LEARNING CURVE IN ESOPHAGEAL ENDOSCOPIC SUBMUCOSAL DISSECTION BY WESTERN ENDOSCOSPISTS TRAINED IN JAPAN: EXPERIENCE IN LATIN AMERICA.

•This study aimed to assess the learning curve effect on patient's clinical outcome for EESD. Retrospective observational study, enrolling patients that underwent EESD from 2009 to 2021, divided in 2 groups. Mean procedure time was 111.8 min and 103.6 min for T1 and T2, respectively (P=0.004). The learning curve in esophageal ESD could be overcomed effectively and safely by an adequately trained Western endoscopist. Background - Esophageal endoscopic submucosal dissection (EESD) is a complex and time-consuming procedure at which training are mainly available in Japan. There is a paucity of data concerning the learning curve to master EESD by Western endoscopists. Objective - This study aimed to assess the learning curve effect on patient's clinical outcome for EESD. Methods - This is a retrospective observational study. Enrolling patients that underwent EESD from 2009 to 2021. The analysis was divided into two periods; T1: case 1 to 49 and T2: case 50 to 98. The following features were analyzed for each group: patients and tumors characteristics, en-bloc, complete and curative resection rates, procedure duration and adverse events rate. Results - Ninety-eight EESD procedures were performed. Mean procedure time was 111.8 min and 103.6 min for T1 and T2, respectively (P=0.004). En bloc resection rate was 93.8% and 97.9% for T1 and T2, respectively (P=0.307). Complete resection rate was 79.5% and 85.7% for T1 and T2, respectively (P=0.424). Curative resection rate was 65.3% and 71.4% for T1 and T2, respectively (P=0.258). Four patients had complications; three during T1 period and one during T2 period. Overall mortality rate: 0%. Conclusion - The esophageal endoscopic submucosal dissection could be performed effectively and safely by an adequately trained Western endoscopist.

Management of esophageal neoplasms by endoscopic submucosal dissection: experience over 100 consecutive procedures.

BACKGROUND/AIMS: Endoscopic submucosal dissection (ESD) is currently considered the first-line treatment for the eradication of superficial neoplasms of the esophagus in Eastern countries. However, in the West, particularly in Latin America, the experience with esophageal ESD is still limited because of the high technical complexity required for its execution. This study aimed to present the results of the clinical application of ESD to manage superficial esophageal neoplasms in a Latin American center in over 100 consecutive cases. METHODS: This retrospective study included consecutive patients who underwent endoscopic ESD for superficial esophageal neoplasms between 2009 and 2022. The following clinical outcomes were assessed: en bloc, complete, and curative resection rates, local recurrence, adverse events, and procedure-related mortality. RESULTS: Esophageal ESD was performed mainly for squamous cell carcinoma (66.6%), high-grade intraepithelial neoplasia (17.1%), and adenocarcinoma (11.4%). En bloc and complete resection rates were 96.2% and 81.0%, respectively. The curative resection rate was 64.8%. Adverse events occurred in six cases (5.7%). Endoscopic follow-up was performed for an average period of 29.7 months. CONCLUSION: ESD performed by trained operators is feasible, safe, and clinically effective for managing superficial neoplastic lesions of the esophagus in Latin America.

Curva de aprendizagem de dissecção endoscópica de submucosa por endoscopistas ocidentais treinados no Japão: Experiência na América Latina / Learning curve in esophageal endoscopic submucosal dissection by western endoscospists trained in japan: experience in latin america

ABSTRACT Background: Esophageal endoscopic submucosal dissection (EESD) is a complex and time-consuming procedure at which training are mainly available in Japan. There is a paucity of data concerning the learning curve to master EESD by Western endoscopists. Objective: This study aimed to assess the learning curve effect on patient's clinical outcome for EESD. Methods: This is a retrospective observational study. Enrolling patients that underwent EESD from 2009 to 2021. The analysis was divided into two periods; T1: case 1 to 49 and T2: case 50 to 98. The following features were analyzed for each group: patients and tumors characteristics, en-bloc, complete and curative resection rates, procedure duration and adverse events rate. Results: Ninety-eight EESD procedures were performed. Mean procedure time was 111.8 min and 103.6 min for T1 and T2, respectively (P=0.004). En bloc resection rate was 93.8% and 97.9% for T1 and T2, respectively (P=0.307). Complete resection rate was 79.5% and 85.7% for T1 and T2, respectively (P=0.424). Curative resection rate was 65.3% and 71.4% for T1 and T2, respectively (P=0.258). Four patients had complications; three during T1 period and one during T2 period. Overall mortality rate: 0%. Conclusion: The esophageal endoscopic submucosal dissection could be performed effectively and safely by an adequately trained Western endoscopist.

