Systematic review and meta-analysis of endoscopic ablative treatment of Barrett’s esophagus / Revisión sistemática y meta-análisis del tratamiento ablativo endoscópico del esófago de Barrett

Background: Barrett’s esophagus (BE) is the main risk factor for esophageal adenocarcinoma. Its therapeutic approach is controversial and surgical treatment in the presence of high-grade intraepithelial neoplasia may be indicated. Endoscopic approach is an alternative with lower mortality and morbidity rates and favorable results. Objective: To define the best option, according to literature, to treat Barrett’s Esophagus. Materials and methods: Design: Systematic review of PUBMED, EMBASE, LILACS, and Cochrane Library databases was conducted and articles of randomized, controlled studies on BE endoscopic ablative treatment were selected. The systematic review through PUBMED retrieved results with higher evidence level and available recommendation grade regarding BE ablative therapy. Nine articles on randomized, controlled studies classified as A or B according to the Oxford table were selected. Cryotherapy, laser, photodynamic therapy (PDT), multipolar electrocoagulation (MPEC), and ablation through argon plasma coagulation (APC) and radiofrequency were considered ablation therapies. Patients: 649 patients from 10 different studies were analysed. Results: PDT was found to present an increase in treatment failure compared with APC, NNH = -7. BE ablation through MPEC or APC was found to have similar risk for treatment failure in meta-analysis. PDT associated with proton pump inhibitor (PPI) is beneficial for BE ablation regarding PPI use alone, NNT = 2. Radiofrequency with PPI is an efficient method to reduce risk of treatment failure, NNT = 1. Conclusions: There are no studies demonstrating the benefit of indicating cryotherapy or laser therapy for BE endoscopic approach. APC ablation was found to have superior efficacy compared with PDT and ablation through APC and MPEC was found to present effective, similar results. Radiofrequency is the most recent approach requiring comparative studies for indication.

Introducción: El esófago e Barrett (BE) es un factor de riesgo importante para adenocarcinoma de esófago.Su manejo terapéutico es controversial y el tratamiento quirúrgico en la presencia de neoplasia intraepitelial de alto grado puede estar indicado. El manejo endoscópico es una alternative con menores tasas de morbilidad y mortalidad y con resultados favorables. Objetivo: Definir la major opción de tratamiento del esófago de Barrett de acuerdo a la literatura. Materiales y métodos: Diseño: Se realize una revisión sistemática de PUBMED, EMBASE, LILACS yla librería Cochrane y los artículos randomizados, controlados en ablación endoscópica de BE fueron seleccionados. Esta revisión de PUBMED mostró resultados de una evidencia muy alta y recomendación alta para el uso de terapia ablativa. Nueve artículos de studios randomizados y controlados fueron catalogados grado A o B de aacuerdo a la table de Oxford y fueron seleccionados.Fueron consideradas como terapia ablativa, la crioterapia, laser,terapia fotodinámica (PDT),electrocoagulación multipolar (MPEC) ,ablación con coagulación por argón plasma (APC) y radiofrecuencia. Pacientes: 649 pacientes de 10 estudios diferentes fueron analizados. Resultados: El PDT se halló que tenía mas fallas que el APC , NNH=-7. La ablación del esófago de barrett por MPEC o APC tuvieron el mismo riesgo de fracaso terapéutico en los meta-análisis.La PDT asociado al uso de Inhibidores de bomba de protones (PPI) es beneficiosa versus el uso de, los PPI solos, NNT=2. La radiofrecuencia con PPI es un método eficiente para reducer el riesgo de fracas terapéutico, NNT=1. Conclusiones: No hay studios que demuestren el beneficio de la crioterapia o la terapia con laser para el esófago de Barrett, se encontró que tiene una eficacia superior comparada con el PDT y la ablación por APC y MPEC tenían resultados efectivos y similares.La radiofrecuencia es el manejo más reciente y requiere estudios comparativos para su indicación.

[A novel endoscopic treatment of pancreas divisum]. / A novel endoscopic treatment of pancreas divisum.

Pancreas divisum is the most common congenital malformation of the pancreas that results from the non-fusion or incomplete fusion of the ventral and dorsal portions of the embryonic pancreas. It is found in 7% of autopsy studies (range 1-14%) and is generally asymptomatic. 5% of the patients have symptoms, which are basically cases of abdominal pain and recurrent pancreatitis. We report the case of a woman of 51 y, postcholecystectomy with 2 episodes of pancreatitis with imaging from magnetic resonance of pancreatic divisum with communication between the dorsal and ventral pancreas. We proceeded by endoscopy (ERCP) to dilate the major duct, and then made a minor duct papillotomy and made a hydropneumatic ball dilatation with the catheter balloon up the waist portion. The procedure was successful with 9 months of follow up.

