Endoscopic Versus Surgical Treatment for Ampullary Lesions: A Systematic Review With Meta-Analysis.

Ampullary lesions (ALs) can be treated through either an endoscopic approach (EA) or a surgical approach (SA). However, it is important to note that EAs carry a significant risk of incomplete resection, while opting for surgical interventions can result in substantial morbidity. We performed a systematic review and meta-analysis for R0 resection, recurrence, adverse events in general, major adverse events, mortality, and length of hospital stay between SAs and EAs. Electronic databases were searched from inception to 2023. We identified nine independent studies. The risk difference was -0.32 (95% CI: -0.50, -0.15; p <0.001) for R0, 0.12 (95% CI: 0.06, 0.19; p < 0.001) for recurrence, -0.22 (95% CI: -0.43, 0.00; p 0.05) for overall adverse events, -0.11 (95% CI: -0.32, 0.10; p = 0.31) for major complications, -0.01 (95% CI: -0.02, 0.01; p = 0.43) for mortality, and -14.69 (95% CI: -19.91, -9.47; p < 0.001) for length of hospital stay. As expected, our data suggest a higher complete resection rate and lower recurrence from surgical interventions, but this is associated with an elevated risk of adverse events and a longer hospital stay.

EVALUATION OF QUALITY INDICATORS OF SCREENING COLONOSCOPY PERFORMED IN A PRIVATE QUARTERNARY HOSPITAL IN BRAZIL.

BACKGROUND: Colorectal cancer is the third most common type of cancer in Brazil, despite the availability of screening methods that reduce its risk. Colonoscopy is the only screening method that also allows therapeutic procedures. The proper screening through colonoscopy is linked to the quality of the exam, which can be evaluated according to quality criteria recommended by various institutions. Among the factors, the most used is the Adenoma Detection Rate, which should be at least 25% for general population. AIMS: To evaluate the quality of the screening colonoscopies performed in a quarternary private Brazilian hospital. METHODS: This is a retrospective study evaluating the quality indicators of colonoscopies performed at a private center since its inauguration. Only asymptomatic patients aged over 45 years who underwent screening colonoscopy were included. The primary outcome was the Adenoma Detection Rate, and secondary outcomes included polyps detection rate and safety profile. Subanalyses evaluated the correlation of endoscopic findings with gender and age and the evolution of detection rates over the years. RESULTS: A total of 2,144 patients were include with a mean age of 60.54 years-old. Polyps were diagnosed in 68.6% of the procedures. Adenoma detection rate was 46.8%, with an increasing rate over the years, mainly in males. A low rate of adverse events was reported in 0.23% of the cases, with no need for surgical intervention and no deaths. CONCLUSIONS: This study shows that high quality screening colonoscopy is possible when performed by experienced endoscopists and trained nurses, under an adequate infrastructure.

Endoscopic vacuum therapy: pitfalls, tips and tricks, insights, and perspectives.

This article provides a comprehensive review of the use of endoscopic vacuum therapy (EVT) in the management of transmural gastrointestinal (GI) defects (TGIDs) and its future perspectives, such as pre-emptive EVT and novel indications, including GI bleeding and large gastroduodenal ulcers management. This review is based on the available literature data and personal experience to demystify the mentioned limitations of EVT as technical difficulties related to the procedure, possible patients' complaints, and institutions' concerns, by sharing several tips and tricks to overcome EVT-related challenges that may discourage endoscopists from using this live-saving technique, and consequently, restricting patients to receive this therapy, which may lead to undesired outcomes. Several factors, such as placement techniques, EVT type selection, management during its use, EVT system exchanges, device removal, type of anesthesia, and how to avoid EVT-related adverse events are described in detail. Additionally, this review discusses good ways to promote effective communication with patients and relatives, surgeons, and multidisciplinary team. EVT possesses a unique mechanism of action including macro/micro deformation, changes in perfusion (stimulating angioneogenesis), exudate control, and bacterial clearance, promoting healing. EVT has an adequate safety profile and higher clinical success rate compared to any other endoscopic therapy for TGID. Additionally, pre-emptive EVT and its novel indications are promising due to its satisfactory effectiveness in initial studies. Therefore, detailing some practical solutions obtained by years of experience may collaborate to widespread EVT adoption, providing less-invasive treatment for several critical conditions to more patients worldwide.