RESUMO Contexto: A dissecção endoscópica da submucosa do esôfago (DSEE) é um procedimento complexo, cujo treinamento está disponível principalmente no Japão. Há uma escassez de dados sobre a curva de aprendizado para se capacitar na realização da DSEE por endoscopistas ocidentais. Objetivo: Este estudo teve como objetivo avaliar o efeito da curva de aprendizado no resultado clínico dos pacientes submetidos a DSEE. Métodos: Trata-se de um estudo observacional retrospectivo. Foram incluídos pacientes submetidos a DSEE no período de 2009 a 2021. A análise foi dividida em dois períodos; T1: caso 1 a 49 e T2: caso 50 a 98. Os seguintes parâmetros foram analisados para cada grupo: características clínicas dos pacientes e dos tumores de esôfago, taxas de ressecção em bloco, completa e curativa, duração do procedimento e taxa de eventos adversos. Resultados: Noventa e oito procedimentos de DSEE foram realizados. O tempo médio do procedimento foi de 111,8 min e 103,6 min nos períodos T1 e T2, respectivamente (P=0,004). A taxa de ressecção em bloco foi de 93,8% e 97,9% nos períodos T1 e T2, respectivamente (P=0,307). A taxa de ressecção completa foi de 79,5% e 85,7% nos períodos T1 e T2, respectivamente (P=0,424). A taxa de ressecção curativa foi de 65,3% e 71,4% para T1 e T2, respectivamente (P=0,258). Quatro pacientes tiveram complicações; três durante o período T1 e um durante o período T2. Taxa de mortalidade geral: 0%. Conclusão: A DSEE pode ser realizada de forma eficaz e segura por um endoscopista ocidental adequadamente treinado.

Histopathologic Diagnosis Discrepancies Between Preoperative Endoscopic Forceps Biopsies and Specimens Resected by Endoscopic Submucosal Dissection in Superficial Gastric Neoplasms.

BACKGROUND: The standard of practice when a superficial lesion was identified during upper GI endoscopy is to take an endoscopic forceps biopsy (EFB) of the lesion. The histopathologic findings then will determine the management plan. Endoscopic submucosal dissection (ESD) enables en-bloc resection for early neoplasms of the gastrointestinal tract and provides an adequate specimen that permits a more reliable histopathologic assessment. The objective of this study was to determine the rate of histopathologic discrepancy between EFB and specimens resected by ESD, and to identify the predisposing risk factors for this discordance. MATERIALS AND METHODS: This is a retrospective study, enrolling patients with superficial gastric neoplasms that underwent EFB followed by ESD. We divided cases to concordant or discordant group according to the histopathologic diagnosis of EFB and ESD specimens. We also analyzed the features that may have influenced the occurrence of histopathologic discordance and the association between discordant samples of adenocarcinoma and neoplastic invasion to deeper layers. RESULTS: A total of 115 gastric ESD procedures were performed with 84 patients meeting the inclusion criteria. Histopathologic discordance between EFB and ESD specimens were observed in 35.8% of cases (30/84 lesions). The univariant-bivariant analysis and multivariate logistic regression analysis showed that histologic discordance was closely related to the size of the lesions ( P =0.028). CONCLUSION: Histopathologic discrepancy between EFB and ESD specimens may occur in approximately one-third of cases, particularly for lesions over 20 mm, which may lead to crucial delays in gastric cancer precise diagnosis and treatment.

Clinical effectiveness of short course oral prednisone for stricture prevention after semi-circumferential esophageal endoscopic submucosal dissection.

