Validation of classic and expanded criteria for endoscopic submucosal dissection of early gastric cancer: 7 years of experience in a Western tertiary cancer center.

OBJECTIVE: Our aim was to evaluate the Japan Gastroenterological Endoscopy Society criteria for endoscopic submucosal resection of early gastric cancer (EGC) based on the experience in a Brazilian cancer center. METHODS: We included all patients who underwent endoscopic submucosal resection for gastric lesions between February 2009 and October 2016. Demographic data and information regarding the endoscopic resection, pathological report and follow-up were obtained. Statistical calculations were performed with Fisher's exact test and chi-square tests, with 95% confidence intervals. RESULTS: In total, 76% of the 51 lesions were adenocarcinomas, 16% were adenomas, and 8% had other diagnoses. The average size was 19.9 mm (±11.7). The average procedure length was 113.9 minutes (±71.4). The complication rate was 21.3%, with only one patient who needed surgical treatment (transmural perforation). Among the adenocarcinomas, 39.5% met the classic criteria for curability, 31.6% met the expanded criteria and 28.9% met the criteria for noncurative resection. Analysis of the indication criteria and curability revealed differences among cases with "only-by-size" expanded criteria (64.28%), other expanded criteria (40%) and classic criteria (89.47%), with a p-value of 0.049. During follow-up (15.8 months; ±14.3), 86.1% of the EGC patients had no recurrence. When well-differentiated and poorly differentiated lesions or lesions included in the classic and expanded criteria were compared, there were no differences in recurrence. The noncurative group presented a higher recurrence rate than the classic group (p=0.014). CONCLUSION: These results suggest that the Japanese endoscopic submucosal resection criteria might be useful for endoscopic treatment of EGC in Western countries.

Validation of classic and expanded criteria for endoscopic submucosal dissection of early gastric cancer: 7 years of experience in a Western tertiary cancer center

OBJECTIVE: Our aim was to evaluate the Japan Gastroenterological Endoscopy Society criteria for endoscopic submucosal resection of early gastric cancer (EGC) based on the experience in a Brazilian cancer center. METHODS: We included all patients who underwent endoscopic submucosal resection for gastric lesions between February 2009 and October 2016. Demographic data and information regarding the endoscopic resection, pathological report and follow-up were obtained. Statistical calculations were performed with Fisher's exact test and chi-square tests, with 95% confidence intervals. RESULTS: In total, 76% of the 51 lesions were adenocarcinomas, 16% were adenomas, and 8% had other diagnoses. The average size was 19.9 mm (±11.7). The average procedure length was 113.9 minutes (±71.4). The complication rate was 21.3%, with only one patient who needed surgical treatment (transmural perforation). Among the adenocarcinomas, 39.5% met the classic criteria for curability, 31.6% met the expanded criteria and 28.9% met the criteria for noncurative resection. Analysis of the indication criteria and curability revealed differences among cases with "only-by-size" expanded criteria (64.28%), other expanded criteria (40%) and classic criteria (89.47%), with a p-value of 0.049. During follow-up (15.8 months; ±14.3), 86.1% of the EGC patients had no recurrence. When well-differentiated and poorly differentiated lesions or lesions included in the classic and expanded criteria were compared, there were no differences in recurrence. The noncurative group presented a higher recurrence rate than the classic group (p=0.014). CONCLUSION: These results suggest that the Japanese endoscopic submucosal resection criteria might be useful for endoscopic treatment of EGC in Western countries.

II Brazilian consensus statement on endoscopic ultrasonography.

BACKGROUND AND OBJECTIVES: At the time of its introduction in the early 80s, endoscopic ultrasonography (EUS) was indicated for diagnostic purposes. Recently, EUS has been employed to assist or to be the main platform of complex therapeutic interventions. METHODS: From a series of relevant new topics in the literature and based on the need to complement the I Brazilian consensus on EUS, twenty experienced endosonographers identified and reviewed the pertinent literature in databases. The quality of evidence, strength of recommendations, and level of consensus were graded and voted on. RESULTS: Consensus was reached for eight relevant topics: treatment of gastric varices, staging of nonsmall cell lung cancer, biliary drainage, tissue sampling of subepithelial lesions (SELs), treatment of pancreatic fluid collections, tissue sampling of pancreatic solid lesions, celiac neurolysis, and evaluation of the incidental pancreatic cysts. CONCLUSIONS: There is a high level of evidence for staging of nonsmall cell lung cancer; biopsy of SELs as the safest method; unilateral and bilateral injection techniques are equivalent for EUS-guided celiac neurolysis, and in patients with visible ganglia, celiac ganglia neurolysis appears to lead to better results. There is a moderate level of evidence for: yield of tissue sampling of pancreatic solid lesions is not influenced by the needle shape, gauge, or employed aspiration technique; EUS-guided and percutaneous biliary drainage present similar clinical success and adverse event rates; plastic and metallic stents are equivalent in the EUS-guided treatment of pancreatic pseudocyst. There is a low level of evidence in the routine use of EUS-guided treatment of gastric varices.

