Gastric cancer with concurrent pancreatic schwannoma: A case report.

BACKGROUND: The differential diagnosis of abdominal masses is somewhat troublesome, especially when there is a malignancy to be evaluated. We report herein a unique case of gastric adenocarcinoma concurrent with a pancreatic schwannoma. Correct assessment of intraoperative findings is essential for adequate tumor staging and to decide the proper management of a concurrent pancreatic lesion. CASE SUMMARY: Computed tomography scan performed for gastric cancer staging revealed a solid and cystic pancreatic mass that had no signs of local invasiveness. Surgical resection of the pancreas was decided preoperatively since a radical approach of the gastric tumor could be performed. There were no signs of distant metastases, and the large pancreatic mass was in contact with the posterior gastric wall. Histopathological study revealed a pancreatic schwannoma, which is an uncommon neoplasm that arises from Schwann cells around peripheral nerves. CONCLUSION: Therefore, pancreatic masses deserve special attention regarding the differential diagnosis in patients with gastric cancer. The presence of a large pancreatic mass should not preclude the potentially curative intent of the gastric cancer treatment.

Endoscopic retrograde cholangiopancreatography versus endoscopic ultrasound for tissue diagnosis of malignant biliary stricture: Systematic review and meta-analysis.

BACKGROUND AND AIMS: There are no systematic reviews comparing the use of endoscopic retrograde cholangiopancreatography (ERCP)-based brush cytology and forceps biopsy and endoscopic ultrasound (EUS)-guided fine-needle aspiration (FNA) for the diagnosis of malignant biliary stricture; so in this revision, we will compare ERCP against EUS-FNA for tissue diagnosis of malignant biliary stricture. DESIGN: A systematic review was conducted of comparative studies (prospective or retrospective) analyzing EUS and ERCP for tissue diagnosis of malignant biliary stricture. MATERIALS AND METHODS: The databases Medline, EMBASE, Cochrane, LILACS, CINAHL, and Scopus were searched for studies dated previous to November 2014. We identified three prospective studies comparing EUS-FNA and ERCP for the diagnosis of malignant biliary stricture and five prospective studies comparing EUS-FNA with the same diagnosis of the other three studies. All patients were subjected to the same gold standard method. We calculated study variables (sensitivity, specificity, prevalence, positive and negative predictive values, and accuracy) and performed a meta-analysis using the Review Manager (RevMan) 5.3 software. RESULTS: A total of 294 patients were included in the analysis. The pretest probability for malignant biliary stricture was 76.66%. The mean sensitivities of ERCP and EUS-FNA for tissue diagnosis of malignant biliary stricture were 49% and 75%, respectively; the specificities were 96.33% and 100%, respectively. The posttest probabilities positive predictive value (98.33% and 100%, respectively) and negative predictive value (34% and 47%, respectively) were determined. The accuracies were 60.66% and 79%, respectively. CONCLUSION: We found that EUS-FNA was superior to ERCP with brush cytology and forceps biopsy for diagnosing malignant biliary strictures. However, a negative EUS-FNA or ERCP test may not exclude malignant biliary stricture because both have low negative posttest probabilities.

Guide wire-assisted cannulation versus conventional contrast to prevent pancreatitis: A systematic review and meta-analysis based on randomized control trials / Canulación asistida por alambre guía versus contraste convencional para prevenir la pancreatitis: Una revisión sistemática y meta-análisis basados en ensayos aleatorios controlados

Objective: Through this systematic review and meta-analysis, we aim to clarify the differences between these two techniques, thus improving primary success cannulation and reducing complications during endoscopic retrograde cholangiopancreatography, primarily pancreatitis. Methods: A comprehensive search was conducted to search for data available up until June2015from the most important databases available in the health field: EMBASE, MEDLINE (via PubMed), Cochrane, LILACS and CENTRAL (via BVS), SCOPUS, the CAPES database (Brazil), and gray literature. Results: Nine randomized clinical trialsincluding2583 people were selected from20,198 studies for meta-analysis. Choledocholithiasis had been diagnosed in mostly (63.8%) of the patients, who were aged an average of 63.15 years. In those patients treated using the guide wire-assisted cannulation technique, provided a significantly lower instance of pancreatitis (RD=0.03; 95% CI: 0.01-0.05; I2= 45%) and greater primary success cannulation (RD=0.07; 95% CI: 0.03-0.12; I2=12%) than conventional contrast cannulation. Conclusions: The guide wire-assisted technique, when compared to the conventional contrast technique, reduces the risk of pancreatitis and increases primary success cannulation rate. Thus, guide wire-assisted cannulation appears to be the most appropriate first-line cannulation technique

