RESUMEN
BACKGROUND: Endoscopic submucosal dissection (ESD) of extensive superficial cancers of the esophagus may progress with high rates of postoperative stenosis, resulting in significantly decreased quality of life. Several therapies are performed to prevent this, but have not yet been compared in a systematic review. METHODS: A systematic review of the literature and meta-analysis were performed using the MEDLINE, Embase, Cochrane, LILACS, Scopus, and CINAHL databases. Clinical trials and observational studies were searched from March 2014 to February 2015. Search terms included: endoscopy, ESD, esophageal stenosis, and esophageal stricture. Three retrospective and four prospective (three randomized) cohort studies were selected and involved 249 patients with superficial esophageal neoplasia who underwent ESD, at least two-thirds of the circumference. We grouped trials comparing different techniques to prevent esophagus stenosis post-ESD. RESULTS: We conducted different meta-analyses on randomized clinical trials (RCT), non-RCT, and global analysis. In RCT (three studies, n = 85), the preventive therapy decreased the risk of stenosis (risk difference = -0.36, 95 % CI -0.55 to -0.18, P = 0.0001). Two studies (one randomized and one non-randomized, n = 55) showed that preventative therapy lowered the average number of endoscopy dilatations (mean difference = -8.57, 95 % CI -13.88 to -3.25, P < 0.002). There were no significant differences in the three RCT studies (n = 85) in complication rates between patients with preventative therapy and those without (risk difference = 0.02, 95 % CI -0.09 to 0.14, P = 0.68). CONCLUSIONS: The use of preventive therapy after extensive ESD of the esophagus reduces the risk of stenosis and the number of endoscopic dilatations for resolution of stenosis without increasing the number of complications.
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Adenocarcinoma/cirugía , Carcinoma de Células Escamosas/cirugía , Resección Endoscópica de la Mucosa/métodos , Neoplasias Esofágicas/cirugía , Estenosis Esofágica/prevención & control , Esofagoscopía/métodos , Complicaciones Posoperatorias/prevención & control , Resección Endoscópica de la Mucosa/efectos adversos , Estenosis Esofágica/etiología , Esofagoscopía/efectos adversos , Humanos , Complicaciones Posoperatorias/etiología , Calidad de VidaRESUMEN
INTRODUCTION AND AIMS: Rectal prolapse is common in the elderly, having an incidence of 1% in patients over 65years of age. The aim of this study was to evaluate the safety and feasibility of a new endoluminal procedure for attaching the previously mobilized rectum to the anterior abdominal wall using an endoscopic fixation device. MATERIALS AND METHODS: The study is a single-arm phasei experimental trial. Under general anesthesia, total rectal prolapse was surgically reproduced in five pigs. Transanal endoscopic reduction of the rectal prolapse was performed. The best site for transillumination of the abdominal wall, suitable for rectopexy, was identified. The EndoLifter was used to approximate the anterior wall of the proximal rectum to the anterior abdominal wall. Two percutaneous rectopexies were performed by puncture with the Loop FixtureII Gastropexy Kit® at the preset site of transillumination. After the percutaneous rectopexies, rectoscopy and exploratory laparotomy were performed. Finally, the animals were euthanized. RESULTS: The mean procedure time was 16min (11-21) and the mean length of the mobilized specimen was 4.32cm (range 2.9-5.65cm). A total of 10 fixations were performed with a technical success rate of 100%. There was no evidence of postoperative rectal prolapse in any of the animals. The EndoLifter facilitated the process by allowing the mucosa to be held and manipulated during the repair. CONCLUSIONS: Endoscopic-assisted percutaneous rectopexy is a safe and feasible endoluminal procedure for fixation of the rectum to the anterior abdominal wall in experimental animals.
