Carlos K. Furuya

Effects of bariatric surgery on nonalcoholic fatty liver disease: Preliminary findings after 2 years

Background and Aim:  Although nonalcoholic fatty liver disease (NAFLD) is very common among morbidly obese patients, the effect of weight loss after bariatric surgery on inflammation and fibrosis related to NAFLD is still a matter of debate. The aim of this study was to evaluate the impact of Roux‐en‐Y gastric bypass (RYGB) surgery on NAFLD with a follow up of 2 years.

Lipid Peroxidation in Bariatric Candidates with Nonalcoholic Fatty Liver Disease (NAFLD) – Preliminary Findings

Background: Pathogenesis of nonalcoholic fatty liver disease (NAFLD) remains incompletely known, and oxidative stress is one of the mechanisms incriminated. The aim of this study was to evaluate the role of liver oxidative stress in NAFLD affecting morbidly obese patients. Methods: 39 consecutive patients with BMI >40 kg/m2 submitted to Roux-en-Y gastric bypass were enrolled, and wedge liver biopsy was obtained during operation. Oxidative stress was measured by concentration of hydroperoxides (CEOOH) in liver tissue. Results: Female gender was dominant (89.7%) and median age was 43.6 ± 11.1 years. Histology showed fatty liver in 92.3%, including 43.6% with nonalcoholic steatohepatitis (NASH), 48.7% with isolated steatosis and just 7.7% with normal liver. Liver cirrhosis was present in 11.7% of those with nonalcoholic steatohepatitis. Concentration of CEOOH was increased in the liver of patients with NASH when compared to isolated steatosis and normal liver (0.26± 0.17, 0.20± 0.01 and 0.14± 0.00 nmol/mg protein, respectively) (P <0.01). Liver biochemical variables were normal in 92.3% of all cases, and no difference between NASH and isolated steatosis could be demonstrated. Conclusions: 1) Nonalcoholic steatosis, steatohepatitis and cirrhosis were identified in substantial numbers of morbidly obese patients; 2) Concentration of hydroperoxides was increased in steatohepatitis, consistent with a pathogenetic role for oxidative stress in this condition.

ERCP Using Double-Balloon Enteroscopy in Patients with Roux-en-Y Anatomy

Double-balloon enteroscopy (DBE) is a useful method for endoscopic retrograde cholangiopancreatography (ERCP) in patients with Roux-en-Y anatomy. Depending on the distorted anatomy, endoscopic therapies with conventional scopes were very difficult or impossible before the advent of DBE and patients had to be submitted to a percutaneous or surgical approach. The case of 6 patients with different types of Roux-en-Y-altered anatomy in which DBE-ERCP was performed with 83.3% successful rate (5/6) is reported confirming recent data in the literature on the feasibility of this method.

Endoscopic dual therapy for giant peptic ulcer hemorrhage

Upper gastrointestinal bleeding (UGIB) is a common condition with an incidence of 40−150 cases per 100000 inhabitants per year [1, 2]. Peptic ulcer represents the most common cause of UGIB and dual therapy seems to be the best treatment [3]. Chronic ulcerated lesions have a greater chance of severe bleeding and may lead to shock within a few minutes [3–5]. Often, owing to lesion size and the presence of fibrosis, the use of endoscopic clips is not possible and other methods are necessary for dual treatment. To illustrate this, we describe the case of a patient with UGIB caused by a chronic peptic ulcer with active bleeding, which re-bled just after the first endoscopic treatment. We propose a waiting period of a few minutes after achieving initial hemostasis in order to check for rebleeding, especially in cases with a high risk of rebleeding (▶Video1). Video 1 Dual therapy with electrocoagulation and epinephrine injection was performed for active bleeding of a chronic giant peptic ulcer located in the incisura angularis. Owing to the size of the ulcer and the presence of fibrosis, endoscopic clips would not be successful. The importance of review time after the first therapy is emphasized in order to check for rebleeding.

