Eduardo G. de Moura

Endoscopic removal of eroded adjustable gastric band: lessons learned after 5 years and 78 cases

BACKGROUND One of the complications of laparoscopic adjustable gastric banding is intragastric erosion, leading to a revisional procedure to remove the band. Our aim was to present the procedure and results of endoscopic band removal in a 5-year multicenter experience from the Gastro Obeso Center and Universidade de São Paulo, São Paulo, and Universidade Federal de Pernambuco, Recife, Brazil. METHODS From 2003 to 2008, 82 patients were diagnosed with band erosion. The clinical data concerning the endoscopic procedure were prospectively recorded and retrospectively reviewed. RESULTS The average preoperative body mass index was 43.2 kg/m(2) (range 34-50). At the diagnosis of intragastric erosion, the body mass index was 24-41 kg/m(2) (average 31.8). The erosion occurred an average of 16.3 months (range 6-36) postoperatively. The symptoms included pain in 25 (31%), port infection in 21 patients (27%), and weight regain in 20 (25%), and 12 patients (15%) were asymptomatic. Endoscopic removal was possible for 78 patients (95%). In 85% of patients, the band was removed in the first session, with an average duration of 55 minutes (range 25-150). Five cases of pneumoperitoneum occurred after the procedure. Of these, 3 were treated conservatively, 1 was treated by laparoscopy, and 1 was treated by abdominal puncture using the Veress needle. CONCLUSION Endoscopic removal of eroded laparoscopic adjustable gastric banding is safe and effective. It can be used as a first choice procedure in clinical practice.

EUS-guided percutaneous endoscopic gastrostomy for enteral feeding tube placement

BACKGROUND Patients without adequate abdominal-wall transillumination are at a high risk of developing complications after PEG. OBJECTIVE We evaluated the feasibility and utility of EUS to guide PEG in patients lacking abdominal-wall transillumination. DESIGN Single-center case series. SETTING Tertiary-referral center. PATIENTS Six patients who lacked adequate abdominal-wall transillumination and 2 patients with a large laparotomy scar deemed to be at high risk of developing complications after PEG. INTERVENTIONS Patients underwent EUS-guided PEG and deployment of a standard enteral feeding tube. MAIN OUTCOME MEASUREMENTS Technical success and complication rates. RESULTS PEG was successful under EUS guidance in 5 of 8 patients. Causes of failure included an inadequate EUS window because of a prior Billroth 1 gastrectomy in one and suspected bowel interposition in 2 patients. There were no complications. LIMITATIONS A small number of patients, uncontrolled study, and short follow-up period. CONCLUSIONS This technique may facilitate deployment of PEG in patients who lack adequate abdominal-wall transillumination.

Endoscopic ultrasound versus magnetic resonance cholangiopancreatography in suspected choledocholithiasis: A systematic review.

Background and Objectives: There is a lack of consensus about the optimal noninvasive strategy for patients with suspected choledocholithiasis. Two previous systematic reviews used different methodologies not based on pretest probabilities that demonstrated no statistically significant difference between Endoscopic ultrasound (EUS) and magnetic resonance cholangiopancreatography (MRCP) for the detection of choledocholithiasis. In this article, we made a comparison of the diagnostic ability of EUS and MRCP to detect choledocholithiasis in suspected patients. Methods: We conducted a systematic review in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) recommendations with all published randomized prospective trials. We performed the systemic review using MedLine, EMBASE, Cochrane, LILACS, and Scopus reviews through May 2015. We identified eight randomized, prospective, blinded trials comparing EUS and MRCP. All the patients were submitted to a gold standard method. We calculated the study-specific variables and performed analyses using aggregated variables such as sensitivity, specificity, prevalence, positive predictive value (PPV) and negative predictive value (NPV), and accuracy. Results: Five hundred and thirty eight patients were included in the analysis. The pretest probability for choledocholithiasis was 38.7. The mean sensitivity of EUS and MRCP for detection of choledocholithiasis was 93.7 and 83.5, respectively; the specificity was 88.5 and 91.5, respectively. Regarding EUS and MRCP, PPV was 89 and 87.8, respectively, and NPV was 96.9 and 87.8, respectively. The accuracy of EUS and MRCP was 93.3 and 89.7, respectively. Conclusions: For the same pretest probability of choledocholithiasis, EUS has higher posttest probability when the result is positive and a lower posttest probability when the result is negative compared with MRCP.

