Bruno da Costa Martins

Metabolic Improvements in Obese Type 2 Diabetes Subjects Implanted for 1 Year with an Endoscopically Deployed Duodenal–Jejunal Bypass Liner

BACKGROUND The purpose of this study was to evaluate the effect of the duodenal-jejunal bypass liner (DJBL), a 60-cm, impermeable fluoropolymer liner anchored in the duodenum to create a duodenal-jejunal bypass, on metabolic parameters in obese subjects with type 2 diabetes. METHODS Twenty-two subjects (mean age, 46.2±10.5 years) with type 2 diabetes and a body mass index between 40 and 60 kg/m(2) (mean body mass index, 44.8±7.4 kg/m(2)) were enrolled in this 52-week, prospective, open-label clinical trial. Endoscopic device implantation was performed with the patient under general anesthesia, and the subjects were examined periodically during the next 52 weeks. Primary end points included changes in fasting blood glucose and insulin levels and changes in hemoglobin A1c (HbA1c). The DJBL was removed endoscopically at the end of the study. RESULTS Thirteen subjects completed the 52-week study, and the mean duration of the implant period for all subjects was 41.9±3.2 weeks. Reasons for early removal of the device included device migration (n=3), gastrointestinal bleeding (n=1), abdominal pain (n=2), principal investigator request (n=2), and discovery of an unrelated malignancy (n=1). Using last observation carried forward, statistically significant reductions in fasting blood glucose (-30.3±10.2 mg/dL), fasting insulin (-7.3±2.6 μU/mL), and HbA1c (-2.1±0.3%) were observed. At the end of the study, 16 of the 22 subjects had an HbA1c<7% compared with only one of 22 at baseline. Upper abdominal pain (n=11), back pain (n=5), nausea (n=7), and vomiting (n=7) were the most common device-related adverse events. CONCLUSIONS The DJBL improves glycemic status in obese subjects with diabetes and therefore represents a nonsurgical, reversible alternative to bariatric surgery.

Role of proximal gut exclusion from food on glucose homeostasis in patients with Type 2 diabetes.

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.

Complications of gastrectomy with lymphadenectomy in gastric cancer

BackgroundCurrently, gastrectomy and extended lymphadenectomy (LN) is the treatment of choice for gastric cancer. Although a survival rate benefit of D2 LN compared to D1 LN has been shown, the D2 LN procedure is not fully employed, due to possible higher morbidity and mortality rates. These higher rates are being questioned in more recent series, in which D1 and D2 LN complication rates have been similar. The aim of this study was to analyze the immediate postoperative complications of patients submitted to total or subtotal gastrectomy with D1 or D2 LN (according to the Japanese guidelines for gastric cancer) at the Gastrointestinal Surgery Division of the Medical School of São Paulo University, between January 2001 and April 2003.MethodsOne hundred consecutive patients were studied; 61 were men and 39, women. Total gastrectomy was performed in 52 patients (13 with D1 LN and 39 with D2 LN), and subtotal gastrectomy was performed in 48 (11 with D1 LN and 37 with D2 LN). Total or subtotal gastrectomy with D1 or D2 LN was performed according to the tumor extent and histological classification (Lauren’s diffuse or intestinal type), considering the patient’s general condition and the gastric cancer stage. Roux-en-Y reconstruction was performed in almost all patients.ResultsNo difference was observed regarding complications and mortality related to the extent of the gastrectomy. Although morbidity was higher in the D1 group, no significant difference was observed. Mortality was higher in the D1 group, and this was probably related to their poor surgical condition and more advanced tumors.ConclusionAccording to these results, it appears that total or subtotal gastrectomy with D2 LN in gastric cancer treatment, performed according to the Japanese guidelines, can be considered a safe procedure, with acceptable morbidity and mortality, when performed by a trained surgical team.

Etiology, endoscopic management and mortality of upper gastrointestinal bleeding in patients with cancer

Background The source and outcomes of upper gastrointestinal bleeding (UGIB) in oncologic patients are poorly investigated. Objective The study aimed to investigate these issues in a tertiary academic referral center specialized in cancer treatment. Methods This was a retrospective study including all patients with cancer referred to endoscopy due to UGIB in 2010. Results UGIB was confirmed in 147 (of 324 patients) referred to endoscopy for a suspected episode of GI bleeding. Tumor was the most common cause of bleeding (N = 35, 23.8%), followed by varices (N = 30, 19.7%), peptic ulcer (N = 29, 16.3%) and gastroduodenal erosions (N = 16, 10.9%). Among the 32 patients with cancer of the upper GI tract, the main causes of bleeding were cancer (N = 27, 84.4%) and peptic ulcer (N = 5, 6.3%). Forty-one patients (27.9%) presented with bleeding from the primary tumor or from a metastatic lesion, and seven received endoscopic therapy, with successful initial hemostasis in six (85.7%). Rebleeding and mortality rates were not different between endoscopically treated (N = 7) and non-treated (N = 34) patients (28.6% vs. 14.7%, p = 0.342; 43.9% vs. 44.1%, p = 0.677). Median survival was 20 days, and the overall 30-day mortality rate was 44.9%. There was no predictive factor of mortality or rebleeding. Conclusion Tumor bleeding is the most common cause of UGIB in cancer patients. UGIB in cancer patients correlates with a high mortality rate regardless of the bleeding source. Current endoscopic treatments may not be effective in preventing rebleeding or improving survival.