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Endoscopía Gastrointestinal/instrumentación , Endoscopía Gastrointestinal/métodos , Prolapso Rectal/cirugía , Animales , Estudios de Factibilidad , Laparotomía , Sus scrofa , PorcinosRESUMEN
BACKGROUND: The effectiveness of endoscopic submucosal dissection (ESD) is similar to that of surgery in the treatment of early lesions. The technique requires a high level of technical skill. Training on biologic models and the mastering of accessories facilitate ESD. AIMS: The aim was to evaluate the usefulness of the Endolifter in facilitating tissue exposure during ESD in an in vivo porcine model performed at the experimental surgery laboratory of the School of Medicine at the Universidad de São Paulo in Brazil. MATERIAL AND METHOD: A study with an experimental design employing an in vivo porcine model was conducted on 5 Yorkshire pigs weighing 20-25kg. ESDs were performed using the Endolifter. Mucosal layer dissection was carried out with a dual knife and IT knife and all the endoscopic procedures were performed by a single expert endoscopist. RESULTS: A total of 25 ESDs were performed, with a technical success rate of 100%. The mean dissection time was 12.34min (range: 10.40-14.50 min) and the mean lesion size was 2.7cm (range: 2.3-3.2cm). There were no episodes of bleeding or perforations during the procedures. CONCLUSIONS: The Endolifter enables rapid and effective ESDs to be carried out. It is an applicable and easy-to-use device that can be manipulated by a single operator.
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Disección/instrumentación , Endoscopía Gastrointestinal/instrumentación , Animales , Endoscopía Gastrointestinal/métodos , Diseño de Equipo , Femenino , Masculino , Membrana Mucosa/cirugía , Porcinos , Factores de TiempoRESUMEN
AIMS: To report Type 2 diabetes-related outcomes after the implantation of a duodenal-jejunal bypass liner device and to investigate the role of proximal gut exclusion from food in glucose homeostasis using the model of this device. METHODS: Sixteen patients with Type 2 diabetes and BMI <36 kg/m(2) were evaluated before and 1, 12 and 52 weeks after duodenal-jejunal bypass liner implantation and 26 weeks after explantation. Mixed-meal tolerance tests were conducted over a period of 120 min and glucose, insulin and C-peptide levels were measured. The Matsuda index and the homeostatic model of assessment of insulin resistance were used for the estimation of insulin sensitivity and insulin resistance. The insulin secretion rate was calculated using deconvolution of C-peptide levels. RESULTS: Body weight decreased by 1.3 kg after 1 week and by 2.4 kg after 52 weeks (P < 0.001). One year after duodenal-jejunal bypass liner implantation, the mean (sem) HbA(1c) level decreased from 71.3 (2.4) mmol/mol (8.6[0.2]%) to 58.1 (4.4) mmol/mol (7.5 [0.4]%) and mean (sem) fasting glucose levels decreased from 203.3 (13.5) mg/dl to 155.1 (13.1) mg/dl (both P < 0.001). Insulin sensitivity improved by >50% as early as 1 week after implantation as measured by the Matsuda index and the homeostatic model of assessment of insulin resistance (P < 0.001), but there was a trend towards deterioration in all the above-mentioned variables 26 weeks after explantation. Fasting insulin levels, insulin area under the curve, fasting C-peptide, C-peptide area under the curve, fasting insulin and total insulin secretion rates did not change during the duodenal-jejunal bypass liner implantation period or after explantation. CONCLUSIONS: The duodenal-jejunal bypass liner improves glycaemia in overweight and obese patients with Type 2 diabetes by rapidly improving insulin sensitivity. A reduction in hepatic glucose output is the most likely explanation for this improvement.
