Eduardo Moura

Endoscopy vs surgery in the treatment of early gastric cancer: Systematic review.

AIM To report a systematic review, establishing the available data to an unpublished 2a strength of evidence, better handling clinical practice. METHODS A systematic review was performed using MEDLINE, EMBASE, Cochrane, LILACS, Scopus and CINAHL databases. Information of the selected studies was extracted on characteristics of trial participants, inclusion and exclusion criteria, interventions (mainly, mucosal resection and submucosal dissection vs surgical approach) and outcomes (adverse events, different survival rates, mortality, recurrence and complete resection rates). To ascertain the validity of eligible studies, the risk of bias was measured using the Newcastle-Ottawa Quality Assessment Scale. The analysis of the absolute risk of the outcomes was performed using the software RevMan, by computing risk differences (RD) of dichotomous variables. Data on RD and 95%CIs for each outcome were calculated using the Mantel-Haenszel test and inconsistency was qualified and reported in χ(2) and the Higgins method (I (2)). Sensitivity analysis was performed when heterogeneity was higher than 50%, a subsequent assay was done and other findings were compiled. RESULTS Eleven retrospective cohort studies were selected. The included records involved 2654 patients with early gastric cancer that filled the absolute or expanded indications for endoscopic resection. Three-year survival data were available for six studies (n = 1197). There were no risk differences (RD) after endoscopic and surgical treatment (RD = 0.01, 95%CI: -0.02-0.05, P = 0.51). Five-year survival data (n = 2310) showed no difference between the two groups (RD = 0.01, 95%CI: -0.01-0.03, P = 0.46). Recurrence data were analized in five studies (1331 patients) and there was no difference between the approaches (RD = 0.01, 95%CI: -0.00-0.02, P = 0.09). Adverse event data were identified in eight studies (n = 2439). A significant difference was detected (RD = -0.08, 95%CI: -0.10--0.05, P < 0.05), demonstrating better results with endoscopy. Mortality data were obtained in four studies (n = 1107). There was no difference between the groups (RD = -0.01, 95%CI: -0.02-0.00, P = 0.22). CONCLUSION Three-, 5-year survival, recurrence and mortality are similar for both groups. Considering complication, endoscopy is better and, analyzing complete resection data, it is worse than surgery.

Factors associated with complications or failure of endoscopic balloon dilation of anastomotic stricture secondary to Roux-en-Y gastric bypass surgery

INTRODUCTION Roux-en-Y gastric bypass is a commonly used technique of bariatric surgery. One of the most important complications is gastrojejunal anastomotic stricture. Endoscopic balloon dilation appears to be well tolerated and effective, but well-designed randomized, controlled trials have not yet been conducted. OBJECTIVE Identify factors associated with complications or failure of endoscopic balloon dilation of anastomotic stricture secondary to Roux-en-Y gastric bypass surgery. SETTING Gastrointestinal endoscopy service, university hospital, Brazil. METHODS The records of 64 patients with anastomotic stricture submitted to endoscopic dilation with hydrostatic balloon dilation were reviewed. Information was collected on gastric pouch length, anastomosis diameter before dilation, number of dilation sessions, balloon diameter at each session, anastomosis diameter after the last dilation session, presence of postsurgical complications, endoscopic complications, and outcome of dilation. Comparisons were made among postsurgical and endoscopic complications; number of dilations, balloon diameter; anastomosis diameter before dilation; and dilation outcome. RESULTS Success of dilation treatment was 95%. Perforation was positively and significantly associated with the number of dilation sessions (P = .03). Highly significant associations were found between ischemic segment and perforation (P<.001) and between ischemic segment and bleeding (P = .047). Ischemic segment (P = .02) and fistula (P = .032) were also associated with dilation failure. CONCLUSION Ischemic segment and fistula were found to be important risk factors for balloon dilation failure. The greater the number of dilation sessions, the greater the number of endoscopic complications.

Overtube-assisted enteroscopy and capsule endoscopy for the diagnosis of small-bowel polyps and tumors: a systematic review and meta-analysis.