C1-C2 Transarticular Anterior Fixation for the Treatment of Atlantoaxial Traumatic Dislocation: A Clinical Case.

Fractures of the odontoid apophysis are one of the most frequent lesions in the elderly population, and an increasingly preponderant problem with the progressive aging of the world population. In the present work, we report a clinical case of an 88-year-old male patient who suffered a fall resulting in a type-II fracture of the odontoid apophysis on the Anderson-D'Alonzo classification. Given the age and comorbidities of the patient, we decided to perform osteosynthesis of the fracture through anterior fixation with a transarticular screw in combination with fixation with an odontoid screw. This technique enables the necessary stability for the consolidation of Anderson-D'Alonzo's type II odontoid apophysis fracture, with the advantage of the lower levels of dissection of the cervical extensor musculature and hemorrhage resulting from this aggression when compared with the posterior approach; moreover, it is a readily-available technique that yields clear benefits in the treatment of this pathology in the geriatric population.

Treatment of Two-column Acetabular Fractures by Double Extrapelvic Approach: Three Clinical Cases / Tratamento de fraturas acetabulares de duas colunas por dupla via extrapélvica: Três casos clínicos

Abstract Fractures of two columns of the acetabulum according to the Letournel classification are among the most common in frequency, indication and surgical complexity. These are mainly the result of lateral compression mechanisms and are characterized by originating a disconnected acetabulum from the axial skeleton. Its surgical treatment may include: isolated anterior or posterior approach; combined, at the same surgical time or not; or broad approaches. The authors present another surgical option with association of the Kocher-Langenbeck pathway with the iliac crest approach simultaneously and in the same positioning (lateral decubitus) based on the first three clinical cases performed and their clinical and imaging results. In addition to the presentation of the cases, a description of the three characteristic fragments of this type of acetabular fractures, the approach pathway, and the reduction sequence performed are made. From the results obtained and the associated advantages, the authors believe that the addition of the iliac crest approach to the Kocher-Langenbeck pathway may be a very attractive option to consider in the surgical treatment of properly selected fractures of two columns of the acetabula.

Resumo As fraturas de duas colunas do acetábulo segundo a classificação de Letournel são das mais comuns em frequência, indicação e complexidade cirúrgica. Estas resultam essencialmente de mecanismos de compressão lateral e caracterizam-se por originarem um acetábulo desconectado do esqueleto axial. O seu tratamento cirúrgico pode incluir: abordagem anterior ou posterior isolada; combinadas, no mesmo tempo cirúrgico ou não; ou abordagens alargadas. Os autores apresentam outra opção cirúrgica com associação de via de Kocher-Langenbeck e abordagem da crista ilíaca simultânea e no mesmo posicionamento (decúbito lateral) com base nos três primeiros casos clínicos realizados e seus resultados clínicos e imagiológicos. Para além da apresentação dos casos, é feita uma descrição dos três fragmentos característicos deste tipo de fraturas acetabulares, da via de abordagem e da sequência de redução realizada. Pelos resultados obtidos e vantagens associadas, os autores acreditam que a adição da abordagem da crista ilíaca à via de Kocher-Langenbeck pode ser uma opção muito atrativa a ter em conta no tratamento cirúrgico de fraturas de duas colunas do acetábulo devidamente selecionadas.

Treatment of Two-column Acetabular Fractures by Double Extrapelvic Approach: Three Clinical Cases.