Endoscopic gastric submucosal dissection: experimental comparative protocol between standard technique and Hybrid-Knife(r) / Dissecção endoscópica submucosa gástrica: protocolo experimental comparativo entre a técnica convencional e o Hybrid-Knife(r)

ABSTRACT Background Endoscopic treatment of superficial gastrointestinal tumors is routinely performed, however the advantages and shortcomings of submucosal pressure-jet dissection is still debated. Objective - Aiming to compare this technique with conventional submucosal dissection, a study was designed in pigs. Methods - Areas of the antral mucosa of the stomach with a diameter of 2 cm2 (6 per animal) were marked, and resected by means of the hybrid-knife (experimental technique), and Flush-knife or IT-knife (controls). An ERBE ICC 300 electrosurgical unit was adopted. End-points were procedural time, complications, and quality of the resected specimen. Results - A total of 27 interventions were conducted in five animals. Time spent with the two options was quite short, and similar: 9.5±3.1 vs 8.0±3.0 minutes (P=0.21). Complications didn't differ (three per group, not significant), and removed specimen looked adequate in both circumstances. Conclusion - The hybrid-knife technique is an acceptable alternative to submucosal dissection, showing no difference compared to the standard technique taking into consideration the procedure, the presence of complications and the quality of the resected specimen.

RESUMO Contexto O tratamento endoscópico de tumores gastrointestinais superficiais é realizado rotineiramente, no entanto as vantagens e deficiências da dissecção submucosa com jato de pressão ainda é debatido. Objetivo - Visando comparar esta técnica com dissecção submucosa convencional, um estudo foi realizado em suínos. Métodos - Áreas da mucosa antral do estômago com um diâmetro de 2 cm2 (um total de 6 por animal) foram marcadas, e a ressecção através do hybrid-knife (técnica experimental), e do Flush-knife ou IT-knife (controles). Uma unidade eletro cirúrgica ERBE ICC 300 foi adotada. Os desfechos foram: tempo do procedimento, complicações e qualidade da amostra ressecada. Resultados - Um total de 27 intervenções foram realizadas em cinco animais. O tempo gasto com as duas técnicas foi curto e semelhante: 9,5±3,1 vs 8,0±3,0 minutos (P=0,21). As complicações não diferiram (três por grupo, não significativas), e amostras retiradas foram adequadas em ambas as circunstâncias. Conclusão - A técnica de hybrid-knife é uma alternativa aceitável para dissecção submucosa, demonstrando não haver diferença em comparação à técnica convencional levando em consideração o tempo de procedimento, a presença de complicações e a qualidade da amostra ressecada.

ENDOSCOPIC GASTRIC SUBMUCOSAL DISSECTION: experimental comparative protocol between standard technique and Hybrid-Knife(r).

BACKGROUND: Endoscopic treatment of superficial gastrointestinal tumors is routinely performed, however the advantages and shortcomings of submucosal pressure-jet dissection is still debated. OBJECTIVE: - Aiming to compare this technique with conventional submucosal dissection, a study was designed in pigs. METHODS: - Areas of the antral mucosa of the stomach with a diameter of 2 cm2 (6 per animal) were marked, and resected by means of the hybrid-knife (experimental technique), and Flush-knife or IT-knife (controls). An ERBE ICC 300 electrosurgical unit was adopted. End-points were procedural time, complications, and quality of the resected specimen. RESULTS: - A total of 27 interventions were conducted in five animals. Time spent with the two options was quite short, and similar: 9.5±3.1 vs 8.0±3.0 minutes (P=0.21). Complications didn't differ (three per group, not significant), and removed specimen looked adequate in both circumstances. CONCLUSION: - The hybrid-knife technique is an acceptable alternative to submucosal dissection, showing no difference compared to the standard technique taking into consideration the procedure, the presence of complications and the quality of the resected specimen.

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.

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.

Dispepsia em pacientes com hipertensão porta submetidos à esclerose endoscópica de varizes esofagianas: relação com aspectos endoscópicos do estômago / Dyspepsia in patients with portal hypertension undergone esophageal scleroteraphy: correlation with gastric endoscopic findings

Objetivo: avaliar a associação entre dispepsia e alterações endoscópicas do estômago em pacientes com hipertensão portal em tratamento endoscópico de varizes esofagianas. Métodos: a partir da demanda espontânea do programa de tratamento endoscópico de varizes esofágicas do Hospital das Clínicas da UFG, 65 pacientes responderam a um questionário validado (PADYQ) sobre sintomas dispépticos e foram submetidos a EDA (Endoscopia Digestiva Alta) por endoscopista que não teve acesso às informações sobre os sintomas. Os achados endoscópicos do estômago foram correlacionados com os escores dos sintomas dispépticos. Resultados: 22 pacientes (33,84%) com sintomas Dispépticos não tiveram alterações endoscópicas. Por outro lado, foram demonstradas alterações na mucosa antral (erosões ou úlcera) em 13 pacientes (20,0%) que não apresentavam sintomas dispépticos. A correlação entre sintomas dispépticos e achados endoscópicos do antro gástrico não demonstrou significância estatística. Conclusão: sintomas dispépticos em pacientes com HP independem da intensidade de alterações endoscópicas na mucosa gástrica, sugerindo que achados endoscópicos em pacientes que se queixam de sintomas dispépticos não devem ser supravalorizados.