Background and study aims: Several studies have evaluated the utility of double-balloon enteroscopy (DBE) and capsule endoscopy (CE) for patients with small-bowel disease showing inconsistent results. The aim of this study was to determine the sensitivity and specificity of overtube-assisted enteroscopy (OAE) as well as the diagnostic concordance between OAE and CE for small-bowel polyps and tumors. Patients and methods: We conducted a systematic review and meta-analysis of studies in which the results of OAE were compared with the results of CE for the evaluation of small-bowel polyps and tumors. When data for surgically resected lesions were available, the histopathological results of OAE and surgical specimens were compared. The sensitivity, specificity, positive likelihood ratio, and negative likelihood ratio for the diagnosis of small-bowel polyps and tumors were analyzed. Secondarily, the rates of diagnostic concordance and discordance between OAE and CE were calculated. Results: There were 15 full-length studies with a total of 821 patients that met the inclusion criteria. The pooled sensitivity, specificity, positive likelihood ratio, and negative likelihood ratio were as follows: 0.89 (95 % confidence interval [CI] 0.84 – 0.93), with heterogeneity χ2 = 41.23 (P = 0.0002) and inconsistency (I 2) = 66.0 %; 0.97 (95 %CI 0.95 – 0.98), with heterogeneity χ2 = 45.27 (P = 0.07) and inconsistency (I 2) = 69.1 %; 16.61 (95 %CI 3.74 – 73.82), with heterogeneity Cochrane’s Q = 225.19 (P < 0.01) and inconsistency (I 2) = 93.8 %; and 0.14 (95 %CI 0.05 – 0.35), with heterogeneity Cochrane’s Q = 81.01 (P < .01) and inconsistency (I 2) = 82.7 %, respectively. A summary receiver operating characteristic curve (SROC) curve was constructed, and the area under the curve (AUC) was 0.97. Conclusion: OAE is an accurate test for the detection of small-bowel polyps and tumors. OAE and CE have a high diagnostic concordance rate for small-bowel polyps and tumors. This study was registered in the PROSPERO international database (www.crd.york.ac.uk/prospero/) with the study number CRD42015016000.

Endoscopic retrograde cholangiopancreatography versus endoscopic ultrasound for tissue diagnosis of malignant biliary stricture: Systematic review and meta-analysis

Background and Aims: There are no systematic reviews comparing the use of endoscopic retrograde cholangiopancreatography (ERCP)-based brush cytology and forceps biopsy and endoscopic ultrasound (EUS)-guided fine-needle aspiration (FNA) for the diagnosis of malignant biliary stricture; so in this revision, we will compare ERCP against EUS-FNA for tissue diagnosis of malignant biliary stricture. Design: A systematic review was conducted of comparative studies (prospective or retrospective) analyzing EUS and ERCP for tissue diagnosis of malignant biliary stricture. Materials and Methods: The databases Medline, EMBASE, Cochrane, LILACS, CINAHL, and Scopus were searched for studies dated previous to November 2014. We identified three prospective studies comparing EUS-FNA and ERCP for the diagnosis of malignant biliary stricture and five prospective studies comparing EUS-FNA with the same diagnosis of the other three studies. All patients were subjected to the same gold standard method. We calculated study variables (sensitivity, specificity, prevalence, positive and negative predictive values, and accuracy) and performed a meta-analysis using the Review Manager (RevMan) 5.3 software. Results: A total of 294 patients were included in the analysis. The pretest probability for malignant biliary stricture was 76.66%. The mean sensitivities of ERCP and EUS-FNA for tissue diagnosis of malignant biliary stricture were 49% and 75%, respectively; the specificities were 96.33% and 100%, respectively. The posttest probabilities positive predictive value (98.33% and 100%, respectively) and negative predictive value (34% and 47%, respectively) were determined. The accuracies were 60.66% and 79%, respectively. Conclusion: We found that EUS-FNA was superior to ERCP with brush cytology and forceps biopsy for diagnosing malignant biliary strictures. However, a negative EUS-FNA or ERCP test may not exclude malignant biliary stricture because both have low negative posttest probabilities.

Percutaneous endoscopic versus surgical gastrostomy in patients with benign and malignant diseases: a systematic review and meta-analysis

To compare the complications and mortality related to gastrostomy procedures performed using surgical and percutaneous endoscopic gastrostomy techniques, this review covered seven studies. Five of these were retrospective and two were randomized prospective studies. In total, 406 patients were involved, 232 of whom had undergone percutaneous endoscopic gastrostomy and 174 of whom had undergone surgical gastrostomy. The analysis was performed using Review Manager. Risk differences were computed using a fixed-effects model and forest and funnel plots. Data on risk differences and 95% confidence intervals were obtained using the Mantel-Haenszel test. There was no difference in major complications in retrospective (95% CI (-0.11 to 0.10)) or randomized (95% CI (-0.07 to 0.05)) studies. Regarding minor complications, no difference was found in retrospective studies (95% CI (-00.17 to 0.09)), whereas a difference was observed in randomized studies (95% CI (-0.25 to -0.02)). Separate analyses of retrospective and randomized studies revealed no differences between the methods in relation to mortality and major complications. Moreover, low levels of minor complications were observed among endoscopic procedures in randomized studies, with no difference observed compared with retrospective studies.