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Glucemia/metabolismo , Péptido C/sangre , Diabetes Mellitus Tipo 2/sangre , Derivación Gástrica , Hemoglobina Glucada/metabolismo , Obesidad/cirugía , Área Bajo la Curva , Remoción de Dispositivos , Diabetes Mellitus Tipo 2/cirugía , Duodeno/cirugía , Ayuno , Femenino , Homeostasis , Humanos , Insulina/metabolismo , Resistencia a la Insulina , Secreción de Insulina , Yeyuno/cirugía , Masculino , Persona de Mediana Edad , Obesidad/sangre , Estudios Prospectivos , Resultado del Tratamiento , Pérdida de PesoRESUMEN
BACKGROUND: Patients presenting with Barrett's esophagus (BE) should be under life-long surveillance in an attempt to detect cancer in its early stages. Esophageal capsule endoscopy (ECE) is a new technique that enables a noninvasive evaluation of the esophagus. AIMS: To evaluate ECE effectiveness compared with methylene blue (MB) chromoendoscopy for the detection of esophageal lesions in which there was suspicion of cancer, the length and pattern of BE, and the presence of hiatal hernia. MATERIAL AND METHODS: Twenty-one patients with BE who underwent Nissen fundoplication and had a follow-up period of more than five years were prospectively enrolled in the study. The patients underwent ECE and chromoendoscopy with MB performed by different physicians who were blinded to each of the procedures. RESULTS: ECE sensitivity, negative predictive value, and accuracy were 100%, 100%, and 79%, respectively, for the detection of esophageal lesions suspected of cancer. ECE accuracy in assessing BE length was 89% and in the evaluation of finger-like projections, circumferential BE, and mixed BE was 74%, 79%, and 74%, respectively. In relation to hiatal hernia detection, ECE sensitivity was 43% and its accuracy was 74%. CONCLUSIONS: ECE appears to be a good method for detecting lesions in which there is suspicion of esophageal cancer and it had modest results in regard to the accurate identification of BE length and pattern. ECE is not a good method for detecting hiatal hernia. Further studies are needed in order to define the definitive role of ECE in BE monitoring.
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Esófago de Barrett/patología , Endoscopía Capsular , Esofagoscopía/métodos , Azul de Metileno , Adulto , Anciano , Anciano de 80 o más Años , Femenino , Hernia Hiatal/patología , Humanos , Masculino , Persona de Mediana Edad , Estudios Prospectivos , Adulto JovenRESUMEN
BACKGROUND AND STUDY AIMS: In many patients, percutaneous endoscopic gastrostomy (PEG) can be limited by digestive tract stenosis. PEG placement using an introducer is the safest alternative for this group of patients, but the available devices are difficult to implement and require smaller-caliber tubes. The aim of this study was to evaluate the modification of an introducer technique device for PEG placement with regard to the following: procedure feasibility, possibility of using a 20-Fr balloon gastrostomy tube, tube-related function and problems, complications, procedure safety, and mortality. PATIENTS AND METHODS: Between March 2007 and February 2008, 30 consecutive patients with head and neck malignancies underwent introducer PEG placement with the modified device and gastropexy. Each patient was evaluated for 60 days after the procedure for the success of the procedure, infection, pain, complications, mortality, and problems with the procedure. RESULTS: The procedure was successful in all cases with no perioperative complications. No signs of stomal infection were observed using the combined infection score. The majority of patients experienced mild-to-moderate pain both in the immediate postoperative period and at 72 hours. One major early complication (3.3%) and two minor complications (6.7%) were observed. No procedure-related deaths occurred during the first 60 days after the procedure. CONCLUSION: The device modification for PEG using the introducer technique is feasible, safe, and efficient in outpatients with obstructive head and neck cancer. In this series, it allowed the use of a larger-caliber tube with low complication rates and no procedure-related mortality.