Argon plasma coagulation for the endoscopic treatment of gastrointestinal tumor bleeding: A retrospective comparison with a non-treated historical cohort

Background The endoscopic use of argon plasma coagulation (APC) to achieve hemostasis for upper gastrointestinal tumor bleeding (UGITB) has not been adequately evaluated in controlled trials. This study aimed to evaluate the efficacy of APC for the treatment of upper gastrointestinal bleeding from malignant lesions. Methods Between January and September 2011, all patients with UGITB underwent high-potency APC therapy (up to 70 Watts). This group was compared with a historical cohort of patients admitted between January and December 2010, when the endoscopic treatment of bleeding malignancies was not routinely performed. Patients were stratified into two categories, grouping the Eastern Cooperative Oncology Group (ECOG) performance status scale: Category I (ECOG 0–2) patients with a good clinical status and Category II (ECOG 3–4) patients with a poor clinical status. Results Our study had 25 patients with UGITB whom underwent APC treatment and 28 patients whom received no endoscopic therapy. The clinical characteristics of the groups were similar, except for endoscopic active bleeding, which was more frequently detected in APC group. We had 15 patients in the APC group whom had active bleeding, and initial hemostasis was obtained in 11 of them (73.3%). In the control group, four patients had active bleeding. There were no differences in 30-day re-bleeding (33.3% in the APC group versus 14.3% in the control group; p = 0.104) and 30-day mortality rates (20.8% in the APC group, versus 42.9% in the control group; p = 0.091). When patients were categorized according to their ECOG status, we found that APC therapy had no impact in re-bleeding and mortality rates (Group I: APC versus no endoscopic treatment: re-bleeding p = 0.412, mortality p = 0.669; Group II: APC versus no endoscopic treatment: re-bleeding p = 0.505, mortality p = 0.580). Hematemesis and site of bleeding located at the esophagus or duodenum were associated with a higher 30-day mortality. Conclusions Endoscopic hemostasis of UGITB with APC has no significant impact on 30-day re-bleeding and mortality rates, irrespective of patient performance status.

Comparative evaluation of esophageal Barrett's epithelium through esophageal capsule endoscopy and methylene blue chromoendoscop

BACKGROUND Patients presenting with Barretts 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.

Strongyloides stercoralis hyperinfection: an unusual cause of gastrointestinal bleeding.

Strongyloidiasis is a parasitic disease that may progress to a disseminated form, called hyperinfection syndrome, in patients with immunosuppression. The hyperinfection syndrome is caused by the wide multiplication and migration of infective larvae, with characteristic gastrointestinal and/or pulmonary involvement. This disease may pose a diagnostic challenge, as it presents with nonspecific findings on endoscopy.

Colonic stent versus emergency surgery as treatment of malignant colonic obstruction in the palliative setting: a systematic review and meta-analysis

[This corrects the article DOI: 10.1055/a-0591-2883.].

The impact of probe-based confocal endomicroscopy on the management of indeterminate bile duct strictures

GIE Volume 3, No. 1 : 2018 ERCP. Probe-based confocal laser endomicroscopy (pCLE) is a safe, innovative endoscopic method, which offers the potential of real-time in vivo diagnosis. High sensitivity, negative predictive value, and diagnostic accuracy (>95%) have been demonstrated by the use of pCLE according to the Miami and Paris classifications for biliary strictures. A 62-year-old woman presented with abdominal pain, vomiting, and jaundice. After the diagnosis of cholecystitis and cholelithiasis, she underwent cholecystectomy and ERCP in another hospital. After 3 months, she presented with recurrent jaundice and weight loss of 23 kg (about 30% of body weight) without signs of cholangitis. An abdominal CT scan identified a solid mass at the hilum (Fig. 1). Owing to infiltration of the hepatic artery, surgical resection was contraindicated. The patient underwent ERCP for biliary drainage in addition to pCLE evaluation of the hilar stricture with the use of CholangioFlex (Mauna Kea Technologies, Paris, France). The resulting images showed characteristics of malignant stenosis with thick bands, and increased dark cells (Fig. 2). Biopsy specimens were obtained, and brush cytology was performed to confirm the diagnosis, followed by the insertion of plastic stents. After histologic confirmation of cholangiocarcinoma, the patient underwent another

The Role of Endoscopy

Endoscopy has become an important tool in the diagnosis, staging, treatment, and palliation of patients with gastric cancer, including of the diffuse type. During upper endoscopy, suspicious-appearing gastric lesions can be identified and carefully analyzed to guide proper management. This chapter will focus on the endoscopic approach to diffuse gastric cancer: macroscopic classification, tissue acquisition, staging, and the window for endoscopic management.