Background and study aims Esophageal strictures (ES) occur frequently after semi-circumferential endoscopic submucosal dissection (ESD) for the eradication of superficial esophageal neoplasms and negatively impact a patient's quality of life. Oral corticosteroids have been shown to be clinically effective, but the most appropriate drug, dose and duration is yet to be determined. The aim of the study was to investigate the clinical effectiveness and safety of 30 mg prednisone with a shortened tapering schedule on ES after semi-circumferential ESD. Patients and methods This was a retrospective observational study that analyzed consecutive patients with esophageal neoplasms who underwent semi-circumferential ESD with a resection defect greater than 75 % of the circumference that received a protocol of oral steroids for stricture prevention. On postoperative day 3, 30 mg prednisone was prescribed, tapering weekly to 20 mg/10 mg/5 mg over 4 weeks. Follow-up included clinic consultation and endoscopic review at weeks 2 and 4. Effectiveness outcomes included ES rates, safety, tolerability, resection, dilatation and recurrence rates. Results Ninety ESD procedures were carried out during the specified time period and 18 patients met the inclusion criteria for the final analysis. The mean age was 61.5 years, lesion size was 52.5 mm, and final histology was squamous cell carcinoma in all patients. Incidence of intra-procedure complications was: bleeding 5.5 % (1/18) and ES 5.5 % (1/18), requiring a median two endoscopic dilatations. En bloc, R0 and curative resection rates were 88.8 %, 72.2 %, and 55.5 %, respectively. Conclusions The short tapering schedule of 30 mg oral prednisone is clinically efficacious and safe for prevention of ES after semi-circumferential ESD in Latin American patients.

Usefulness of a mobile app to improve performance of specialists in responding correctly to CRC screening and surveillance clinical scenarios.

Background and study aims The adherence to and knowledge of physicians about colorectal cancer (CRC) screening and surveillance guidelines is still suboptimal, threatening the effectiveness of CRC screening. This study assessed the usefulness of a mobile decision support system (MDSS) to improve physician ability to recommend proper timing of and intervals for CRC screening and surveillance. Patients and methods This was a binational, single-blinded, randomized clinical trial including gastroenterologists and colorectal surgeons from Argentina and Uruguay. The specialists were invited to respond to a questionnaire with 10 CRC screening and surveillance clinical scenarios, randomized into two groups, with and without access to a dedicated app (CaPtyVa). The main outcome measure was the proportion of physicians correctly solving at least 60 % of the clinical cases according to local guidelines. Results A total of 213 physicians were included. The proportion of physicians responding correctly at least 60 % of the vignettes was higher in the app group as compared to the control group (90 % versus 56 %) (relative risk [RR] 1.6 95 % confidence interval [CI] 1.34-1.91). The performance was also higher in the app group for both vignette categories: CRC screening (93 % vs 75 % RR 1.24, 95 %CI 1.01-1.40) and surveillance (85 % vs 47 % RR 1.81 95 %CI 1.46-2.22), respectively. Physicians considered the app easy to use and of great utility in daily practice. Conclusions A MDSS was shown to be a useful tool that improved specialist performance in solving CRC screening and surveillance clinical scenarios. Its implementation in daily practice may facilitate the adherence of physicians to CRC screening and surveillance guidelines.

ENDOSCOPIC SUBMUCOSAL DISSECTION WITH CIRCUMFERENTIAL INCISION VERSUS TUNNELING METHOD FOR TREATMENT OF SUPERFICIAL ESOPHAGEAL CANCER.

BACKGROUND: Endoscopic submucosal dissection (ESD) of esophageal superficial neoplasm is associated with a high en bloc R0 resection rate and low recurrence. OBJECTIVE: We aim to compare the performance and clinical outcomes of ESD via ESD after circumferential incision (ESD-C) versus submucosal tunneling (ESD-T). METHODS: Single-center retrospective analysis of all consecutive patients who underwent ESD for superficial esophageal cancer, between 2009 and 2018. ESD-T was defined as the technique of making the mucosal incisions followed by submucosal tunneling in the oral to anal direction. ESD-C consisted of completing a circumferential incision followed by ESD. Main study outcomes included en bloc and R0 resection rates. Secondary outcomes included procedural characteristics, curative resection rate, local recurrence and adverse events. RESULTS: A total of 65 procedures (23 ESD-T and 42 ESD-C) were performed for ESCC (40; 61.5%) and BE-neoplasia (25; 38.5%). There were no statistically significant differences between patients who underwent ESD-T versus ESD-C in en bloc (91.3% vs 100%, P=0.12), R0 (65.2% vs 78.6%, P=0.24), curative resection rates (65.2% vs 73.8%, P=0.47) and mean procedure time (118.7 min with vs 102.4 min, P=0.35). Adverse events for ESD-T and ESD-C were as follows: bleeding (0 versus 2.4%; P=0.53), perforation (4.3% vs 0; P=0.61), esophageal stricture (8.7% versus 9.5%; P=0.31). Local recurrence was encountered in 8.7% after ESD-T and 2.4% after ESD-C (P=0.28) at a mean follow-up of 8 and 2.75 years, respectively (P=0.001). CONCLUSION: ESD-T and ESD-C appear to be equally effective with similar safety profiles for the management of superficial esophageal neoplasms.

