Niti-S Esophageal Mega-Stent: An Emerging Endoscopic Tool with Different Applications in the Management of Surgical Anastomotic Leaks.

Introduction: Anastomotic leak (AL) is a dangerous complication in the early postoperative period after total gastrectomy or esophagectomy being associated with high mortality. Self-expandable metal stents (SEMS) play a significant role in AL management. Only one case report described the use of Mega-Stent in AL setting. The authors report a two-case series with different applications of a Niti-S esophageal Mega-Stent in AL management. Case Report: Case 1 is a 67-year-old male who underwent an esophagectomy due to a squamous cell carcinoma of the distal esophagus. The early postoperative period was complicated with AL and gastropleural fistula. Initially, an OTSC was deployed in the dehiscence but failed to resolve AL. The esophageal Mega-Stent was further placed in-between the esophagus and the bulbus. Post-stenting contrast studies confirmed no further AL.Case 2 is an 86-year-old woman who underwent total gastrectomy with roux-en-y esophagojejunostomy due to a gastric adenocarcinoma, complicated with AL. A partially covered metal stent (PCMS) was placed to cover the anastomosis. Computed tomography confirmed leakage persistence and a second PCMS was deployed, resolving the AL. Several weeks later, both PCMSs presented ingrowth from granulation tissue. An esophageal Mega-Stent was placed (stent-in-stent technique) and 2 weeks later, all stents were removed, with no AL recurrence. Discussion/Conclusion: SEMS placement for AL is a safe, well-established therapeutic technique. Limitations include stent migration and incomplete cover of large AL. Mega-Stent can be an emerging tool for endoscopic AL management.

Introdução: A deiscência anastomótica (DA) é uma complicação grave no pós-operatório precoce da esofagectomia e gastrectomia total, pela sua elevada mortalidade. As próteses metálicas autoexpansíveis (PMAE) desempenham um papel fundamental no tratamento das DA. Na literatura, há apenas um caso descrito sobre a utilização de um Mega-Stent no contexto de DA, que não complicação bariátrica. Os autores reportam uma série de dois casos com diferente aplicação do Mega-Stent esofágico no tratamento de DA. Descrição do caso: Caso 1: Homem de 67 anos, submetido a esofagectomia por carcinoma epidermóide do esófago distal. O período pós-operatório precoce foi complicado de DA com fístula gastro-pleural. Inicialmente foi colocado um clip OTSC no orifício da deiscência com insucesso técnico e clínico, sendo posteriormente utilizado o Mega-Stent, posicionado desde o esófago até ao bulbo duodenal. Estudos contrastados posteriores confirmaram resolução da DA. Caso 2: Mulher de 86 anos, submetida a gastrectomia total com reconstrução em Y-Roux e esofagojejunostomia por adenocarcinoma gástrico, complicada de DA. Neste contexto foi colocada uma PMAE parcialmente coberta (PMAE-PC) sobre a área da anastomose. A tomografia computorizada subsequente demonstrou persistência de extravasamento. Foi colocada uma segunda PMAE-PC, com posterior resolução da DA. Semanas depois, ambas as PMAE-PC apresentavam tecido de granulação nos topos, tendo sido colocado o Mega-Stent (técnica stent-in-stent) e decorridas duas semanas, todas as próteses foram facilmente extraídas, confirmando-se sucesso no tratamento da DA. Discussão/conclusão: A utilização de PMAE nas DA constitui uma técnica terapêutica segura e bem estabelecida, contudo passível de apresentar limitações tais como a migração ou incapacidade de cobrir totalmente DA de maiores dimensões. O Mega-Stent esofágico pode constituir uma ferramenta útil na terapêutica endoscópica destes doentes.

Duodenal angiolipoma: a rare tumor causing recurrent upper gastrointestinal bleeding.