Fractures of two columns of the acetabulum according to the Letournel classification are among the most common in frequency, indication and surgical complexity. These are mainly the result of lateral compression mechanisms and are characterized by originating a disconnected acetabulum from the axial skeleton. Its surgical treatment may include: isolated anterior or posterior approach; combined, at the same surgical time or not; or broad approaches. The authors present another surgical option with association of the Kocher-Langenbeck pathway with the iliac crest approach simultaneously and in the same positioning (lateral decubitus) based on the first three clinical cases performed and their clinical and imaging results. In addition to the presentation of the cases, a description of the three characteristic fragments of this type of acetabular fractures, the approach pathway, and the reduction sequence performed are made. From the results obtained and the associated advantages, the authors believe that the addition of the iliac crest approach to the Kocher-Langenbeck pathway may be a very attractive option to consider in the surgical treatment of properly selected fractures of two columns of the acetabula.

Endoscopic transoral outlet reduction induces enterohormonal changes in patients with weight regain after Roux-en-Y gastric bypass.

Background and study aims Transoral outlet reduction (TORe) has long been employed in treating weight regain after Roux-en-Y gastric bypass. However, its impact on gut hormones and their relationship with weight loss remains unknown. Patients and methods This was a substudy of a previous randomized clinical trial. Adults with significant weight regain and dilated gastrojejunostomy underwent TORe with argon plasma coagulation (APC) alone or APC plus endoscopic suturing (APC-suture). Serum levels of ghrelin, GLP-1, and PYY were assessed at fasting, 30, 60, 90, and 120 minutes after a standardized liquid meal. Results were compared according to allocation group, clinical success, and history of cholecystectomy. Results Thirty-six patients (19 APC vs. 17 APC-suture) were enrolled. There were no significant baseline differences between groups. In all analyses, the typical postprandial decrease in ghrelin levels was delayed by 30 minutes, but no other changes were noted. GLP-1 levels significantly decreased at 12 months in both allocation groups. Similar findings were noted after dividing groups according to the history of cholecystectomy and clinical success. The APC cohort presented an increase in PYY levels at 90 minutes, while the APC-suture group did not. Naïve patients had significantly lower PYY levels at baseline ( P = 0.01) compared with cholecystectomized individuals. This latter group experienced a significant increase in area under the curve (AUC) for PYY levels, while naïve patients did not, leading to a higher AUC at 12 months ( P = 0.0001). Conclusions TORe interferes with the dynamics of gut hormones. APC triggers a more pronounced enteroendocrine response than APC-suture, especially in cholecystectomized patients.

Beyond Restrictive: Sleeve Gastrectomy to Single Anastomosis Duodeno-Ileal Bypass with Sleeve Gastrectomy as a Spectrum of One Single Procedure.

INTRODUCTION: Single anastomosis duodeno-ileal bypass with sleeve gastrectomy (SADI-S) is a restrictive/hypoabsorptive procedure recommended for patients with obesity class 3. For safety reasons, SADI-S can be split into a two-step procedure by performing a sleeve gastrectomy (SG) first. This stepwise approach also provides an unprecedented opportunity to disentangle the weight loss mechanisms triggered by each component. The objective was to compare weight trajectories and post-prandial endocrine and metabolic responses of patients with obesity class 3 submitted to SADI-S or SG as the first step of SADI-S. METHODS: Subjects submitted to SADI-S (n = 7) or SG (n = 7) at a tertiary referral public academic hospital underwent anthropometric evaluation and a liquid mixed meal tolerance test (MMTT) pre-operatively and at 3, 6, and 12 months post-operatively. RESULTS: Anthropometric parameters, as well as metabolic and micronutrient profiles, were not significantly different between groups, neither before nor after surgery. There were no significant differences in fasting or post-prandial glucose, insulin, C-peptide, ghrelin, insulin secretion rate, and insulin clearance during the MMTT between subjects submitted to SADI-S and SG. There was no lost to follow-up. CONCLUSIONS: The restrictive component seems to be the main driver for weight loss and metabolic adaptations observed during the first 12 months after SADI-S, given that the weight trajectories and metabolic profiles do not differ from SG. These data provide support for surgeons' choice of a two-step SADI-S without jeopardizing the weight loss outcomes.