Objetivo: A través de esta revisión sistemática y meta-análisis, nuestro objetivo es aclarar las diferencias entre estas dos técnicas, mejorando así la canulación de éxito primario y reducir las complicaciones durante la colangiopancreatografía retrógrada endoscópica, principalmente la pancreatitis. Métodos: Una búsqueda exhaustiva se realizó para buscar datos disponibles hasta junio de 2015, desde las bases de datos más importantes disponibles en el campo de la salud: EMBASE, MEDLINE (vía PubMed), Cochrane, LILACS y CENTRAL (a través de la BVS), SCOPUS, la base de datos CAPES (Brasil), y la literatura gris. Resultados: Nueve ensayos clínicos aleatorios incluyendo 2583 personas fueron seleccionados de 20198 estudios de meta- análisis. Coledocolitiasis había sido diagnosticada en su mayoría (63,8%) de los pacientes, que tenían entre un promedio de 63,15 años. En los pacientes tratados con la técnica de canulación guiada, proporcionado una instancia significativamente menor de pancreatitis (RD=0,03; IC del 95%: 0,01-0,05; I2=45%) y una mayor canalización de éxito primario (RD=0,07; IC del 95%: 0,03-0.12; I2=12%) que la canulación por contraste. Conclusiones: La técnica canulación con alambre guía, en comparación a la técnica de contraste convencional, reduce el riesgo de pancreatitis y aumenta la tasa de canulación con éxito primario. Por lo tanto, canulación con alambre guía parece ser la técnica de canulación de primera línea y la más adecuada

Endoscopic versus surgical approach in the treatment of Zenker's diverticulum: systematic review and meta-analysis.

BACKGROUND: Zenker's diverticulum is a rare disease in the general population. Its treatment can be carried out by either an endoscopic or surgical approach. The objective of this study was to systematically identify all reports that compare both treatment modalities and to assess the outcomes in terms of length of procedure, length of hospitalization, time until diet introduction, complication rates, and recurrence rates. METHODS: A search of Medline and Embase selected all studies that compared different methods of surgical and endoscopic treatment for Zenker's diverticulum published in the English, Portuguese, and Spanish languages between 1975 and 2014. The meta-analysis was developed in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) statement. Data were extracted and analyzed for five different outcomes. RESULTS: Eleven studies met the inclusion criteria, describing outcomes of endoscopic versus surgical treatment for 596 patients with Zenker's diverticulum. A meta-analysis of the studies suggested a statistically significant reduction in operating time and length of hospitalization, favoring endoscopic treatment (standardized mean difference (SMD) - 78.06, 95 %CI - 90.63, - 65.48 and SMD - 3.72, 95 %CI - 4.49, - 2.95, respectively), just as with the reduction in the fasting period (SMD - 4.30, 95 %CI - 5.18, - 3.42) and risk of complications (SMD - 0.09, 95 %CI 0.03, 0.43) for patients who had undergone the endoscopic approach in comparison with the surgical group. Also, a statistically significant reduction in the risk of symptom recurrence was seen when the treatment of Zenker's diverticulum was carried out by a surgical approach compared with endoscopic treatment (SMD 0.08, 95 %CI 0.03, 0.13). CONCLUSION: Compared with a surgical approach, endoscopic treatment appeared to result in a shorter length of procedure and hospitalization, earlier diet introduction, and lower rates of complications, but in higher rates of symptom recurrence.

Percutaneous endoscopic versus surgical gastrostomy in patients with benign and malignant diseases: a systematic review and meta-analysis.

