected between June 2002 and August 2005. The most common macroscopic types were IIa and IIa + IIc. Tumor size ranged from 10 to 30 mm (mean = 16.5 mm). En bloc resection was carried out in nine patients. Angio-lymphatic invasion was not observed; however, submucosal invasion was found in two cases. In four cases, the lateral margin was involved. Perforation occurred in two patients who then received conservative treatment. CONCLUSION: The relatively small series presented here suggests that the method is safe and feasible. Appropriate patient selection is the most important criteria. Long follow-up is required after treatment due to the risk of relapse.

RACIONAL: O tratamento endoscópico do câncer gástrico precoce quando realizado em casos bem selecionados proporciona resultados comparáveis ao tratamento cirúrgico convencional, porém com menor morbidade, menor mortalidade e melhor qualidade de vida. Diversas opções técnicas para a realização de ressecção endoscópica mucosa já foram descritas e há grande experiência acumulada nos países orientais com este procedimento. Nos países ocidentais, em particular no Brasil, as limitações técnicas associadas ao pequeno número de casos de câncer gástrico precoce se refletem na pequena experiência com esta modalidade terapêutica. OBJETIVO: Avaliar as indicações, resultados histopatológicos e morbidade de uma série de ressecções mucosas endoscópicas utilizando duas variantes técnicas, além de verificar a segurança e exeqüibilidade do método. MÉTODO: Pacientes com adenocarcinomas gástricos precoces e bem diferenciados, com até 30 mm de diâmetro, sem cicatriz ou úlcera foram submetidos a tratamento endoscópico. Foram utilizadas duas variantes técnicas de "strip biopsy". O estudo histopatológico avaliou a profundidade de invasão, margens laterais e profundas além da invasão angiolinfática. RESULTADOS: Foram ressecadas 13 lesões em 12 pacientes no período de junho de 2002 a agosto de 2005. Os tipos macroscópicos mais comuns foram IIa e IIa + IIc. O tamanho das lesões variou de 10 a 30 mm (média de 16,5 mm). A ressecção foi efetuada em monobloco em nove casos. Não foi observada invasão angiolinfática, porém em duas oportunidades havia acometimento da camada submucosa. Quatro lesões tinham comprometimento da margem lateral. Dois pacientes apresentaram perfuração gástrica e foram tratados de forma conservadora. CONCLUSÃO: A série relativamente pequena aqui apresentada demonstra que o método é seguro e exeqüível, quando realizado em pacientes adequadamente selecionados. É necessário que estes sejam mantidos sob estreita vigilância para verificação dos resultados...

Percutaneous endoscopic gastrostomy in advanced head and neck cancer / Gastrostomia endoscópica percutânea em pacientes com tumores avançados de cabeça e pescoço

BACKGROUND: Percutaneous endoscopic gastrostomy performed as proposed by Gauderer et al. in 1980, has been used quite frequently in patients with head and neck tumors. Some authors believe that this so-called pull technique would be associated to the risk of a tumor implantation in the wound as well as high levels of peristomal wound infection. Although some alternative techniques provide better results, doubts about their technical applicability in daily practice still persists. AIM: To assess the feasibility, safety and morbidity of percutaneous endoscopic gastrostomy performed through a well-defined and standardized technique in patients with nonresectable or advanced head and neck cancer. METHODS: A consecutive series of patients who had either nonresectable or advanced tumors and were unable to be fed orally were submitted to an oncologic-hospital-based tertiary-referral endoscopy practice. Tubes were implanted through an introducer technique comprised of two main stages. The first consisted of the application of two stitches aiming to fixate the anterior gastric wall to the abdominal wall, and the second being the inserting of the gastrostomy tube. RESULTS: Between February 2003 and May 2004, 129 percutaneous endoscopic gastrostomies were performed. This study included 60 patients. They were all able to receive food on the same day. Operative morbidity was observed in six patients (10%) and one procedure-related mortality was also observed (1.6%). CONCLUSION: Percutaneous endoscopic gastrostomy is both feasible and safe, associated to low morbidity, and to acceptable mortality rates.

