Complex Intrahepatic Lithiasis: A Case Report of Combined Treatment With Surgical Exploration of the Bilioenteric Anastomosis and Laser Lithotripsy by Cholangioscopy.

Intrahepatic lithiasis, or hepatolithiasis, is an endemic disease in southeast Asia, although, with immigration from Eastern countries, the incidence of this pathology is rising worldwide. The Latin American experience demonstrates morbidity and mortality compatible with other Western countries, but minimally invasive procedures are lacking. We demonstrate a case of a combined surgical and endoscopic approach for stone clearance. We present a case of a 47-year-old female patient with biliary enteric anastomosis to treat recurrent pyogenic cholangitis resulting from intrahepatic lithiasis. The patient was admitted to the emergency room, presented with a new episode of cholangitis, and submitted to transcutaneous hepatobiliary drainage. The multidisciplinary approach, including the endoscopic and surgical teams, successfully performed the stone clearance with laser lithotripsy and stone removal by open access. The postoperative period was uneventful, and the patient did not present any sign of recurrence after one year. A combined surgical and endoscopic approach achieved short-term clinical and technical success in this novel case. Moreover, individualizing cases requiring open surgical access is feasible, which allows a combined endoscopic approach with safety.

Endoscopic Ultrasound View of Pneumatosis Cystoides Intestinalis.

Pneumatosis cystoid intestinalis (PCI) is a rare condition, with a worldwide incidence of 0.3-1.2%. PCI is classified into primary (idiopathic) and secondary forms, with 15% and 85% of presentations, respectively. This pathology was associated with a wide variety of underlining etiologies to explain the abnormal accumulation of gas within the submucosa (69.9%), subserosa (25.5%), or both layers (4.6%). Many patients endure misdiagnosis, mistreatment, or even inadequate surgical exploration. In this case, a patient presented acute diverticulitis, after treatment, a control colonoscopy was performed that found multiple rounds and elevated lesions. To further study the subepithelial lesion (SEL), a colorectal endoscopic ultrasound (EUS) was performed with an overtube in the same procedure. For safe insertion of the curvilinear array EUS, an overtube with colonoscopy was positioned through the sigmoid as described by Cheng et al. The EUS evaluation evidenced air reverberation in the submucosal layer. The pathological analysis was consistent with PCI's diagnosis. The diagnosis of PCI is usually made by colonoscopy (51.9%), surgery (40.6%), and radiological findings (10.9%). Although the diagnosis can be made by radiological studies, a colorectal EUS and colonoscopy can be made in the same section without radiation and with high precision. As it is a rare disease, there are not enough studies to define the best approach, although colorectal EUS should be preferred for a reliable diagnosis.

Gastroesophageal Reflux Waning Over Time in Endoscopic Versus Surgical Myotomy for the Treatment of Achalasia: A Systematic Review and Meta-Analysis.

Peroral endoscopic myotomy (POEM) and Heller myotomy with fundoplication (HMF) effectively treat achalasia, an esophageal motor disease. Although a significant number of meta-analyses have compared POEM and HMF, these studies showed discrepant postoperative gastroesophageal reflux disease (GERD) conclusions. This review aimed to objectively compare GERD over time, as well as the efficiency, safety, and adverse events in POEM versus HMF for treating achalasia. We performed a systematic review and meta-analysis by searching Medline, Embase, Cochrane Library, Scopus, and Clinicaltrials.gov. The evaluated outcomes included early (within 12 months) and late (beyond 12 months) endoscopic assessment of GERD using the Lyon Consensus, clinical success, operative duration (OD), length of stay (LOS), and major adverse events (MAE). A total of 29 observational studies and two randomized clinical trials (RCTs) with 13,914 patients were included. GERD was 28% higher among RCTs discussing POEM at early assessment (95%CI 0.02, 0.54) and was not different at late evaluation (95% confidence interval (CI) = 0.00, 0.22). No difference in reflux was observed among observational studies in both periods. The clinical success was 9% higher (95% CI = 0.05, 0.12), and the OD was 37.74 minutes shorter (95% CI = -55.44, -20.04) in POEM among observational studies, whereas it was not different among RCTs. The LOS and MAE were similar in the groups. Comparisons among studies yielded divergent results. RCTs revealed that POEM had a higher incidence of GERD in the early assessment, whereas observational studies showed higher clinical success and a shorter OD in POEM. Ultimately, the between-group difference waned over time in GERD in all comparisons, resulting in no difference among RCTs in the late evaluation. Our meta-analysis demonstrated a non-preferential treatment of achalasia between endoscopic or surgical cardiomyotomy, prioritizing an individualized approach in the long term.