To compare the complications and mortality related to gastrostomy procedures performed using surgical and percutaneous endoscopic gastrostomy techniques, this review covered seven studies. Five of these were retrospective and two were randomized prospective studies. In total, 406 patients were involved, 232 of whom had undergone percutaneous endoscopic gastrostomy and 174 of whom had undergone surgical gastrostomy. The analysis was performed using Review Manager. Risk differences were computed using a fixed-effects model and forest and funnel plots. Data on risk differences and 95% confidence intervals were obtained using the Mantel-Haenszel test. There was no difference in major complications in retrospective (95% CI (-0.11 to 0.10)) or randomized (95% CI (-0.07 to 0.05)) studies. Regarding minor complications, no difference was found in retrospective studies (95% CI (-00.17 to 0.09)), whereas a difference was observed in randomized studies (95% CI (-0.25 to -0.02)). Separate analyses of retrospective and randomized studies revealed no differences between the methods in relation to mortality and major complications. Moreover, low levels of minor complications were observed among endoscopic procedures in randomized studies, with no difference observed compared with retrospective studies.

Percutaneous endoscopic versus surgical gastrostomy in patients with benign and malignant diseases: a systematic review and meta-analysis

To compare the complications and mortality related to gastrostomy procedures performed using surgical and percutaneous endoscopic gastrostomy techniques, this review covered seven studies. Five of these were retrospective and two were randomized prospective studies. In total, 406 patients were involved, 232 of whom had undergone percutaneous endoscopic gastrostomy and 174 of whom had undergone surgical gastrostomy. The analysis was performed using Review Manager. Risk differences were computed using a fixed-effects model and forest and funnel plots. Data on risk differences and 95% confidence intervals were obtained using the Mantel-Haenszel test. There was no difference in major complications in retrospective (95% CI (-0.11 to 0.10)) or randomized (95% CI (-0.07 to 0.05)) studies. Regarding minor complications, no difference was found in retrospective studies (95% CI (-00.17 to 0.09)), whereas a difference was observed in randomized studies (95% CI (-0.25 to -0.02)). Separate analyses of retrospective and randomized studies revealed no differences between the methods in relation to mortality and major complications. Moreover, low levels of minor complications were observed among endoscopic procedures in randomized studies, with no difference observed compared with retrospective studies.

Endoscopic versus surgical treatment of ampullary adenomas: a systematic review and meta-analysis.

The aim of this study is to address the outcomes of endoscopic resection compared with surgery in the treatment of ampullary adenomas. A systematic review and meta-analysis were performed according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) recommendations. For this purpose, the Medline, Embase, Cochrane, Literatura Latino-Americana e do Caribe em Ciências da Saúde (LILACS), Scopus and Cumulative Index to Nursing and Allied Health Literature (CINAHL) databases were scanned. Studies included patients with ampullary adenomas and data considering endoscopic treatment compared with surgery. The entire analysis was based on a fixed-effects model. Five retrospective cohort studies were selected (466 patients). All five studies (466 patients) had complete primary resection data available and showed a difference that favored surgical treatment (risk difference [RD] = -0.24, 95% confidence interval [CI] = -0.44 to -0.04). Primary success data were identified in all five studies as well. Analysis showed that the surgical approach outperformed endoscopic treatment for this outcome (RD = -0.37, 95% CI = -0.50 to -0.24). Recurrence data were found in all studies (466 patients), with a benefit indicated for surgical treatment (RD = 0.10, 95% CI = -0.01 to 0.19). Three studies (252 patients) presented complication data, but analysis showed no difference between the approaches for this parameter (RD = -0.15, 95% CI = -0.53 to 0.23). Considering complete primary resection, primary success and recurrence outcomes, the surgical approach achieves significantly better results. Regarding complication data, this systematic review concludes that rates are not significantly different.