The role of kyphoplasty and expandable intravertebral implants in the acute treatment of traumatic thoracolumbar vertebral compression fractures: a systematic review.

Purpose: The aim of the study was to assess the role of kyphoplasty and expandable intravertebral implants in the treatment of traumatic vertebral compression fractures. Design: This is a systematic review. Methods: A bibliographic search was carried out in the PubMed/MEDLINE database according to PRISMA guidelines regarding kyphoplasty and expandable intravertebral implants in the treatment of traumatic thoracolumbar vertebral fractures. Results: A total of 611 records were screened. In total, 51 studies were obtained referring to traumatic vertebral fractures treated with kyphoplasty; however, of these, only studies addressing traumatic burst fractures were selected, resulting in 12 studies: 10 about kyphoplasty and 2 regarding armed kyphoplasty. In all studies, there was a statistically significant improvement in clinical and functional parameters, restoration of vertebral height and decreasing of vertebral and segmental kyphosis. Overall, there was only a residual loss of height and a slight increase in kyphosis throughout the follow-up period, while complications consisted essentially of cement leakage, all with no clinical repercussions. Conclusion: After the discussion, where we address the concepts of direct and indirect reduction, the association of kyphoplasty with pedicle fixation, the potential advantages of expandable intravertebral implants, as well as the vertebral body type of filling in kyphoplasty, it is concluded that kyphoplasty demonstrates favorable outcomes as a method of posterior percutaneous transpedicular access for reconstruction of the anterior column in burst fractures. It allows for the reconstruction of the vertebral body closer to its original anatomy, carried out in a minimally invasive and safe way, which provides a clinical-functional and imaging improvement maintained at the medium-long term.

Conventional Versus Traction-Assisted Endoscopic Submucosal Dissection for Esophageal, Gastric, and Colorectal Neoplasms: A Systematic Review and Meta-Analysis of Randomized Controlled Trials.

Endoscopic submucosal dissection (ESD) is increasingly being utilized for the resection of superficial gastrointestinal neoplasms. However, the long procedure time poses a technical challenge for conventional ESD (C-ESD). Traction-assisted ESD (T-ESD) was developed to facilitate the procedure by reducing its duration. This study compares the efficacy and safety of C-ESD versus T-ESD in the treatment of esophageal, gastric, and colorectal neoplasms. Nine randomized controlled trials (RCTs) were analyzed. Traction-assisted ESD exhibited shorter mean dissection times for the esophagus and colorectal regions and lower perforation rates in colorectal cases. No significant differences were observed in en bloc resection or bleeding rates. Traction-assisted ESD proves to be more efficient in mean procedure time for esophageal and colorectal cases and safer in perforation rates for colorectal cases, but similar rates are noted for en bloc resection or bleeding.

Radiofrequency ablation for ampullary neoplasia with intraductal extension after endoscopic papillectomy: Systematic review and meta-analysis.