Anti-reflux versus conventional self-expanding metal stents in the palliation of esophageal cancer: A systematic review and meta-analysis.

Background and study aims Self-expanding metal stents (SEMS) are an effective palliative endoscopic therapy to reduce dysphagia in esophageal cancer. Gastroesophageal reflux disease (GERD) is a relatively common complaint after non-valved conventional SEMS placement. Therefore, valved self-expanding metal stents (SEMS-V) were designed to reduce the rate of GERD symptoms. We aimed to perform a systematic review and meta-analysis comparing the two stents. Material and methods This was a systematic review and meta-analysis including only randomized clinical trials (RCT) comparing the outcomes between SEMS-V and non-valved self-expanding metal stents (SEMS-NV) following the Preferred Reporting Items for Systematic Reviews and Meta-analysis guidelines. The risk of bias was assessed using the Cochrane Risk of Bias 2 tool. Data were analyzed with Review Manager Software. Quality of evidence was evaluated using Grading of Recommendations Assessment, Development, and Evaluation guidelines. Results Ten randomized clinical trials including a total of 467 patients, 234 in the SEMS-V group and 233 in the SEMS-NV group, were included. There were no statistically significant differences regarding GERD qualitative analysis (RD -0.17; 95 % CI -0.67, 0.33; P  = 0.5) and quantitative analysis (SMD -0.22; 95 % CI -0.53, 0.08; P  = 0.15) technical success (RD -0.03; 95 % CI -0.07, 0.01; P  = 0.16), dysphagia improvement (RD -0.07; 95 % CI -0.19, 0.06; P  = 0.30), and adverse events (RD 0.07; 95 % CI -0.07, 0.20; P  = 0.32). Conclusions Both SEMS-V and SEMS-NV are safe and effective in the palliation of esophageal cancer with similar rates of GERD, dysphagia relief, technical success, adverse events, stent migration, stent obstruction, bleeding, and improvement of the quality of life.

Endoscopic Resection Versus Surgery in the Treatment of Early Gastric Cancer: A Systematic Review and Meta-Analysis.

Background and Aim: Endoscopic resection (ER) is the preferred approach to treat early gastric cancer (EGC) in patients without suspected lymph node involvement and that meet the criteria for ER. Surgery is a more aggressive treatment, but it may be associated with less recurrence and the need for reintervention. Previous meta-analyses comparing ER with surgery for EGC did not incorporate the most recent studies, making accurate conclusions not possible. Methods: This systematic review and meta-analysis aimed to examine complete resection, length of hospital stay (LOHS), adverse events (AEs), serious AEs, recurrence, 5-year overall survival (OS), and 5-year cancer-specific survival (CSS) in patients with EGC. Results: A total of 29 cohorts studies involving 20559 patients were included. The ER (n = 7709) group was associated with a lower incidence of AEs (RD = -0.07, 95%CI = -0.1, -0.04, p < 0.0001) and shorter LOHS (95% CI -5.89, -5.32; p < 0,00001) compared to surgery (n = 12850). However, ER was associated with lower complete resection rates (RD = -0.1, 95%CI = -0.15, -0.06; p < 0.00001) and higher rates of recurrence (RD = 0.07, 95%CI = 0.06; p < 0.00001). There were no significant differences between surgery and ER in 5-year OS (RD = -0.01, 95%CI = -0.04, 0.02; p = 0.38), 5-year CSS (RD = 0.01, 95%CI = 0.00, 0.02; p < 0.17), and incidence of serious AEs (RD = -0.03, 95%CI = -0.08, 0.01; p = 0.13). Conclusions: ER and surgery are safe and effective treatments for EGC. ER provides lower rates of AEs and shorter LOHS compared to surgery. Although ER is associated with lower complete resection rates and a higher risk of recurrence, the OS and CSS were similar between both approaches. Systematic Review Registration: https://www.crd.york.ac.uk/PROSPERO/, identifier CRD42021255328.