Gastrointestinal Transcriptomic Response of Metabolic Vitamin B12 Pathways in Roux-en-Y Gastric Bypass

OBJECTIVES: Vitamin B12 (B12) deficiency after Roux‐en‐Y gastric bypass (RYGB) is highly prevalent and may contribute to postoperative complications. Decreased production of intrinsic factor owing to gastric fundus removal is thought to have a major role, but other components of B12 metabolism may also be affected. We evaluated changes in the expression levels of multiple B12 pathway‐encoding genes in gastrointestinal (GI) tissues to evaluate the potential roles in contributing to post‐RYGB B12 deficiency. METHODS: During double‐balloon enteroscopy, serial GI biopsies were collected from 20 obese women (age, 46.9±6.2 years; body mass index, 46.5±5.3 kg/m2) with adult‐onset type 2 diabetes (fasting plasma glucose ≥126 mg/dl; hemoglobin A1c≥6.5%) before and, at the same site, 3 months after RYGB. Gene expression levels were assessed by the Affymetrix Human GeneChip 1.0 ST microarray. Findings were validated by real‐time quantitative PCR (RT–qPCR). RESULTS: Gene expression levels with significant changes (P≤0.05) included: transcobalamin I (TCN1) in remnant (−1.914‐fold) and excluded (−1.985‐fold) gastric regions; gastric intrinsic factor (GIF) in duodenum (−0.725‐fold); and cubilin (CUBN) in duodenum (+0.982‐fold), jejunum (+1.311‐fold), and ileum (+0.685‐fold). Validation by RT–qPCR confirmed (P≤0.05) observed changes for TCN1 in the remnant gastric region (−0.132‐fold) and CUBN in jejunum (+2.833‐fold). CONCLUSIONS: RYGB affects multiple pathway‐encoding genes that may be associated with postoperative B12 deficiency. Decreased TCN1 levels seem to be the main contributing factor. Increased CUBN levels suggest an adaptive genetic reprogramming of intestinal tissue aiming to compensate for impaired intestinal B12 delivery.

Comparison of Endoscopic Therapies forChronic Radiation Proctitis: A SystematicReview and Meta-Analysis

Background: Radiation injury to the lower intestine may result following treatment of cancers of the pelvis. The rectum is most often affected. Argon plasma coagulation (APC), bipolar electro coagulation (BEC) and topical formalin are recognized as effective treatments. Objectives: This study aimed to determine in a systematic review and metaanalysis the most effective endoscopic therapy in the treatment of complications secondary Chronic Radiation Colo-Proctopathy (CRCP). Data sources: A systematic review of English and non-English articles using MEDLINE, COCHRANE, EMBASE, EBSCO, LILACS, Library University of Sao Paulo, BVS, and SCOPE. Criteria: The main outcome measures while undergoing endoscopic therapies are as follows: mean hemoglobin level before and after treatment, complications, and success in patients with chronic radiation Colo-Proctopathy (CRCP). Results: Three comparative studies were selected: one was a cohort study comparing APC with Formalin; the other two were unblinded randomized clinical trials with different comparisons (i.e., APC with BEC and APC with formalin). Based on the power of evidence from clinical trials and cohort studies, we can say that the APC seems to have the same efficacy as formalin and the BEC. Conclusions: The evidence for treatment modalities of CRCP is insufficient, although for endoscopic therapy APC appears to be the most promising treatment.