Dissecção endoscópica submucosa com incisão circunferencial versus túnel submucoso no tratamento da neoplasia superficial do esôfago / Endoscopic submucosal dissection with circumferential incision versus tunneling method for treatment of superficial esophageal cancer

ABSTRACT BACKGROUND: Endoscopic submucosal dissection (ESD) of esophageal superficial neoplasm is associated with a high en bloc R0 resection rate and low recurrence. OBJECTIVE: We aim to compare the performance and clinical outcomes of ESD via ESD after circumferential incision (ESD-C) versus submucosal tunneling (ESD-T). METHODS: Single-center retrospective analysis of all consecutive patients who underwent ESD for superficial esophageal cancer, between 2009 and 2018. ESD-T was defined as the technique of making the mucosal incisions followed by submucosal tunneling in the oral to anal direction. ESD-C consisted of completing a circumferential incision followed by ESD. Main study outcomes included en bloc and R0 resection rates. Secondary outcomes included procedural characteristics, curative resection rate, local recurrence and adverse events. RESULTS: A total of 65 procedures (23 ESD-T and 42 ESD-C) were performed for ESCC (40; 61.5%) and BE-neoplasia (25; 38.5%). There were no statistically significant differences between patients who underwent ESD-T versus ESD-C in en bloc (91.3% vs 100%, P=0.12), R0 (65.2% vs 78.6%, P=0.24), curative resection rates (65.2% vs 73.8%, P=0.47) and mean procedure time (118.7 min with vs 102.4 min, P=0.35). Adverse events for ESD-T and ESD-C were as follows: bleeding (0 versus 2.4%; P=0.53), perforation (4.3% vs 0; P=0.61), esophageal stricture (8.7% versus 9.5%; P=0.31). Local recurrence was encountered in 8.7% after ESD-T and 2.4% after ESD-C (P=0.28) at a mean follow-up of 8 and 2.75 years, respectively (P=0.001). CONCLUSION: ESD-T and ESD-C appear to be equally effective with similar safety profiles for the management of superficial esophageal neoplasms.

RESUMO CONTEXTO: A dissecção endoscópica submucosa (DES) no tratamento da neoplasia superficial do esôfago está associada a uma alta taxa de ressecção R0 em bloco e baixa taxa de recorrência. OBJETIVO: O objetivo deste estudo é comparar o desempenho e os resultados clínicos da DES com incisão circunferencial (DES-C) versus com DES com túnel submucoso (DES-TS). MÉTODOS: Estudo retrospectivo de banco de dados coletados prospectivamente de um centro especializado em DES, investigando pacientes consecutivos submetidos à DES por câncer de esôfago superficial, entre 2009 e 2018. DES-TS foi definida como a técnica de realizar primeiro incisões na mucosa seguida de tunelamento submucoso no sentido oral para anal. DES-C consistiu em completar uma incisão circunferencial seguida da dissecção submucosa. As principais variáveis do estudo incluíram taxas de ressecção em bloco e R0. Os resultados secundários incluíram características do procedimento, taxa de ressecção curativa, recorrência local e eventos adversos. RESULTADOS: Um total de 65 procedimentos (23 DES-TS e 42 DES-C) foram realizados para CCE de esôfago (40; 61,5%) e neoplasia associada ao EB (25; 38,5%). Não houve diferenças estatisticamente significativas entre os pacientes submetidos a DES-TS versus DES-C nas taxas de ressecção em bloco (91,3% vs 100%, P=0,12), R0 (65,2% vs 78,6%, P=0,24), taxas de ressecção curativa (65,2% vs 73,8%, P=0,47) e tempo médio do procedimento (118,7 min com vs 102,4 min, P=0,35). Os eventos adversos para DES-TS e DES-C foram os seguintes: sangramento (0 vs 2,4%; P=0,53), perfuração (4,3% vs 0; P=0,61), estenose esofágica (8,7% vs 9,5%; P=0,31). A recorrência local foi encontrada em 8,7% após DES-TS e 2,4% após DES-C (P=0,28) em um seguimento médio de 8 e 2,75 anos, respectivamente (P=0,001). CONCLUSÃO: DES-TS e DES-C demostram ser igualmente eficazes com perfil de segurança semelhante para o tratamento das neoplasias superficiais do esôfago.