Crescimento e estado nutricional d e adolescentesda rede pública estadual de ensino / Growth and nutritional status of adolescents of public education system

INTRODUCTION: The prevalence of obesity in children and adults has increased worldwide exponentially over the past two decades, becoming an important issue of global public health. OBJECTIVE: To describe the growth and nutritional status of adolescents of public schools. METHODS: Epidemiological, cross-sectional study, a representative sample of students aged 10 to 14 years of the public schools of the Metropolitan Region of Grande Vitória (MRGV), State of Espírito Santo, Brazil. Data on gender, age, skin colour/race, pubertal stage, socioeconomic class, weight and height were obtained. In the nutritional evaluation, the Height/Age (H/A) and Body Mass Index/Age (BMI/A) indexes, in z-score, of the WHO reference (2007) were considered. For statistical analysis, we used the Qui-square test and Student's t test (Mann-Whitney test for non-normal distribution), and significance level of p < 0.05. Study approved by the Institutional Research Ethics Committee. RESULTS: There were assessed 818 adolescents, with average age of 12.8 ± 1.1 years, female predominance (58.3%), mixed skin colour/race (41.7%), post-pubertal stage (53, 4%) and socioeconomic class C (59.5%). It was identified very low stature in 0.4% and low stature in 1.8% of adolescents. Overweight was diagnosed in 227 (27.7%) students, represented by overweight (18.7%), obesity (8.4%) and severe obesity (0.6%); While 0.2% presented severe thinness and 2.7% thinness. The mean z-score of girls' height (p = 0.024) was higher than the WHO reference, as well as the BMI z-score of girls (p = 0.0001) and boys (p = 0.0002). CONCLUSION: Adolescents of public schools of MRGV achieve adequate growth, even higher, on average, proposed by WHO (2007). However, they also present a high prevalence of overweight, indicating that the region is at an advanced stage of nutritional transition.

INTRODUÇÃO: A prevalência de obesidade em crianças e adultos tem aumentando de modo exponencial nas últimas duas décadas, configurando-se como importante problema de saúde pública global. OBJETIVO: Descrever o crescimento e o estado nutricional de adolescentes frequentadores de escolas públicas. MÉTODO: Estudo epidemiológico, transversal, com amostra representativa de estudantes (dez a 14 anos) da rede pública estadual da Região Metropolitana da Grande Vitória (RMGV), ES, Brasil. Obtidos dados referentes ao sexo, idade, cor/raça, estádio puberal, classe socioeconômica, peso e estatura. Na avaliação nutricional, foram considerados os índices de estatura para idade (E/I) e índice de massa corporal para idade (IMC/I), em escore z, do referencial da OMS (2007). Para análise estatística, utilizou-se o teste Qui-quadrado e t de Student (Mann-Whitney para distribuição não normal), e nível de significância de p < 0,05. Estudo aprovado pelo Comitê de Ética em Pesquisa Institucional. RESULTADOS: Avaliados 818 adolescentes, média de idade da amostra de 12,8 ± 1,1 anos, predomínio do sexo feminino (58,3%), cor/raça parda (41,7%), estádio pós-púbere (53,4%) e classe socioeconômica C (59,5%). Identificou-se muito baixa estatura em 0,4% e baixa estatura em 1,8% dos adolescentes. O excesso de peso foi diagnosticado em 227 (27,7%) estudantes, representado por sobrepeso (18,7%), obesidade (8,4%) e obesidade grave (0,6%); enquanto 0,2% e 2,7% deles apresentaram magreza acentuada e magreza, respectivamente. A média do escore z de estatura das meninas (p = 0,024) foi superior ao referencial da OMS, assim como a do escore z do IMC das meninas (p=0,0001) e dos meninos (p = 0,0002). CONCLUSÃO: Os adolescentes da rede pública estadual da RMGV já alcançam um crescimento adequado, inclusive superior, em média, ao proposto pela OMS (2007). Contudo, também apresentam prevalência elevada de excesso de peso, indicando que a Região está em fase avançada de transição nutricional.