Duodenal angiolipoma is a rare adipocytic tumor, with non-specific symptoms precluding an early diagnosis. We present a case of a 67-year-old female admitted due to upper gastrointestinal bleeding. The upper endoscopy and endoscopic ultrasound evaluation showed a subepithelial lesion in the third portion of the duodenum. Endoscopic excision was performed using a standard polypectomy technique after endoloop placement. Histopathology was compatible with duodenal angiolipoma. The authors highlight duodenal angiolipoma as a rare adipocytic tumor potentially causing gastrointestinal bleeding, which can be safely treated with endoscopic excision.

EUS-guided hepaticogastrostomy in multimetastatic liver disease - an effective approach for biliary drainage that may complement ERCP.

A 36-year-old male was diagnosed with a metastasized colon adenocarcinoma causing obstructive jaundice. Magnetic resonance cholangiography showed a dominant lesion causing hilar stenosis. The patient was submitted to endoscopic retrograde cholangiopancreatography (ERCP), nevertheless it was just possible to place a single uncovered self-expandable metallic stent (SEMS) in the right lobe. Although cholestasis significantly improved, safe levels for oncologic therapy were not reached. EUS-guided hepaticogastrostomy was proposed to complement ERCP biliary drainage. Using a forward-viewing echoendoscope and a transgastric approach, EUS-guided puncture of a dilated left intrahepatic duct at segment III was accomplished with a 19G needle (EchoTip ProCore®) that allowed passage of a 0.035 guidewire. A 6F cystotome and biliary dilators (5Fr+8.5Fr) were used for needle tract dilation. A partially-covered SEMS (GIOBOR™ 8x100mm) could be deployed under endoscopic and fluoroscopic control, being placed 3cm inside the gastric lumen. No associated complications were observed after the procedure.

A Unique Case of Recurrent Upper Gastrointestinal Bleeding Caused by Two Metachronous Dieulafoy's Lesions: The Role of EUS Evaluation.

INTRODUCTION: Dieulafoy's lesion (DL) is a rare but important cause of acute, severe, life-threatening, and recurrent upper gastrointestinal bleeding (UGIB). It is frequently difficult to diagnose DL with upper GI endoscopy (UGIE), and endoscopic ultrasonography (EUS) may be valuable. There are only 2 reported bleeding cases caused by two synchronous DL but no reported cases of two metachronous DL. CASE REPORT: A 28-year-old healthy male presented with acute severe UGIB. UGIE was inconclusive. Systematic EUS mapping identified a gastric DL. After several attempts of EUS-guided hemostasis, DL was marked using a through-the-scope clip and the patient underwent successful transcatheter arterial embolization (TAE). Three years later, a new severe UGIB episode was caused by a second gastric DL in a different location, which was identified and marked by EUS and further successfully treated through TAE. The patient maintained follow-up without evidence of further bleeding. DISCUSSION/CONCLUSION: The authors report a unique case of severe, recurrent UGIB caused by two metachronous gastric DL lesions. The importance of systematic EUS scanning for diagnosis, treatment, and follow-up of DL is emphasized, as well as the potential influence in the outcome of other techniques like angiographic embolization.

INTRODUÇÃO: a lesão de Dieulafoy (LD) é uma causa rara de hemorragia digestiva alta (HDA), podendo causar hemorragia grave e recorrente. Diagnosticar esta lesão através da endoscopia digestiva alta (EDA) pode ser um desafio e a ecoendoscopia (EUS) é uma ferramenta muito útil. Há apenas dois casos reportados de hemorragia digestiva por duas LD síncronas, mas não há casos descritos de doentes com duas HDA por LD metácronas. CASO CLÍNICO: homem de 28 anos, saudável, admitido por HDA grave, EDA inconclusiva. Mapeamento gástrico sistemático por EUS identificou LD gástrica. Várias tentativas ineficazes de hemostase endoscópica e guiada por EUS. Marcação da LD com clip guiada por EUS e referenciação para embolização arterial (EA), bem-sucedida. Três anos depois, nova HDA grave devido a uma segunda LD gástrica, em topografia diferente, diagnosticada e marcada com clip por EUS, tratada com EA. Até à data sem recidiva. DISCUSSÃO/CONCLUSÃO: relatamos um caso único de HDA grave recorrente, causada por duas LD gástricas metácronas. Salienta-se a importância de uma avaliação sistemática por EUS no diagnóstico destas lesões. Salientamos o papel desta técnica no diagnóstico e tratamento das LD e possibilidade de articulação com outras técnicas, nomeadamente a EA.