RACIONAL: A gastrostomia endoscópica percutânea executada conforme a técnica proposta por Gauderer et al., em 1980, tem sido freqüentemente utilizada em pacientes com tumores de cabeça e pescoço. Diversos autores relatam que ela, conhecida como técnica de “puxar”, está associada a risco de implante de tumor na parede abdominal assim como risco bastante elevado de infecção na ferida operatória. Algumas variantes técnicas proporcionam melhores resultados, contudo existem dúvidas acerca da sua viabilidade técnica na prática diária. OBJETIVO: Verificar a exeqüibilidade, segurança e morbidade da gastrostomia endoscópica percutânea realizada por técnica padronizada e bem definida em pacientes com tumores avançados ou irressecáveis da cabeça e pescoço. MÉTODO: É descrita série consecutiva de pacientes com tumores avançados ou irressecáveis de cabeça e pescoço, incapazes de receber dieta por via oral, submetidos à gastrostomia endoscópica percutânea no setor de endoscopia digestiva de um hospital oncológico de referência terciária. As sondas foram implantadas pela técnica de punção compreendida de duas etapas principais. A primeira, consistiu na aplicação de dois pontos transfixantes com o propósito de fixar a parede anterior do estômago à parede abdominal. A segunda, introdução do tubo de gastrostomia por punção percutânea. RESULTADOS: Foram realizadas 129 gastrostomias endoscópicas percutâneas e incluiu 60 pacientes. Todos foram liberados para receber dieta no mesmo dia. Morbidade operatória ocorreu em seis pacientes (10%) e mortalidade relacionada ao procedimento foi verificada em um paciente (1,6%). CONCLUSÃO: A gastrostomia endoscópica percutânea é exeqüível e segura, além de estar associada à baixa morbidade e aceitável mortalidade.

Metastatic cancer to the stomach.

BACKGROUND: Metastases in the stomach are rare. The increased use of esophagogastroduodenoscopy (EGD), associated with better treatment results for malignancies, requires them to be acknowledged. The aim of this study was to describe a series of cases of metastasis to the stomach, their primary sites, clinical and endoscopic features, treatment, and results. METHODS: Twenty cases were diagnosed between December 1999 and January 2004. Their analysis included symptomatology, macroscopic presentation, time from diagnosis of the primary tumor to the detection of the gastric metastasis, treatment approach, and survival. RESULTS: The primary sites were the esophagus, skin, lung, cervix, breast, sigmoid colon, and testis. The symptom most frequently requiring EGD was upper gastrointestinal bleeding. Ten patients showed concomitant metastases to other organs. The mean time between diagnosis of the primary tumor and diagnosis of gastric metastasis was 16 months (range, 0 to 56 months). Only seven patients were given some form of treatment after diagnosis of the gastric metastasis. The median survival was 4.75 months. Overall survival during the first year was 20% and survival was nil at 2 years. CONCLUSIONS: Gastric metastasis marks advanced disease and the prognosis is poor. New advances in diagnosis and treatment are required for better results.

Origem esofágica de dor precordial em pacientes chagásicos com artérias coronárias subepicárdicas normais / Esophageal origin of precordial pain in chagasic patients with normal subepicardial coronary arteries

PURPOSE--To study the chest pain of esophageal origin in chagasic patients (CH) and non-chagasic subjects (NCH) with normal coronary arteries. METHODS--The study comprised 48 patients: 33 CH (age 56 years, 50 male) and 15 NCH (age 47 years, 25 male), with precordial chest pain and normal subepicardial coronary arteries. They were assigned to upper digestive tract radiologic and endoscopic study, esophageal manometric evaluation at baseline and after provocative tests (Bernstein and intravenous edrophonium). RESULTS--Radiologic study: 14 (42) CH and 4 (27) NCH had esophageal dilation (p > 0.05). Hiatal hernia was documented in 7 (21) CH and 6 (40) NCH (p > 0.05). 2) Digestive endoscopy: In 15 (45) CH and 6 (40) NCH distal esophagitis were seen. In the NCH, esophagitis occurred with hiatal hernia; however only 30 of CH with esophagitis had also hiatal hernia while another 30 had esophageal dilation. 3) Esophageal motility disorders (EMD): 11 (33) CH showed EMD--8 with inferior esophageal sphincter achalasia (IESA) and 3 with diffuse esophageal spasm. Among NCH, 2 (13) had IESA (p > 0.05). 4) Bernstein test--a positive test was seen in 5 (15) CH and 3 (20) NCH-p > 0.05. CH with esophageal dilation had 14 of positive results, while CH without esophageal dilation had 16-p > 0.05. 5) Intravenous edrophonium-esophageal contraction amplitude enhancement provoked by the drug infusion was clearly attenuated in the chagasic (6.9 +/- 12.7 mmHg) when compared with the NCH group (18.8 +/- 21.4 mmHg). A positive test (i.e. chest pain) was obtained in only one patient who was NCH. CONCLUSION--Esophageal pain could be elicited at a relatively low and comparable rate in both groups of patients.