Background and study aims Noninvasive ampullary neoplasms may be removed by surgery or endoscopy. However, given the morbidity and mortality associated with surgery, endoscopic papillectomy (EP) is the preferred approach. Radiofrequency ablation (RFA) after EP has emerged as a promising alternative therapy to avoid surgery after incomplete EP. Our goal was to evaluate the efficacy and safety of RFA for residual or recurrent lesions with intraductal extension after endoscopic papillectomy. Patients and methods The inclusion criteria include clinical trials, cohort studies, and case series evaluating patients with residual or recurrent lesions with intraductal extension after EP treated with RFA. Case reports, duplicated data, and studies with follow-up periods < 10 months were excluded. The metanalysis evaluated adverse events, surgical conversion rate, clinical success and recurrence. Results Seven studies were selected, totaling 124 patients. RFA was associated with a clinical success rate of 75.7% (95% confidence interval [CI] 65.0-88.0%; I 2 = 23.484) in a mean follow-up period < 10 months. However, the biliary stricture rate was 22.2% (95% CI 12.1-28.4%; I 2 = 61.030), 14.3% of pancreatitis (95% CI 8.8-22.3%; I 2 < 0.001), 7.0% of cholangitis (95% CI 3.3-14.5%; I 2 < 0.001), 4.0% of bleeding (95% CI 1.7-9.3%; I 2 < 0.001), and recurrence of 24.3% (95% CI 16.0-35.0%; I 2 = 23.484). Conclusions RFA is feasible and appears to be effective for managing residual or recurrent lesions with intraductal extension after EP. However, long-term follow-up and high-quality studies are required to confirm our findings.

HOT VERSUS COLD SNARE FOR COLORECTAL POLYPECTOMIES SIZED UP TO 10MM: A SYSTEMATIC REVIEW AND META-ANALYSIS OF RANDOMIZED CONTROLLED TRIALS.

BACKGROUND: Colorectal cancer is the third most common cancer, and prevention relies on screening programs with resection complete resection of neoplastic lesions. OBJECTIVE: We aimed to evaluate the best snare polypectomy technique for colorectal lesions up to 10 mm, focusing on complete resection rate, and adverse events. METHODS: A comprehensive search using electronic databases was conducted to identify randomized controlled trials comparing hot versus cold snare resection for polyps sized up to 10 mm, and following PRISMA guidelines, a meta-analysis was performed. Outcomes included complete resection rate, en bloc resection rate, polypectomy, procedure times, immediate, delayed bleeding, and perforation. RESULTS: Nineteen RCTs involving 8720 patients and 17588 polyps were included. Hot snare polypectomy showed a higher complete resection rate (RD, 0.02; 95%CI [+0.00,0.04]; P=0.03; I 2=63%), but also a higher rate of delayed bleeding (RD 0.00; 95%CI [0.00, 0.01]; P=0.01; I 2=0%), and severe delayed bleeding (RD 0.00; 95%CI [0.00, 0.00]; P=0.04; I 2=0%). Cold Snare was associated with shorter polypectomy time (MD -46.89 seconds; 95%CI [-62.99, -30.79]; P<0.00001; I 2=90%) and shorter total colonoscopy time (MD -7.17 minutes; 95%CI [-9.10, -5.25]; P<0.00001; I 2=41%). No significant differences were observed in en bloc resection rate or immediate bleeding. CONCLUSION: Hot snare polypectomy presents a slightly higher complete resection rate, but, as it is associated with a longer procedure time and a higher rate of delayed bleeding compared to Cold Snare, it cannot be recommended as the gold standard approach. Individual analysis and personal experience should be considered when selecting the best approach.

Correction: Intraductal radiofrequency ablation plus biliary stent versus stent alone for malignant biliary obstruction: a systematic review and meta-analysis.

[This corrects the article DOI: 10.1055/a-2204-8316.].

Role of endoscopic duodenojejunal bypass liner in obesity management and glycemic control.

The treatment of obesity and its comorbidities ranges from clinical management involving lifestyle changes and medications to bariat-ric and metabolic surgery. Various endoscopic bariatric and metabolic therapies recently emerged to address an important therapeutic gap by offering a less invasive alternative to surgery that is more effective than conservative therapies. This article compre-hensively reviews the technical aspects, mechanism of action, outcomes, and future perspectives of one of the most promising endoscopic bariatric and metabolic therapies, named duodenojejunal bypass liner. The duodenojejunal bypass liner mimics the mechanism of Roux-en-Y gastric bypass by preventing food contact with the duodenum and proximal jejunum, thereby initiating a series of hormonal changes that lead to delayed gastric emptying and malabsorptive effects. These physiological changes result in significant weight loss and improved metabolic control, leading to better glycemic levels, preventing dyslipidemia and non-alcoholic fatty liver disease, and mitigating cardiovascular risk. However, concern ex-ists regarding the safety profile of this device due to the reported high rates of severe adverse events, particularly liver abscesses. Ongo-ing technical changes aiming to reduce adverse events are being evaluated in clinical trials and may provide more reliable data to sup-port its routine use in clinical practice.