IS ENDOSCOPIC SUBMUCOSAL DISSECTION STILL LIMITED TO FEW TERTIARY CENTERS IN THE WEST? RESULTS FROM A NATIONAL SURVEY IN BRAZIL.

BACKGROUND: Endoscopic submucosal dissection (ESD) enables en bloc excision of superficial neoplasms. Although ESD is widely practiced in Eastern countries like Japan, South Korea and China, its use in the West is supposed to be still limited to few tertiary centers. OBJECTIVE: This study aimed to investigate the clinical practice of ESD in Brazil by means of an electronic questionnaire elaborated by the Brazilian Society of Digestive Endoscopy (SOBED). METHODS: In October 2019, 3512 endoscopist members of SOBED were invited to respond to an electronic survey containing 40 questions divided into four topics: operator profile; clinical experience with ESD; adverse events and training. Informed consent was requested to all participants. The investigators reviewed all responses and considered valid if more than 50% of the questions were answered and additional information, when requested, was provided. RESULTS: A total of 155 (4.4%) qualified responses entered the study. ESD has been practiced in 22 of 26 Federation States and majority of respondents (32.2%) have 10 to 20 years of practice. ESD has been performed more frequently in private hospitals (101 individuals, 66.9%) and private ambulatory centers (41 individuals, 27.1%). ESD was performed mainly in the stomach (72%), followed by the rectum (57%) and 80% of the individuals reported less than 25 operations. Twenty-four (15.4 %) individuals reported perforation and 4 (2.5%) of them reported postoperative deaths. Approximately a quarter of responders denied hands-on training in models or visit to training centers. CONCLUSION: ESD appears to be practiced throughout the country, not only in tertiary or academic institutions and mainly in private practice. Most operators received limited training and still are at the beginning of their learning curve. The reported adverse events and mortality rates appear to be higher than Eastern reports.

A dissecção endoscópica de submucosa ainda está limitada a poucos centros terciários no Ocidente? Resultados de uma pesquisa nacional no Brasil / Is endoscopic submucosal dissection still limited to few tertiary centers in the west? results from a national survey in brazil

ABSTRACT BACKGROUND: Endoscopic submucosal dissection (ESD) enables en bloc excision of superficial neoplasms. Although ESD is widely practiced in Eastern countries like Japan, South Korea and China, its use in the West is supposed to be still limited to few tertiary centers. OBJECTIVE: This study aimed to investigate the clinical practice of ESD in Brazil by means of an electronic questionnaire elaborated by the Brazilian Society of Digestive Endoscopy (SOBED). METHODS: In October 2019, 3512 endoscopist members of SOBED were invited to respond to an electronic survey containing 40 questions divided into four topics: operator profile; clinical experience with ESD; adverse events and training. Informed consent was requested to all participants. The investigators reviewed all responses and considered valid if more than 50% of the questions were answered and additional information, when requested, was provided. RESULTS: A total of 155 (4.4%) qualified responses entered the study. ESD has been practiced in 22 of 26 Federation States and majority of respondents (32.2%) have 10 to 20 years of practice. ESD has been performed more frequently in private hospitals (101 individuals, 66.9%) and private ambulatory centers (41 individuals, 27.1%). ESD was performed mainly in the stomach (72%), followed by the rectum (57%) and 80% of the individuals reported less than 25 operations. Twenty-four (15.4 %) individuals reported perforation and 4 (2.5%) of them reported postoperative deaths. Approximately a quarter of responders denied hands-on training in models or visit to training centers. CONCLUSION: ESD appears to be practiced throughout the country, not only in tertiary or academic institutions and mainly in private practice. Most operators received limited training and still are at the beginning of their learning curve. The reported adverse events and mortality rates appear to be higher than Eastern reports.