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Carcinoma de Células Escamosas/complicaciones , Gastrostomía/instrumentación , Neoplasias de Cabeza y Cuello/complicaciones , Adulto , Anciano , Anciano de 80 o más Años , Constricción Patológica/etiología , Nutrición Enteral , Estenosis Esofágica/etiología , Femenino , Gastrostomía/efectos adversos , Gastrostomía/métodos , Humanos , Masculino , Persona de Mediana Edad , Dolor Postoperatorio/etiología , Faringe/patología , Factores de Tiempo , Trismo/etiologíaRESUMEN
Biliary endoscopic drainage using metallic self-expanded stents has become a well-established method for palliative treatment of malignant biliary obstruction. However, its occlusion, mainly by tumor overgrowth, is still the main complication without a standard treatment. We here describe a new method of treatment for biliary metallic stent occlusion, through the echo guided biliary drainage. We present a 68-year-old patient with metastatic pancreatic cancer previously treated for jaundice with ERCP and self-expandable metallic stent insertion. Four weeks later, the patient developed jaundice and symptoms of gastric outlet obstruction. A new ERCP confirmed obstruction of the second portion of the duodenum, due to diffuse tumor growth. EUS was performed, and the previous metal biliary stent was seen occluded at the distal portion in the common bile duct. A EUS-guided choledocododenostomy was performed and then, an overlapping self-expanding metal enteral stent was placed through the malignant obstruction. There were no early complications and the procedure was also clinically effective in relieving jaundice and gastric outlet obstruction symptoms. If ERCP fails in the management of occluded biliary metallic stents, EUS biliary drain can provide effective biliary decompression and should be considered an alternative to other endoscopic techniques.
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Colestasis/diagnóstico por imagen , Colestasis/cirugía , Drenaje/instrumentación , Endosonografía , Migración de Cuerpo Extraño/etiología , Implantación de Prótesis/métodos , Stents/efectos adversos , Anciano , Humanos , Masculino , Diseño de PrótesisRESUMEN
Epidermolysis bullosa acquisita (EBA) is a rare auto-immune dermatologic disease, produced by auto-antibodies against colagen VII. We report a 44 years old male patient with EBA diagnosed 15 years before, who presented with progressive disphagia, being diagnosed an esophageal involvement of EBA. The patient was submitted to endoscopic treatment with thermoplastic bougie dilation and intralesional corticosteroid injection. The patient improved clinically with recovery of nutritional status. Esophageal involvement in EBA is very rare and its reason is still unknown. Endoscopic approach must be cautiously performed with the use of small diameter endoscopes, small caliber dilators, intralesional injection of corticosteroid and enteral tube in order to minimize the risks of complications, as well as esophageal rest from food trauma and better reparatory molding of the epithelium.
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Epidermólisis Ampollosa Adquirida/complicaciones , Estenosis Esofágica/etiología , Estenosis Esofágica/terapia , Esofagoscopía , Glucocorticoides/administración & dosificación , Prednisona/administración & dosificación , Adulto , Terapia Combinada , Dilatación/instrumentación , Humanos , Inyecciones Intralesiones , MasculinoRESUMEN
A 65 year-old male was admitted to the University hospital with obstructive jaundice. Endoscopic examination revealed a grossly abnormal major ampulla, situated at the edge of a large duodenal diverticulum. Biopsy of the ampulla was positive for villous adenoma. We describe the technique utilized to successfully perform an end-bloc endoscopic resection of a major ampulla on a diverticulum.
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Adenoma Velloso/cirugía , Ampolla Hepatopancreática/cirugía , Neoplasias del Conducto Colédoco/cirugía , Endoscopía del Sistema Digestivo , Adenoma Velloso/complicaciones , Anciano , Neoplasias del Conducto Colédoco/complicaciones , Divertículo/complicaciones , Enfermedades Duodenales/complicaciones , Endoscopía del Sistema Digestivo/métodos , Humanos , MasculinoRESUMEN
Plasmacytoma presents more frequently in middle age men with aerodigestive tract involvement, especially in the head and the neck. Gastrointestinal tract involvement is uncommon, but the organ most commonly involved is the stomach. We report the first case in the literature in which final diagnosis was made by fine- needle aspiration biopsy guided by endoscopic ultrasound with adequate sample for pathologic analysis. The treatment of this entity is systemic chemotherapy but its effectiveness is limited. Plasmacytoma should be taken into account in differential diagnosis of pancreatic masses.