Solid serous cystadenoma of the pancreas - Difficult assessment by EUS-FNA/FNB? / Cistoadenoma seroso sólido del páncreas: ¿valoración de dificultad mediante EUS-FNA/FNB?

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First case report of pancreatic myeloid sarcoma diagnosed through EUS-FNA / Primer caso clínico de sarcoma mieloide pancreático diagnosticado mediante AAF-EE

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Distant Thromboembolic Disease Diagnosed by Endoscopic Ultrasound in Pancreatic Cancer: A Case Series.

Thrombosis and cancer have a very well-known association. Pancreatic cancer has the highest risk for thrombotic events amongst gastrointestinal cancers and is a leading direct cause of death in cancer patients. We assessed the role of endoscopic ultrasound (EUS) in identifying distant thrombotic events in pancreatic cancer patients. We performed a retrospective review of all EUS cases for pancreatic cancer in two centers and assessed all remotely located thrombotic events diagnosed. In a period of 6 months, a total of 55 EUS for pancreatic neoplasm were performed and the following thrombotic events were identified in 4 patients (7.3%): pulmonary thromboembolism (75%) and vena cava thrombosis (25%). The authors present these 4 cases of thrombotic disease identified by EUS, 50% of them previously missed by noninvasive imaging. EUS evaluation is not seldom limited to the targeted lesion prior identified in other imaging studies. Vascular thrombus can be an incidental finding on EUS. If untreated, pulmonary embolism has a high overall mortality. This series underlines the importance of a systematic, station approach EUS technique, namely in the mediastinum, regardless of the clinical indication.

A trombose e o cancro têm uma associação bem conhe-cida. As neoplasias pancreáticas têm, de todos os tumores gastrointestinais, o risco mais elevado de eventos trom-bóticos e são uma das principais causas diretas de morte nestes doentes. Pretendeu avaliar-se o papel da ultrassonografia endoscópica (EUS) na identificação de eventos trombóticos à distância em doentes com neopla-sias pancreáticas. Realizámos uma análise retrospetiva de todas as EUS realizadas por neoplasias pancreáticas em dois centros e analisámos os eventos trombóticos re-motamente localizados diagnosticados. Num período de 6 meses, foram realizadas um total de 55 EUS por neopla-sias pancreáticas e foram identificados estes eventos trombóticos em 4 doentes (7.3%): 75% tromboembolis-mo pulmonar e 25% trombose da veia cava inferior. Os autores apresentam estes 4 casos de doença trombótica identificada na EUS, sendo que metade deles não tinham sido diagnosticados pelos métodos de imagem não inva-sivos já realizados. Não infrequentemente, a avaliação por EUS é limitada à lesão alvo previamente identificada por outros métodos de imagem. Os trombos vasculares po-dem ser um achado acidental na EUS. Se não tratado, o tromboembolismo pulmonar tem uma alta taxa de mor-talidade. Esta série reforça a importância de uma aborda-gem sistemática, por estação, na EUS, principalmente no mediastino, independentemente da indicação clínica.

Pancreatoblastoma: an unusual diagnosis in an adult patient.