Endoscopic treatment of large pancreatic fluid collections (PFC) using self-expanding metallic stents (SEMS) – a two-center experience

Background/study aim: During the last several years, endoscopic ultrasound (EUS)-guided pancreatic fluid collections’ (PFC) drainage has evolved into the preferred drainage technique. Recently, self-expanding metallic stents (SEMS) have been used as an alternative to double pigtail stents, with the advantage of providing a larger diameter fistula, thereby decreasing the risk of early obstruction and also allowing for direct endoscopic exploration of the cavity. The aim of this study was to evaluate the technical and clinical success, safety, and outcome of patients undergoing EUS-guided drainage of complex PFC using SEMS. Patients/materials and methods: The study was conducted at two tertiary hospitals from January 2010 to January 2013. All patients with PFC referred for endoscopic drainage were enrolled in a prospective database. The inclusion criteria were: (1) patients with pseudocysts or walled-off necrosis based on the revised Atlanta classification; (2) symptomatic patients with thick PFC; (3) PFC that persisted more than 6 weeks; and (4) large PFC diameter (≥ 9 cm). The exclusion criteria consisted of coagulation disorders, PFC bleeding or infection, and failure-to-inform written consent. Results: A total of 16 patients (9 females, 7 males; mean age 52.6, range 20 – 82) underwent EUS drainage with SEMS. There were 14 cases of pseudocysts and 2 cases of walled-off necrosis. The etiologies of the PFC were mainly gallstones (8 of 16 patients, 50 %) and alcohol (5 of 16 patients, 31 %). Technical success was achieved in 100 % of the cases. All patients had a complete resolution of the PFC. Conclusion: Transmural EUS-guided drainage of complex PFC using SEMS is feasible, appears safe, and is efficacious. However, the exchange of the UC (uncovered)-SEMS for plastic stents is mandatory within 1 week. Future prospective studies, preferably multicenter studies, comparing SEMS versus traditional plastic stents for the drainage of PFC are warranted.

Endoscopic polymer injection and endoluminal plication in treatment of gastroesophageal reflux disease: evaluation of long-term results

Background and study aims  Us of proton pump inhibitors (PPIs) has made endoscopic treatment of gastroesophageal reflux disease (GERD) more efficient, with reduction in morbidity and complications. However, some patients persist with symptoms despite medical treatment and some are not compliant with it or cannot afford it for financial reasons, and thus they require non-pharmacological therapeutic options such as surgical fundoplication. Surgery may be effective in the short term, but there is related morbidity and concern about its long-term efficacy. The possibility of minimally invasive endoluminal surgeries has resulted in interest in and development of newly endoscopic devices. Good short-term results with surgical fundoplication lack of studies of is with long follow-up justify our interest in this study. The aim of this study was to investigate the efficacy of endoscopic polymer injection and endoluminal full-thickness plication in the long-term control of GERD. Patients and methods  Forty-seven patients with GERD who underwent an endoscopic procedure were followed up for 60 months and evaluated for total response (RT), partial response (RP) and no response (SR) to endoscopic treatment with reintroduction of PPIs. Results  Twenty-one patients received polymer injection (G0) and 26 endoluminal plication (G1). The number of patients with no response to endoscopic treatment with reintroduction of PPIs increased in time for both techniques (G0 P  = 0.006; G1 P  < 0.001). There was symptomatic improvement up to 12 months, with progressive loss of this trending up to 60 months in G0 and G1 ( P  < 0.001). Health-related quality of life score (GERD-HRQL) demonstrated TR in G0 and G1 at 1, 3, 6 and 12 months. The 60-month analysis showed an increased number of patients with SR in both groups. The quality of life assessment (SF-36) showed benefit in G0 up to 3 months. G0 showed a higher rate of complications. There were no deaths. There was healing of esophagitis at 3 months in 45 % of patients in G0 and 40 % in G1. There was no improvement in manometric or pH findings. Conclusion  Endoscopic therapies were ineffective in controlling GERD in the long term.

Endoscopic pneumatic dilatation and peroral endoscopic myotomy in dilated megaesophagus

Achalasia is a primary esophageal disorderth variable causes, with an incidence between 0.03 to 1/100,000 people, and prevalence of approximately 10/100,000, with no difference between gender. It is more frequent in South and Central America, where Chagas disease is endemic. There are several methods to treat achalasia including endoscopic and surgical procedures, however, all of these methods are palliative. This article discusses 2 different endoscopic methods to treat advanced megaesophagus in Chagas disease, pneumatic balloon dilatation (PBD), and peroral endoscopic myotomy (POEM). Although varying between studies, PBD has an average symptom relief in 93% of patients in 6 months and 44% in 6 years. Some risk factors for failure of PBD are: younger age, male gender, a wider esophagus, poor emptying on posttreatment barium esophagogram and Eckardt scale < 3 before the treatment. Despite relatively short-term follow-up of an average of 3 years, POEM has excellent results. The clinical success achieved in 98 % with the Eckardt score decreased from 6.9 preoperatively to 0.77. Regarding sigmoid-shaped esophagus, only a few papers have been published on POEM. The largest population was 32 patients with a follow-up of 2 years. There was an efficacy of 96%, with the Eckardt scale decreasing from 7.8 to 1.4. In conclusion, PBD, is still widely used mainly due to its availability, especially in patients with a higher surgical risk and in patients who already had a Heller myotomy who persist or develop dysphagia. POEM has already demonstrated excellent results, but it requires advanced technical skills and Long-term results and randomized clinical trials are needed to validate the use of POEM in routine clinical practice.