Endoscopic versus surgical treatment of ampullary adenomas: a systematic review and meta-analysis

The aim of this study is to address the outcomes of endoscopic resection compared with surgery in the treatment of ampullary adenomas. A systematic review and meta-analysis were performed according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) recommendations. For this purpose, the Medline, Embase, Cochrane, Literatura Latino-Americana e do Caribe em Ciências da Saúde (LILACS), Scopus and Cumulative Index to Nursing and Allied Health Literature (CINAHL) databases were scanned. Studies included patients with ampullary adenomas and data considering endoscopic treatment compared with surgery. The entire analysis was based on a fixed-effects model. Five retrospective cohort studies were selected (466 patients). All five studies (466 patients) had complete primary resection data available and showed a difference that favored surgical treatment (risk difference [RD] = -0.24, 95% confidence interval [CI] = -0.44 to -0.04). Primary success data were identified in all five studies as well. Analysis showed that the surgical approach outperformed endoscopic treatment for this outcome (RD = -0.37, 95% CI = -0.50 to -0.24). Recurrence data were found in all studies (466 patients), with a benefit indicated for surgical treatment (RD = 0.10, 95% CI = -0.01 to 0.19). Three studies (252 patients) presented complication data, but analysis showed no difference between the approaches for this parameter (RD = -0.15, 95% CI = -0.53 to 0.23). Considering complete primary resection, primary success and recurrence outcomes, the surgical approach achieves significantly better results. Regarding complication data, this systematic review concludes that rates are not significantly different.

Guide wire-a sisted cannulation versus conventional contrast to prevent pancreatitis. A systematic review and meta-analysis based on randomized control trials.

OBJECTIVE: Through this systematic review and meta-analysis, we aim to clarify the differences between these two techniques, thus improving primary success cannulation and reducing complications during endoscopic retrograde cholangiopancreatography, primarily pancreatitis. METHODS: A comprehensive search was conducted to search for data available up until June2015from the most important databases available in the health field: EMBASE, MEDLINE (via PubMed), Cochrane, LILACS and CENTRAL (via BVS), SCOPUS, the CAPES database (Brazil), and gray literature. RESULTS: Nine randomized clinical trialsincluding2583 people were selected from20,198 studies for meta-analysis. Choledocholithiasis had been diagnosed in mostly (63.8%) of the patients, who were aged an average of 63.15 years. In those patients treated using the guide wire-assisted cannulation technique, provided a significantly lower instance of pancreatitis (RD=0.03; 95% CI: 0.01-0.05; I2= 45%) and greater primary success cannulation (RD=0.07; 95% CI: 0.03-0.12; I2=12%) than conventional contrast cannulation. CONCLUSIONS: The guide wire-assisted technique, when compared to the conventional contrast technique, reduces the risk of pancreatitis and increases primary success cannulation rate. Thus, guide wire-assisted cannulation appears to be the most appropriate first-line cannulation technique.

Endoscopy vs surgery in the treatment of early gastric cancer: Systematic review.

AIM: To report a systematic review, establishing the available data to an unpublished 2a strength of evidence, better handling clinical practice. METHODS: A systematic review was performed using MEDLINE, EMBASE, Cochrane, LILACS, Scopus and CINAHL databases. Information of the selected studies was extracted on characteristics of trial participants, inclusion and exclusion criteria, interventions (mainly, mucosal resection and submucosal dissection vs surgical approach) and outcomes (adverse events, different survival rates, mortality, recurrence and complete resection rates). To ascertain the validity of eligible studies, the risk of bias was measured using the Newcastle-Ottawa Quality Assessment Scale. The analysis of the absolute risk of the outcomes was performed using the software RevMan, by computing risk differences (RD) of dichotomous variables. Data on RD and 95%CIs for each outcome were calculated using the Mantel-Haenszel test and inconsistency was qualified and reported in χ(2) and the Higgins method (I (2)). Sensitivity analysis was performed when heterogeneity was higher than 50%, a subsequent assay was done and other findings were compiled. RESULTS: Eleven retrospective cohort studies were selected. The included records involved 2654 patients with early gastric cancer that filled the absolute or expanded indications for endoscopic resection. Three-year survival data were available for six studies (n = 1197). There were no risk differences (RD) after endoscopic and surgical treatment (RD = 0.01, 95%CI: -0.02-0.05, P = 0.51). Five-year survival data (n = 2310) showed no difference between the two groups (RD = 0.01, 95%CI: -0.01-0.03, P = 0.46). Recurrence data were analized in five studies (1331 patients) and there was no difference between the approaches (RD = 0.01, 95%CI: -0.00-0.02, P = 0.09). Adverse event data were identified in eight studies (n = 2439). A significant difference was detected (RD = -0.08, 95%CI: -0.10--0.05, P < 0.05), demonstrating better results with endoscopy. Mortality data were obtained in four studies (n = 1107). There was no difference between the groups (RD = -0.01, 95%CI: -0.02-0.00, P = 0.22). CONCLUSION: Three-, 5-year survival, recurrence and mortality are similar for both groups. Considering complication, endoscopy is better and, analyzing complete resection data, it is worse than surgery.