The authors describe a 31-year-old man admitted due to progressive weight loss, diarrhea and massive hepatomegaly. Laboratory data showed anemia (haemoglobin 11.7 g/dl), abnormal liver tests (total bilirubin 1.4 g/dl, aspartate aminotransferase 70 U/l, alanine aminotransferase 37 U/l and alkaline phosphatase 520 U/l). Abdominal ultrasound (US) displayed a large heterogeneous liver with a segment IV 25 mm nodule. Magnetic resonance revealed a 4 cm pancreatic tail mass and several liver nodules consistent with metastasis. The patient underwent an endoscopic ultrasound (EUS) with fine needle aspiration (FNA) from the pancreatic mass and liver metastasis with cytological evaluation consistent with a pancreatoblastoma, later confirmed through a percutaneous US-guided liver biopsy. During the inpatient period, liver function deteriorated and acute kidney injury developed. Severe progressive cachexia was observed. The patient was discharged on renal replacement therapy and palliative care. Death occurred 3 months after diagnosis. Pancreatoblastoma is an uncommon pancreatic malignant epithelial cancer of the pancreas, typically occurring in the paediatric population. Adult pancreatoblastoma is extremely rare, with about 40 cases reported in the literature and generally presenting a more aggressive biologic and clinical behaviour. Surgical resection is the treatment of choice, but most cases are detected in advanced stages. This case underlines the ability to establish a pancreatoblastoma cytology-based diagnosis with EUS-FNA, and confirms the associated poor outcome.

Human gastric hyperinfection by Anisakis simplex: A severe and unusual presentation and a brief review.

Anisakiasis is an emerging marine food-borne zoonosis resulting from the accidental ingestion of Anisakis larvae, through the consumption of raw or undercooked infected seafood products. The first case of human gastric hyperinfection by Anisakis simplex with an unusual and severe presentation, occurring in a Portuguese woman, is described in this article. Over 140 anisakid larvae were removed by gastroscopy. Massive infection is uncommon in areas where the consumption of raw fish is not part of the traditional diet, as is the case in Portugal. The increased consumption of raw seafood products is considered a health determinant in the rise in cases of anisakiasis. However, clinicians should be aware of the emergence of these infections, not only because of the new dietary habits of the population, but also because of the high prevalence of Anisakis larvae in the different fish species usually consumed by the population, collected on the Portuguese coast.

A diffusely enlarged pancreas: the (un)usual suspect.

An 81-years-old female presented with obstructive jaundice and a non-specific clinical picture of nausea and appetite loss. Labs demonstrated a conjugated hyperbilirrubinemia (7.7 mg/dL), increased aspartate aminotransferase and alanine aminotransferase (10xULN and 8xULN, respectively), increased lactate dehydrogenase (10xULN) and serum lipase (3xULN). CA 19.9 was 342 U/mL (Ref value < 37 U/mL). There was no evidence of peripheral lymphadenopathy or hepatosplenomegaly. Imaging (Figure 1A and 1B) revealed a marked homogeneous enlargement of the pancreas (without any well-defined mass), dilation of the extra and intra-hepatic bile ducts and ascites. Endoscopic ultrasound (Figure 1C and 1D) identified an enlarged homogeneous hypoechoic pancreas, without any well-defined lesion, no dilation of the main pancreatic duct, no peripancreatic or celiac enlarged lymph nodes. A fine-needle biopsy was performed yielding, on cytological examination and cell-block technique (Figure 2A and 2B), numerous medium/large sized atypical lymphoid cells that displayed a B-cell lineage immunophenotype (Figure 2A-2F). Even though, further characterization (by flow cytometric immunophenotyping) could not be obtained, a final diagnosis of primary pancreatic lymphoma (PPL) was assumed. Primary pancreatic lymphoma is a remarkably rare tumor of the pancreas, representing approximately 0.5% of all pancreatic neoplasms and <2% of all lymphomas (1,2). A correct diagnosis is crucial because therapeutic management differs from other pancreatic malignancies (pancreatic ductal adenocarcinoma, neuroendocrine tumor and metastases) (2,3). Two morphologic patterns of PPL are recognized: a focal form (occurring in the pancreatic head in 80% of cases) and a rarer diffuse/infiltrative pattern, as depicted herein, emulating an acute/autoimmune pancreatitis (1).

A diffusely enlarged pancreas: the (un)usual suspect

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