Objective: to evaluate the association between dyspepsia and gastric endoscopic alterations in patients with portal hypertension undergone sclerotherapy. Methods: during the normal attendances on the program of esophageal varices treatment in Hospital das Clinica in the Universidade Federal de Goiás, 65 patients answered a validated dyspeptic symptoms questionnaire. The gastric endoscopic findings including portal hypertension gastropathy and antral mucosa alterations were compared with the dyspeptic symptoms score. Results: 22 patients (33.84%) with dyspeptic symptoms didn?t show endoscopic alterations. In the other hand; alterations in the antral mucosa (erosions or ulcers) were demonstrated in 13 patients (20.0%) that didn?t present any symptoms of dyspepsia. There was no correlation between dyspeptic symptoms score and endoscopic findings. Conclusion: dyspeptic symptoms in patients with portal hypertension are not correlated with the intensity of gastric endoscopic abnormalities.

[Heterotopic ossification in incisional hernia sac]. / Ossificação heterotópica em saco herniário incisional.

The heterotopic ossification (HO) on abdominal scars is a rare but very unconfortable finding. It causes pain, induration and discomfort in the scar, leading patients to undergo reoperation. This report aims to describe a case of HO, and especially to call attention of surgeons to fibroblast transforming potential, once its close relationship with HO is undeniable. Therefore the surgeon should endeavor all atempts on good surgical practice to avoid HO occurrence. He should also associate pure tissue repair techniques to prosthetic management of incisional hernias, in the hope that patient's fibroblast grow factors can be offered to the wound healing as a biologically reinforcement of the repair.

Ossificação heterotópica em saco herniário incisional / Heterotopic ossification in incisional hernia sac

O achado de ossificação heterotópica (OH) sobre cicatriz cirúrgica abdominal é um evento raro, mas que soma morbidade ao paciente. Manifesta-se por dor, endurecimento ou desconforto na cicatriz, levando a novas abordagens cirúrgicas. Relatamos um caso de OH no saco herniário incisional com o objetivo precípuo de chamar a atenção para o potencial "totipotente" do fibroblasto, já que sua íntima relação com a OH é inegável. A partir dessa prerrogativa, qualquer forma de tratamento das hérnias incisionais deveria associar o reparo tecidual ao uso de prótese (tela), para enriquecê-lo com os fibroblastos e seus fatores de crescimento celular do próprio paciente, todos autólogos e prontos para uso. A tática é oferecer uma abordagem combinada ou mista, com menores chances de recidiva na correção dessas afecções.

The heterotopic ossification (HO) on abdominal scars is a rare but very unconfortable finding. It causes pain, induration and discomfort in the scar, leading patients to undergo reoperation. This report aims to describe a case of HO, and especially to call attention of surgeons to fibroblast transforming potential, once its close relationship with HO is undeniable. Therefore the surgeon should endeavor all atempts on good surgical practice to avoid HO occurrence. He should also associate pure tissue repair techniques to prosthetic management of incisional hernias, in the hope that patient's fibroblast grow factors can be offered to the wound healing as a biologically reinforcement of the repair.

MYOSITIS OSSIFICANS PROGRESSIVA: CASE REPORT.

Myositis ossificans progressiva is a rare autosomal dominant disease with less than 1,000 case reports. Such patients present edema, caused by inflammatory processes that progressively calcify, and with loss of mobility in the region affected. The objective of this study was to describe a case of myositis ossificans progressiva, present its clinical manifestations and discuss the treatments available (oral ascorbic acid and intravenous bisphosphonate).

Miosite ossificante progressiva: relato de caso / Myositis ossificans progressiva: case report

A miosite ossificante progressiva é uma doença rara, com menos de 1.000 casos descritos, autossômica dominante. O paciente apresenta edemas, devidos a processos inflamatórios, que vão se calcificando, com perda da mobilidade da região afetada. O objetivo deste trabalho é descrever um caso de miosite ossificante progressiva, apresentando as manifestações clínicas e discutindo os tratamentos disponíveis (ácido ascórbico oral e bifosfonato endovenoso).

Myositis Ossificans Progressiva is a rare autosomal dominant disease with less than 1,000 case reports. Such patients presents edema, caused by inflammatory processes that progressively calcify, and with loss of mobility in the region affected. The objective of this study was to describe a case of myositis ossificans progressiva, present its clinical manifestations and discuss the treatments available (oral ascorbic acid and intravenous bisphosphonate).