Endoscopic stenting for inoperable malignant biliary obstruction: A systematic review and meta-analysis.

AIM: To analyze through meta-analyses the benefits of two types of stents in the inoperable malignant biliary obstruction. METHODS: A systematic review of randomized clinical trials (RCT) was conducted, with the last update on March 2015, using EMBASE, CINAHL (EBSCO), MEDLINE, LILACS/CENTRAL (BVS), SCOPUS, CAPES (Brazil), and gray literature. Information of the selected studies was extracted in sight of six outcomes: primarily regarding dysfunction, complication and re-intervention rates; and secondarily costs, survival, and patency time. The data about characteristics of trial participants, inclusion and exclusion criteria and types of stents were also extracted. The bias was mainly assessed through the JADAD scale. This meta-analysis was registered in the PROSPERO database by the number CRD42014015078. The analysis of the absolute risk of the outcomes was performed using the software RevMan, by computing risk differences (RD) of dichotomous variables and mean differences (MD) of continuous variables. Data on RD and MD for each primary outcome were calculated using the Mantel-Haenszel test and inconsistency was qualified and reported in χ (2) and the Higgins method (I (2)). Sensitivity analysis was performed when heterogeneity was higher than 50%, a subsequent assay was done and other findings were compiled. Student's t-test was used for the comparison of weighted arithmetic means regarding secondary outcomes. RESULTS: Initial searching identified 3660 studies; 3539 were excluded through title, repetition, and/or abstract, while 121 studies were fully assessed and were excluded mainly because they did not compare self-expanding metal stents (SEMS) and plastic stents (PS), leading to thirteen RCT selected, with 13 articles and 1133 subjects meta-analyzed. The mean age was 69.5 years old, that were affected mostly by bile duct (proximal) and pancreatic tumors (distal). The preferred SEMS diameter used was the 10 mm (30 Fr) and the preferred PS diameter used was 10 Fr. In the meta-analysis, SEMS had lower overall stent dysfunction compared to PS (21.6% vs 46.8%, P < 0.00001) and fewer re-interventions (21.6% vs 56.6%, P < 0.00001), with no difference in complications (13.7% vs 15.9%, P = 0.16). In the secondary analysis, the mean survival rate was higher in the SEMS group (182 d vs 150 d, P < 0.0001), with a higher patency period (250 d vs 124 d, P < 0.0001) and a lower cost per patient (4193.98 vs 4728.65 Euros, P < 0.0985). CONCLUSION: SEMS are associated with lower stent dysfunction, lower re-intervention rates, better survival, and higher patency time. Complications and costs showed no difference.

Minute type I gastric carcinoid with regional lymph node metastasis.

Type I gastric carcinoids are indolent lesions that only rarely metastasize. Until now, lymph node metastasis had only being observed in large (≥10 mm) and usually invasive lesions (deep submucosa or beyond). This study reports a diminutive (8 mm) gastric carcinoid, limited to the superficial layer of the submucosa (sm1), with no angiovascular invasion, but with a high Ki-67 index (7%) and an involved perigastric lymph node. The aggressive behavior of this lesion ends the previous believe that small and superficial type I gastric carcinoids do not metastasize. This case also indicates that better parameters are necessary to evaluate the malignant potential of these lesions and presents a further support to the value of 2010 World Health Organization classification of gastrointestinal neuroendocrine tumors.

Inguinal hernia orifice for specimen extraction after laparoscopic resections.