A novel endoscopic treatment of pancreas divisum (un tratamiento endoscópico nuevo para el páncreas divisum)

El páncreas divisum es la malformación congénita más común del páncreas que resulta de la no fusión ó fusión incompleta de las porciones ventral y dorsal del páncreas embrionario. Se encuentra en 7% de los estudios de autopsias (rango 1-14%), siendo generalmente asintomática. Un 5% de estos pacientes presentan síntomas, que son básicamente dolor abdominal y casos de pancreatitis recurrente. Se reporta el caso de una paciente mujer de 52 años, con 2 episodios de pancreatitis postcolecistectomía con imagen por colangioresonancia de páncreas divisum con comunicación entre el páncreas dorsal y ventral. Se procedió a dilatar el conducto mayor; y luego se hizo una papilotomia del conducto menor y se pasó un balón hidroneumático hasta más allá de su diámetro mayor. El procedimiento ha tenido éxito en 9 meses de seguimiento.

Pancreas divisum is the most common congenital malformation of the pancreas that results from the non-fusion or incomplete fusion of the ventral and dorsal portionts of the embryonic pancreas. It is found in 7% of autopsy studies (range 1-14%) and is generally asymptomatic. 5% of the patients have symptoms, wich are basically cases of abdominal pain and recurrent pancreatitis. We report the case of a woman of 51y, postcholecystectomy with 2 episodes of pancreatitis with imaging from magnetic resonance of pancreatic divisum with communication between the dorsal and ventral pancreas. We proceeded bye endoscopy (ERCP) to dilate the major duct, and them made a minor duct papillotomy and made a hydropneumatic ball dilatation with the catheter balloon up the waist portion. The procedure was successful with 9 months of follow up.

A prospective randomized study comparing partially covered metal stent versus plastic multistent in the endoscopic management of patients with postoperative benign bile duct strictures: a follow-up above 5 years.

BACKGROUND: Self-expandable metal stents (SEMS) are often used for biliary drainage due to obstruction of neoplastic etiology, with better results than plastic stents, but seldom for biliary drainage of benign etiology. OBJECTIVE: Primary end point: Verify bile duct patency after placement of self-expandable metal and (multiple) plastic stents in patients with benign strictures resulting from bile duct surgery with follow-up above five years. Secondary end point: Evaluate long-term complication rate in patients with metal self-expandable and plastic stents. RESULTS: Self-expandable stents were placed in 15 patients and multiple plastic stents in 16. Mean age was 45 years with prevalence of female patients in both groups and no statistical difference between groups was observed (SEMS: 66.7%; plastic multistent: 62.5%; p=0.8). Complication rate resulting from stents occurred more often in the metal stent group (40% versus 25%; p=0.37). In the metal stent group, most frequent complications were hemorrhage (n=3; 20%), stent migration (n=2; 13.3%) and perforation (n=1; 6.7%). In plastic multistent group, most frequent complications were perforation (n:2; 12.5%), hemorrhage (n=1; 6.2%) and ulcer (n=1; 6.2%). Long-term patency rate after biliary drainage was higher in the self-expandable metal stent group, SEMS: 81.67% ± 2.56; CI: 76.47-86.54; plastic multistent: 71.88% ± 2.93; CI: 66.08-77.27. CONCLUSION: The temporary passage of partially covered self-expandable metal stents is a feasible option for patients with benign bile duct strictures.

Endoscopy Ultra- Sonography -guided biliary drainage in the surgical -endoscopy era.

BACKGROUND: US-guided hepatico - gastrostomy, choledocho-duodenostomy and choledocho-antrostomy are advanced procedures on biliary and pancreatic endoscopy and together make up the echo-guided biliary drainage. Hepatico - gastrostomy is indicated in cases of hiliar obstruction, while the procedure of choice is choledocho - duodenostomy in distal lesions. Both procedures must be done only after unsuccessful ERCP. AIMS: To clarify to the readers about indication of these procedures, they must be made under a multidisciplinary view while sharing information with the patient or legal guardian. METHODS: All series cases report and selected cohort studies were selected according to the DDTS system in which key words were EUS biliary drainage, choledocho-duodenostomy, hepatico-gastrostomy, EUS, palliation and pancreatic biliary advanced cancer. RESULTS: Separately it was stated definition on the EUS biliary drainage procedures and it includes the techniques details and critical analysis. CONCLUSION: Hepatico- gastrostomy and Choledocho- duodenostomy are feasible when performed by endoscopists with expertise in bilio pancreatic endoscopy and advanced echo-endoscopy and should be performed currently under rigorous protocol in educational institutions.