Consequências da endoscopia digestiva alta na motilidade do esôfago de pacientes com megaesôfago / Effects of endoscopy on esophageal motility of patients with megaesophagus

Em dez pacientes com doença de Chagas e megaesôfago, estudamos a motilidade do esôfago antes e 24 horas após a realizaçao de endoscopia digestiva alta. No exame manométrico, foi utilizada uma sonda aberta de quatro canais e perfusao contínua e, no exame endoscópico, o aparelho GIF-Q Olympus, que tem 1Omm de diâmetro. O objetivo foi avaliar se a endoscopia altera a motilidade do esôfago. Nao houve diferença na pressao do esfíncter inferior e na amplitude da contraçao do corpo do esôfago, na comparaçao entre antes e após a endoscopia. As contraçoes foram síncronas e de baixa amplitude e nao houve relaxamento do esfíncter inferior do esôfago nos dois exames manométricos. Embora, como grupo, a pressao do esfíncter inferior do esôfago nao tenha se modificado com a endoscopia, em metade dos casos ela diminuiu. Concluímos que o exame endoscópico nao altera a motilidade do esôfago, mas alguns pacientes podem ter diminuiçao da pressao do esfíncter inferior.

Paracoccidioidomicose do estômago: relato de caso e consideraçöes sobre a patogenia desta lesäo / Gastric paracoccidiodomycosis: a case report and considerations on the pathogenesis of the disease

Relata-se um caso incomum de lesäo fúngica gástrica em pacientes com a forma crônica de paracoccidioidomicose (blastomicose sul-americana). Durante um período de 8 meses os sintomas principais do paciente foram dor abdominal e perda de peso. A esofagogastroduodenoscopia mostrou uma gastrectomia parcial feita previamente, uma úlcera grande e irregular no estômago e aspecto granuloso da mucosa duodenal. No exame histopatológico do tecido retirado por biopsia do estômago e do duodeno observou-se processo granulomatoso e o Paracoccidioides brasiliensis. A cicatrizaçäo da úlcera gástrica foi verificada em nova avaliaçäo endoscópica feita após 4 meses de tratamento com sulfadiazina. Sugere-se que o comprometimento de gânglios linfáticos abdominais, a infecçäo duodenal e também alteraçöes anatômicas e tróficas do estômago, sejam fatores predisponentes da paracoccidioidomicose gástrica

Urgências em gastroenterologia / Emergencies in gastroenterology

Esta revisäo aborda as mais frequentes urgências gastroenterológicas (hemorragia digestiva alta, pancreatite, insuficiência hepática aguda, peritonite bacteriana espontânea e encefalopatia hepática) na prática clínica, com ênfase em aspectos diagnósticos e terapêuticos

Evidências do declínio da ocorrência do megaesôfago e do megacolon chagásicos: estudo epidemiológico no Hospital das Clínicas de Ribeiräo Preto / Evidence for a decline in the occurrence of chagasic megaesophagus and megacolon: on epidemiological study at the University Hospital of Ribeiräo Preto

Em levantamento de 496 casos de megaesofago e/ou megacolon chagasicos internadosd no Hospital das Clínicas da Faculdade de Medicina de Ribeiräo Preto e com diagnostico efetuado no período de 1979 a 1990 foram encontrados indícios de que a ocorrência de "megas" acha-se em declínio. Evidenciou-se que: 1) näo foi detectado nenhum paciente com menos de 20 anos de idade; 2) ao longo do período em estudo, houve aumento progressivo da mediana das idades dos pacientes; 3) comparativamente a observaçöes anteriores de outros autores, concernentes ao megaesofago (1939 e 1968) e ao megacolon (1950 e 1976), revelou-se sensível deslocamento para a direita da curva de distribuiçäo dos casos segundo os grupos etários e nítida reduçäo do percentual de casos com menos de 40 anos de idade; 4) entre os pacientes com menos de 40 anos, os naturais do Estado de Säo Paulo (considerada zona limpa da doença há cerca de 10 anos) contribuiram em proporçäo nitidamente menor do que os naturais de outros Estados. Os dados obtidos sugerem que nos ultimos anos as populaçöes v em sendo protegidas contra a transmissäo vetorial da doença de Chagas, reduzindo-se consequentemente, o aparecimento de casos de "megas" nos grupos etários mais jovens