RESUMO CONTEXTO: A dissecção endoscópica da submucosa (ESD) é uma técnica popular no Japão e em outros países asiáticos e, supostamente, ainda está limitada a centros terciários no Ocidente. OBJETIVO: Este estudo teve como objetivo investigar a prática clínica da ESD no Brasil por meio de um questionário eletrônico elaborado pela Sociedade Brasileira de Endoscopia Digestiva (SOBED). MÉTODOS: Em outubro de 2019, 3512 endoscopistas membros da SOBED foram convidados a responder a uma pesquisa eletrônica contendo 40 questões divididas em quatro tópicos: perfil do operador; experiência clínica com ESD; eventos adversos e treinamento. O consentimento informado foi solicitado a todos os participantes. Os investigadores analisaram todas as respostas e consideraram válidas se mais de 50% das perguntas fossem respondidas e informações adicionais, quando solicitadas, fossem fornecidas. RESULTADOS: Um total de 155 (4,4%) respostas qualificadas foram incluídas no estudo. A ESD foi executada em 22 dos 26 estados da Federação e a maioria dos entrevistados (32,2%) possuía de 10 a 20 anos de prática endoscópica. A ESD foi realizada com maior frequência em hospitais privados (101 indivíduos; 66,9%) e clínicas ambulatoriais privadas (41 indivíduos; 27,1%). A ESD foi realizada principalmente no estômago (72%), seguido pelo reto (57%) e 80% dos indivíduos relataram menos de 25 operações. Vinte e quatro (15,4%) indivíduos relataram algum caso de perfuração no procedimento e 4 (2,5%) deles relataram óbito pós-operatório. Aproximadamente um quarto dos respondentes negou treinamento prático em modelos ou visita a centros de treinamento. CONCLUSÃO: A ESD parece ser praticada em todo o país, não apenas em instituições terciárias ou acadêmicas e principalmente na prática privada. A maioria dos respondedores recebeu treinamento limitado e ainda está no início da curva de aprendizado. Os eventos adversos relatados e as taxas de mortalidade parecem ser maiores do que os relatos orientais.

Unsedated Transnasal Endoscopy for Preoperative Examination of Bariatric Patients: a Prospective Study.

BACKGROUND: Esophagogastroduodenoscopy is a preoperative examination commonly required for candidates to bariatric surgery (BS). Overweight individuals have a greater risk of cardiorespiratory complications during endoscopy under sedation. This study aimed to investigate the feasibility, tolerance, and cardiovascular stress of transnasal endoscopy (TNE) without sedation in obese patients eligible for BS. METHODS: This prospective study enrolled obese adult patients with indication for BS that consented to undergo unsedated preoperative TNE. All examinations were carried out in an outpatient center. The outcomes assessed were endoscopic findings, procedural success, patients' tolerance according to a visual analogic scale, cardiovascular stress estimated by double product (i.e., systolic blood pressure × heart rate) and adverse events. Statistical analyses were used to compare each patient's double product among different examination periods. RESULTS: Ninety-four patients (77.6% female) completed the study, with an average body mass index (BMI) of 53 kg/m2 (range, 35-73.4 kg/m2). There were 63 super-obese individuals (67%), with BMI > 50 kg/m2. In 93 patients (98.9%), unsedated TNE was successfully completed up to the second part of the duodenum. TNE failed in one patient. Tolerance was rated as excellent or good in 95.7%. Minimal cardiovascular stress was noted in obese individuals, whereas the double product remained stable throughout the procedure in super-obese patients. Three patients (3.2%) had self-limited epistaxis. CONCLUSIONS: Unsedated TNE for preoperative endoscopic evaluation of obese patients is feasible, safe, and well tolerated and should be preferentially considered when examining super-obese patients.

POEM in Latin America: The Rise of a New Standard.

BACKGROUND: Per-oral endoscopic myotomy (POEM) has become the preferred alternative treatment to standard Heller myotomy for patients with esophageal achalasia, in Latin American countries. The aim of our study was to evaluate the efficacy and safety of a POEM in the management of achalasia with and without Chagas disease in patients receiving POEM. METHODS: Patients who underwent POEM from tertiary centers in Latin America were included in a dedicated registry. Countries included Brazil, Colombia, Ecuador, Mexico, Nicaragua, and Venezuela. Patients enrolled needed to have a preoperative manometry and swallow contrast study confirming achalasia. Clinical success was defined as significant improvement in Eckardt score after therapy. RESULTS: POEM was technically successful in 81/89 (91%) patients (mean age, 44 y). There was a significant decrease in preprocedure and postprocedure Eckardt score from 8.7 (range, 3 to 12) to 2.15 (0 to 10) (P<0.001), preprocedure and postprocedure barium swallow evaluation (98% vs. 89%; P=0.017), and preprocedure and postprocedure lower esophageal sphincter pressure measurement (from 35 to 13.8 mm Hg; P<0.001). Clinical success was achieved in 93% of patients. Patients with Chagas disease (n=58) were 9.5 times more likely to respond to POEM (P=0.0020; odds ratio, 9.5). CONCLUSIONS: POEM is an efficacious and safe therapeutic modality for treatment of achalasia in Latin America. Chagas disease-related achalasia seems to particularly respond better to POEM when it is performed by experienced endoscopists.