Intraductal radiofrequency ablation plus biliary stent versus stent alone for malignant biliary obstruction: a systematic review and meta-analysis.

Background and study aims Recurrent biliary stent occlusion and tumor ingrowth remain a major concern among patients with malignant biliary obstruction (MBO) with significant impact on patient morbidity and survival. Intraductal radiofrequency ablation (RFA) has emerged as a promising treatment that seeks to extend stent patency. This study aimed to evaluate the impact of RFA on overall survival (OS) and stent patency among patients with unresectable MBO. Methods A comprehensive search of electronic databases was performed for randomized controlled trials (RCTs) comparing RFA plus biliary stent (RFA+S) versus biliary stent alone (S-alone). Outcomes assessed included overall survival, stent patency, and adverse events (AEs) with mean difference (MD) calculated from pooled proportions. Subgroup analyses were performed for hilar strictures and cholangiocarcinoma (CCA). Results Six RCTs (n=439 patients) were included and demonstrated improved survival among patients who received RFA+S (MD 85.80 days; 95% confidence interval [CI] 35.02-136.58; I 2 =97%; P <0.0009). The pooled MD for total stent patency was 22.25 days (95% CI 17.38-61.87; I 2 =97%; P =0.27). There was no difference in AEs between RFA+S vs S-alone ( P >0.05). On subgroup analyses, RFA+S was associated with improved stent patency (MD 76.73 days; 95% CI 50.11-103.34; I 2 =67%; P <0.01) and OS (MD 83.14 (95% CI 29.52-136.77; I 2 =97%; P <0.01] for CCA. For hilar strictures, stent patency was improved among patients with RFA+S [MD 83.71 days (95% CI 24.85-142.56; I 2 =84%; P <0.01]. Conclusions RFA+S improved OS in the treatment of MBO when compared with S-alone. Moreover, the RFA therapy prolonged stent patency in hilar strictures and CCA, with similar rates of AEs.

Cryotherapy versus radiofrequency ablation in the treatment of dysplastic Barrett's esophagus with or without early esophageal neoplasia: a systematic review and meta-analysis.

BACKGROUND/AIMS: Radiofrequency ablation (RFA) is the first-line therapy for dysplastic Barrett's esophagus (BE). Therefore, cryotherapy has emerged as an alternative treatment option. This study aimed to compare the efficacies of these two techniques based on the rates of complete eradication of intestinal metaplasia (CE-IM) and dysplasia (CE-D). Adverse events and recurrence have also been reported. METHODS: An electronic search was conducted using the Medline (PubMed), Embase, LILACS, and Google Scholar databases until December 2022. Studies were included comparing cryotherapy and RFA for treating dysplastic BE with or without early esophageal neoplasia. This study was performed in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. RESULTS: Three retrospective cohort studies involving 627 patients were included. Of these, 399 patients underwent RFA, and 228 were treated with cryotherapy. There was no difference in CE-IM (risk difference [RD], -0.03; 95% confidence interval [CI], -0.25 to 0.19; p=0.78; I2=86%) as well as in CE-D (RD, -0.03; 95% CI, -0.15 to 0.09; p=0.64; I2=70%) between the groups. The absolute number of adverse events was low, and there was no difference in the recurrence rate. CONCLUSION: Cryotherapy and RFA were equally effective in treating dysplastic BE, with or without early esophageal neoplasia.