Specimen extraction is an unavoidable step in all laparoscopic resections. To this day there is no standardized retrieval incision for each procedure and the choice is made individually, yet based on the surgeon's experience and preference. Additionally, worldwide prevalence of inguinal hernia is high and many patients with this condition require surgical intervention for a distinct reason. In these particular cases, the hernia orifice can be seeing as an opportunity, allowing specimen retrieval when an open repair is performed immediately after the laparoscopic resection. In the present article, the authors propose this new option. Three patients who underwent this technique are also presented. Discussion is focused on the advantages and critics of the approach.

GIST e adenocarcinoma gástrico sincrônicos: relato de caso e revisão da literatura / Synchronous gastric GIST and adenocarcinoma: case report and literature review

INTRODUÇÃO: Tumores estromais gastrointestinais (GISTs) são neoplasias mesenquimais incomuns que afetam o trato gastrointestinal. Existem poucos relatos na literatura da ocorrência sincrônica de tumores mesenquimais e outros tumores primários gastrointestinais. RELATO DO CASO: Paciente de 61 anos do sexo feminino que procurou o serviço com queixa de dor abdominal iniciada há 2 anos. No exame físico palpava-se uma massa de 10 cm no abdome superior. A tomografia evidenciou massa em contato com a grande curvatura gástrica sem linfonodomegalias. Na endoscopia foi identificada apenas na pequena curvatura lesão na mucosa com 2 cm cuja biópsia demonstrou tratar-se de adenocarcinoma. Foi realizado ultra-som endoscópico que demonstrou que a lesão na pequena curvatura estava restrita à camada muscular e também visualizou-se lesão na grande curvatura originária da 4º camada ultra-sonográfica gástrica (muscular). Com esse diagnóstico e estadiamento a paciente foi submetida à gastrectomia total com linfadenectomia D2 e anastomose esôfago-jejunal em Y-de-Roux. O exame anatomopatológico demonstrou que a lesão na pequena curvatura correspondia a um adenocarcinoma microtubular restrito a camada muscular e a lesão na grande curvatura um GIST de alto grau. O estadiamento TNM final foi T2N1M0. A paciente evoluiu sem intercorrências recebendo alta no 11º pós-operatório CONCLUSÃO: A ocorrência sincrônica de GISTs e outros tumores gastrointestinais têm ocorrido com mais freqüência do que antes se considerava. Embora este fato pareça ser apenas uma coincidência sua ocorrência pode envolver agentes carcinogênicos comuns.

BACKGROUND: Gastrointestinal stromal tumors (GISTs) are an uncommon mesenchymal neoplasm affecting the GI tract. The synchronous occurrence of mesenchymal tumors and other primary gastrointestinal malignancies have been rarely reported in the literature. CASE REPORT: A 61 year-old female patient came to our department complaining of diffuse abdominal pain, which had begun 2 years ago. At physical examination a mass with approximately 10 cm, located in the upper abdomen, was palpable. A CT scan demonstrated a mass in contact with the greater gastric curvature without lymphnodal enlargement. At endoscopy, no lesions were seen in the greater curvature, but a 2,0 cm mucosal lesion was visualized in the upper portion of the lesser curvature. The biopsy of the lesion in the lesser curvature was positive for adenocarcinoma. An endoscopic ultrasound was performed and demonstrated that the lesion in the lesser curvature was restricted to the gastric muscular layer and the mass in the greater curvature was originated from the gastric fourth ultrasonographic layer (muscular). The patient was submitted to a total gastrectomy with D2 lymphadenectomy and a Y of Roux esophago-jejunal anastomosis. The pathological exam demonstrated that the lesion in the lesser curvature was a microtubular adenocarcinoma restricted to the muscular layer. The lesion in the greater curvature was a high grade GIST. The final TNM stage was T2N1M0. The patient recovery was uneventful being discharged from the hospital after 11 days. CONCLUSION: The synchronous occurrence of GISTs and other gastrointestinal malignanies is more common than has been considered. Although the synchronous occurrence of GIST and other abdominal malignancies seems to be just a coincidence, the development of these tumors may involve common carcinogenic agents.