Ménétrièr disease in a pediatric patient with particular reference to echoendoscopy, endoscopic and anatomopathological presentation and evolutionary and therapeutic aspects / Doença de Ménétrier em paciente pediátrico com destaque para apresentação eco e endoscópica, anatomopatológica e aspectos evolutivos e de conduta

ABSTRACT Ménétrier's disease (MD) is included in the group of hypertrophic gastropathy; is a rare gastric hyperplasia that affects adults and children, with different behavior between these groups. We know that its etiology is related to allergens and co-infections. It's characterized by the hypertrophy of the gastric folds, with the appearance of cerebral convolutions on Upper Gastrointestinal Endoscopy (UGE) and, histologically, by the mucosal hypertrophy at the expense of foveolar hyperplasia and atrophy of the glands in body and fundus of the stomach. The UGE together with the gastric tissue biopsy confirms the diagnosis. What concerns us in the following case, however, is patient's long-lasting evolution, about eight years.

RESUMO Inclui-se a doença de Ménétrier (DM) no grupo das gastropatias hipertóficas, sendo uma hiperplasia gástrica rara que acomete adultos e crianças, com comportamento distinto entre esses grupos. Sabemos que sua etiologia relaciona-se com alérgenos e coinfecções. Caracteriza-se pela hipertrofia das pregas gástricas, com aspecto de circunvoluções cerebrais à endoscopia digestiva alta (EDA) e, histologicamente, pelo alargamento da mucosa às custas de hiperplasia foveolar e hipotrofia das glândulas em corpo e fundo gástrico. A EDA, junto à biópsia gástrica, confirma o diagnóstico. O que nos intriga no caso a seguir é o tempo evolução arrastado da paciente, cerca de oito anos.

Initial experience of endoscopic submucosal dissection in Brazil to treat early gastric and esophagheal cancer: a multi-institutional analysis.

OBJECTIVE: This study aimed to evaluate the feasibility and clinicopathological characteristics of early gastric and esophageal cancers treated with endoscopic submucosal dissection (ESD) at five centers in Brazil. METHODS: Five centers in Brazil reported their initial experience with ESD. The cases reported had already been collected by each center before pooled analysis. RESULTS: Were resected 62 gastric lesions; 52(83,8%) of the gastric lesions were well-differentiated adenocarcinoma, 31(50%) from the antrum, 24 (38.7%) type IIa. 51 (82.2%) lesions had en-block resection with three showing lateral margin compromise. Concerning invasion, 25 (40.3%) tumors were M1. Mean tumor diameter was 18.9 mm (range, 0.6-5.0 cm) and mean procedure duration was 119.45 minutes. Gastric perforation occurred in three (4.8%) patients. Mean follow-up duration was 11.3 months, with two local recurrences and one death from pneumonia Seven months after treatment. Of the 16 esophageal lesions resected, 14 (87.4%) were squamous cell carcinoma, 10 (62.5%) were located proximally and 8 (50.0%) type IIa. Mean tumor diameter was 23.8 mm (range, 6-60 mm). Thirteen (81.2%) lesions had en-block resection with five cases of lateral margin compromise. Eight (50.0%) lesions were M1. Mean procedure duration was 78 minutes (range, 20-150 min). Complications included pneumomediastinum in two (12.5%) patients and stenosis in one (6.2%). Mean duration of follow-up was 8.6 months, with no local recurrence despite the presence of lateral margin compromise. CONCLUSION: Different centers in Brazil feasibly perform ESD with a high success rate.

INITIAL EXPERIENCE OF ENDOSCOPIC SUBMUCOSAL DISSECTION IN BRAZIL TO TREAT EARLY GASTRIC AND ESOPHAGHEAL CANCER: a multi-institutional analysis