AN INNOVATIVE EX-VIVO MODEL FOR RAPID CHANGE OF THE PAPILLA FOR TEACHING ADVANCED ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY PROCEDURES

ABSTRACT Background: Models for endoscopic retrograde cholangiopancreatography training allow practice with an expert feedback and without risks. A method to rapidly exchange the papilla can be time saving and accelerate the learning curve. Aim: To demonstrate a newly method of rapid exchange papilla in ex-vivo models to teach retrograde cholangiopancreatography advanced procedures. Methods: A new model of ex-vivo papilla was developed in order to resemble live conditions of procedures as cannulation, papilotomy or fistula-papilotomy, papiloplasty, biliary dilatation, plastic and metallic stentings. Results: The ex-vivo model of papilla rapid exchange is feasible and imitates with realism conditions of retrograde cholangiopancreatography procedures. Conclusion: This model allows an innovative method of advanced endoscopic training.

Flexible Endoscopic Zenker's Diverticulotomy Using Endoscopic Hood, Overtube, and Hook Knife

Abstract Zenkers diverticulum affects the elderly and is often without clinical conditions ideal for surgical treatment. In this scenario, endoscopic treatment is an appropriate indication, being a minimally invasive procedure. In this article, three videos demonstrate the techniques and details for a complete and safe treatment with low risk of complications and recurrence of the diverticulum. This article is part of an expert video encyclopedia.

Papillary fistulotomy vs conventional cannulation for endoscopic biliary access: A prospective randomized trial

AIM To compare the cannulation success, biochemical profile, and complications of the papillary fistulotomy technique vs catheter and guidewire standard access. METHODS From July 2010 to May 2017, patients were prospectively randomized into two groups: Cannulation with a catheter and guidewire (Group I) and papillary fistulotomy (Group II). Amylase, lipase and C-reactive protein at T0, as well as 12 h and 24 h after endoscopic retrograde cholangiopancreatography, and complications (pancreatitis, bleeding, perforation) were recorded. RESULTS We included 102 patients (66 females and 36 males, mean age 59.11 ± 18.7 years). Group I and Group II had 51 patients each. The successful cannulation rates were 76.5% and 100%, respectively (P = 0.0002). Twelve patients (23.5%) in Group I had a difficult cannulation and underwent fistulotomy, which led to successful secondary biliary access (Failure Group). The complication rate was 13.7% (2 perforations and 5 mild pancreatitis) vs 2.0% (1 patient with perforation and pancreatitis) in Groups I and II, respectively (P = 0.0597). CONCLUSION Papillary fistulotomy was more effective than guidewire cannulation, and it was associated with a lower profile of amylase and lipase. Complications were similar in both groups.

Endoscopic recanalization technique for complete ligation of bile duct after cholecystectomy

Bile duct injury (BDI) is a major adverse event after cholecystectomy. Within the BDI, ligation/transection of the bile duct is classified as type D of the Amsterdam classification. For this type of BDI, the only available management is surgery. We describe a new endoscopic procedure that allows recanalization of the ligated bile duct. All patients had previously undergone MRCP showing the stenosis and the alignment of the proximal and distal portions of the bile duct. ERCP was performed in a regular fashion through the papilla. A specialized catheter with an 18-gauge needle was introduced in the distal portion of the common bile duct to reach the proximal bile duct, and a 0.035-inch guidewire was introduced (Fig. 1; Video 1, available online at www.giejournal.org). In our initial cases, the procedure included balloon dilation of the stenotic segment and the placement of plastic stents. The first time, 1 plastic stent was placed; on a later

Bleeding angiodysplasia of the major duodenal papilla: how should it be handled?

Angiodysplasia is characterized by degenerative vascular dilation of the capillary net in the absence of dysplastic tissue. On endoscopy, flat or slightly elevated, reddish, roundish or starry lesions are observed, measuring normally between 2 and 10 mm. Angiodysplasia is a frequent cause of unexplained upper gastrointestinal bleeding with significant morbidity. It often occurs in the gastric antrum but may also occur in the duodenum and rarely in the esophagus. In the small bowel, it is the cause of unclear gastrointestinal [...]