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Biopsia por Aspiración con Aguja Fina Guiada por Ultrasonido Endoscópico/métodos , Neoplasias Pancreáticas/diagnóstico , Plasmacitoma/diagnóstico , Adulto , Quimioradioterapia , Resultado Fatal , Humanos , Masculino , Neoplasias Pancreáticas/patología , Neoplasias Pancreáticas/terapia , Plasmacitoma/patología , Plasmacitoma/terapia , Tomografía Computarizada por Rayos XRESUMEN
Bile duct injury is a known complication of cholecystectomy. While minor injuries can be treated endoscopically, successful endoscopic management of complete ligation of the common hepatic duct (CHD) has not been described. Our aim was to report a novel technique for endoscopic recanalization of accidently ligated CHD. We demonstrated a 75 year old woman presented with a small bile leak and complete ligation of the CHD after open cholecystectomy subjected to successful biliary endoscopic recanalization. Cholangiogram demonstrated resolution of the bile leak and minimal residual narrowing of the CHD. Endoscopic intervention following biliary needle puncture access may avoid surgery in patients with CHD ligation or complex stenosis.
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Colecistectomía , Endoscopía del Sistema Digestivo , Conducto Hepático Común/lesiones , Complicaciones Intraoperatorias/cirugía , Anciano , Catéteres , Diseño de Equipo , Femenino , Humanos , LigaduraAsunto(s)
Drenaje/métodos , Endosonografía , Migración de Cuerpo Extraño/complicaciones , Absceso Hepático/terapia , Stents/efectos adversos , Ultrasonografía Intervencional , Anciano , Femenino , Migración de Cuerpo Extraño/diagnóstico por imagen , Humanos , Absceso Hepático/diagnóstico por imagen , Absceso Hepático/etiología , RadiografíaRESUMEN
Chagas' disease (CD) is highly prevalent in South America. Brazilian surgeons and gastroenterologists gained valuable experience in the treatment of CD esophagopathy (chagasic achalasia) due to the high number of cases treated. The authors reviewed the lessons learned with the treatment of achalasia by different centers experienced in the treatment of Chagas' disease. Preoperative evaluation, endoscopic treatment (forceful dilatation and botulinum toxin injection), Heller's myotomy, esophagectomy, conservative techniques other than myotomy, and reoperations are discussed in the light of personal experiences and review of International and Brazilian literature. Aspects not frequently adopted by North American and European surgeons are emphasized. The review shows that nonadvanced achalasia is frequently treated by Heller's myotomy. Endoscopic treatment is reserved to limited cases. Treatment for end-stage achalasia is not unanimous. Esophagectomy was a popular treatment in advanced disease; however, the morbidity/mortality associated to the procedure made some authors seek different alternatives, such as Heller's myotomy and cardioplasties. Minimally invasive approach to esophageal resection may change this concept, although few centers perform the procedure routinely.