Objective This study aimed to evaluate the feasibility and clinicopathological characteristics of early gastric and esophageal cancers treated with endoscopic submucosal dissection (ESD) at five centers in Brazil. Methods Five centers in Brazil reported their initial experience with ESD. The cases reported had already been collected by each center before pooled analysis. Results Were resected 62 gastric lesions; 52(83,8%) of the gastric lesions were well-differentiated adenocarcinoma, 31(50%) from the antrum, 24 (38.7%) type IIa. 51 (82.2%) lesions had en-block resection with three showing lateral margin compromise. Concerning invasion, 25 (40.3%) tumors were M1. Mean tumor diameter was 18.9 mm (range, 0.6-5.0 cm) and mean procedure duration was 119.45 minutes. Gastric perforation occurred in three (4.8%) patients. Mean follow-up duration was 11.3 months, with two local recurrences and one death from pneumonia Seven months after treatment. Of the 16 esophageal lesions resected, 14 (87.4%) were squamous cell carcinoma, 10 (62.5%) were located proximally and 8 (50.0%) type IIa. Mean tumor diameter was 23.8 mm (range, 6-60 mm). Thirteen (81.2%) lesions had en-block resection with five cases of lateral margin compromise. Eight (50.0%) lesions were M1. Mean procedure duration was 78 minutes (range, 20-150 min). Complications included pneumomediastinum in two (12.5%) patients and stenosis in one (6.2%). Mean duration of follow-up was 8.6 months, with no local recurrence despite the presence of lateral margin compromise. Conclusion Different centers in Brazil feasibly perform ESD with a high success rate. .

Objectivo Este estudo tem como objetivo avaliar a viabilidade da técnica de dissecção endoscópica da submucosa (DES) no tratamento do câncer precoce do estômago e do esôfago, assim como as características clinicopatológicas dos pacientes tratados em diferentes centros no Brasil. Métodos Cinco centros no Brasil relataram sua experiência inicial com a técnica de DES. Os casos relatados vinham sendo coletados em cada serviço antes da análise agrupada dos dados. Resultados Foram ressecadas 62 lesões gástricas, sedo 52 (83,8%) adenocarcinoma bem diferenciado, 31 (50%) localizadas no antro e 24 (38.7%) do tipo macroscópico IIa. Foram ressecadas em monobloco 51 (82.2%) lesões, com 3 apresentando margem lateral comprometida. Quanto ao grau de invasão, 25 (40.3%) eram restritas ao epitélio da mucosa (M1). O diâmetro médio das lesões foi de 18.9 (6-50) mm, o tempo médio dos procedimentos foi de 119.45 minutos. A incidência de perfuração gástrica foi de 4,8% (três casos). O tempo médio de seguimento foi de 11.3 meses, com duas recorrências locais e uma morte por pneumonia 7 meses após o tratamento. Das 16 lesões esofágicas ressecadas, 14 (87.4%) eram carcinoma epidermóide, 10 (62.5%) localizados na porção proximal, 8 (50.0%) do tipo macroscópico IIa. O diâmetro médio das lesões foi de 23.8 (6-60) mm. Foram ressecadas em monobloco 13 (81.2%) lesões, sendo que 5 apresentaram margem lateral comprometida e 8 (50.0%) com invasão restrita a camada epitelial (M1). A duração média dos procedimentos foi de 78 (20-150) minutos. Dois (12.5%) pacientes tiveram pequeno pneumomediastino e um (6.2%) evoluiu com estenose esofágica. O tempo médio de seguimento foi de 8.6 meses, ...

Histopathologic correlation of endoscopic ultrasound findings of chronic pancreatitis in human autopsies.

OBJECTIVES: To provide histologic correlation of endoscopic ultrasound (EUS) findings believed to represent chronic pancreatitis (CP). METHODS: Eighteen postmortem pancreatic specimens in patients dying of all causes were examined in vitro by EUS for features of CP: (1) echogenic foci, (2) hypoechoic foci, (3) echogenic main pancreatic duct (MPD), (4) accentuated lobular pattern, (5) cysts, (6) irregular MPD, (7) dilated MPD, (8) side branch dilation, and (9) calculi. The pancreata were then examined by 2 pathologists (blinded to the EUS/clinical findings) for histopathologic features of CP. RESULTS: Six specimens were autolyzed, and in 1 specimen, MPD could not be seen by EUS. In the other 11 patients, 10 had evidence of CP by EUS (> or =3 features) and by histopathologic examination (> or =2 features). One patient did not have CP by both EUS and histologic examination. CONCLUSIONS: Endoscopic ultrasound accurately detected CP, when compared with histopathologic examination. The presence of 3 or more features of CP correlates with the histologic diagnosis of CP, however, up to 3 features are frequently present in elderly patients dying of all causes. Future studies should address the clinical relevance and the specificity of EUS findings of CP in the older population.