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Enfermedad de Chagas/cirugía , Acalasia del Esófago/cirugía , Esófago/patología , Brasil , Cateterismo/métodos , Enfermedad de Chagas/mortalidad , Enfermedad de Chagas/terapia , Acalasia del Esófago/mortalidad , Acalasia del Esófago/terapia , Esofagectomía/métodos , Esofagoplastia/métodos , Esofagoscopía/métodos , Esófago/cirugía , Femenino , Humanos , Inyecciones Intralesiones , Masculino , Procedimientos Quirúrgicos Mínimamente Invasivos/métodos , Fármacos Neuromusculares/uso terapéutico , Pronóstico , Medición de Riesgo , Índice de Severidad de la Enfermedad , Análisis de Supervivencia , Resultado del TratamientoRESUMEN
BACKGROUND AND STUDY AIMS: To determine the clinical features associated with advanced duodenal and ampullary adenomas in familial adenomatous polyposis. Secondarily, we describe the prevalence and clinical significance of jejunal polyposis. PATIENTS AND METHODS: This is a single center, prospective study of 62 patients with familial adenomatous polyposis. Duodenal polyposis was classified according to Spigelman and ampullary adenomas were identified. Patients with Spigelman III and IV duodenal polyposis underwent balloon assisted enteroscopy. Predefined groups according to Spigelman and presence or not of ampullary adenomas were related to the clinical variables: gender, age, family history of familial adenomatous polyposis, type of colorectal surgery, and type of colorectal polyposis. RESULTS: Advanced duodenal polyposis was present in 13 patients (21â%; 9 male) at a mean age of 37.61â±â13.9 years. There was a statistically significant association between family history of the disease and groups according to Spigelman ( P â=â0.03). Seven unrelated patients (6 male) presented ampullary adenomas at a mean age of 36.14â±â14.2 years. The association between ampullary adenomas and extraintestinal manifestations was statistically significant in multivariate analysis ( P â=â0.009). Five endoscopic types of non-ampullary adenoma were identified, showing that lesions larger than 10âmm or with a central depression presented foci of high grade dysplasia. Among 28 patients in 12 different families, a similar Spigelman score was identified; 10/12 patients (83.3â%) who underwent enteroscopy presented small tubular adenomas with low grade dysplasia in the proximal jejunum. CONCLUSIONS: Advanced duodenal polyposis phenotype may be predictable from disease severity in a first-degree relative. Ampullary adenomas were independently associated with the presence of extraintestinal manifestations.
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Aneurisma Falso/tratamiento farmacológico , Coagulantes/uso terapéutico , Arteria Esplénica/diagnóstico por imagen , Trombina/uso terapéutico , Adulto , Aneurisma Falso/diagnóstico por imagen , Endosonografía , Humanos , Inyecciones Intralesiones , Masculino , Radiografía , Ultrasonografía IntervencionalRESUMEN
BACKGROUND: The usual treatment of pyloroduodenal peptic stenosis has been mainly surgical, through pyloroplasty or gastric resection, with or without vagotomy. Since the first description of treatment for this peptic complication by endoscopic balloon dilation perfomed by Benjamin in 1982 [2], this procedure has become a therapeutic option in association with the medical treatment of peptic disease. The aim of this study is to evaluate the results involving clinical, endoscopic, and gastric emptying scintigraphy parameters. METHODS: Between August 1998 and February 2000, 20 patients with pyloroduodenal stenosis refractory to conservative treatment were treated at the Gastrointestinal Endoscopy Unit of the University of São Paulo Medical School. All patients who presented clinical manifestations of pyloroduodenal stenosis underwent upper gastrointestinal endoscopy to confirm peptic stenosis. Biopsy of the narrowing for the confirmation of a benign disease and gastric biopsy for Helicobacter pylori detection were performed. The treatment consisted of dilation of the stenosis with type TTS (Through The Scope) hydrostatic balloon under endoscopic control, treatment of Helicobacter pylori infection, and gastric acid suppression with oral administration of proton pump inhibitor. All patients, except one who was excluded from this study, were submitted to a clinical endoscopic assessment and gastric emptying evaluation by ingestion of (99m)Tc before and after the treatment. Endoscopic evaluation considered the diameter of the stenotic area before and after treatment. A scintigraphic study compared the time of gastric emptying before and after balloon dilation. RESULTS: Nineteen patients completed treatment by hydrostatic balloon dilation. Clinical symptoms such as bloating (p < 0.0001), epigastric pain (p = 0.0159), gastric stasis (p < 0.0001), and weight gain (p = 0.036) showed significant improvement. The diameter of the stenotic area increased significantly (p < 0.01) after the dilation treatment as well as a better gastric emptying of (99m)Tc (p < 0.0001). CONCLUSION: The dilation of the peptic pyloroduodenal stenosis using a hydrostatic balloon is a safe and effective procedure. The evaluation with gastric scintigraphy by ingestion of (99m)Tc is an effective method of assessment for the improvement of gastric function, because its results corresponded to the clinical improvement after endoscopic treatment.