Fabio S. Kawaguti

Endoscopic submucosal dissection for the treatment of early esophageal and gastric cancer - initial experience of a western center

BACKGROUND Endoscopic submucosal dissection is a new Japanese technique characterized by en-bloc resection of the entire lesion irrespective of size, with lower local recurrence when compared to endoscopic mucosal resection. OBJECTIVE To evaluate the feasibility, early results and complications of the endoscopic submucosal dissection technique for treating early gastric and esophageal cancer at the Endoscopic Unit of Clinics Hospital and Cancer Institute of the São Paulo University. MATERIALS AND METHODS Twenty patients underwent endoscopic resection using the endoscopic submucosal dissection technique for early gastric or esophageal cancer. The patients were evaluated prospectively as to the executability of the technique, the short-term results of the procedure and complications. RESULTS Sixteen gastric adenocarcinoma lesions and six esophageal squamous carcinoma lesions were resected. In the stomach, the mean diameter of the lesions was 16.2 mm (0.6–3.5 mm). Eight lesions were type IIa + IIc, four were type IIa and four IIc, with thirteen being well differentiated and three undifferentiated. Regarding the degree of invasion, five were M2, seven were M3, two were Sm1 and one was Sm2. The mean duration of the procedures was 85 min (20–160 min). In the esophagus, all of the lesions were type IIb, with a mean diameter of 17.8 mm (6–30 mm). Regarding the degree of invasion, three were M1, one was M2, one was M3 and one was Sm1. All had free lateral and deep margins. The mean time of the procedure was 78 min (20–150 min) CONCLUSION The endoscopic submucosal dissection technique was feasible in our service with a high success rate.

Secondary lymphangiectasia of the small bowel: utility of double balloon enteroscopy for diagnosis and management.

Sporadic lymphangiectasias are commonly found throughout the small bowel and are considered to be normal. Not uncommonly, lymphangiectasias are pathologic and can lead to mid-gastrointestinal bleeding, abdominal pain and protein-losing enteropathy. Pathologic lymphangiectasias of the small bowel include primary lymphangiectasia, secondary lymphangiectasia and lymphaticovenous malformations. In this report we present three different cases of small bowel lymphangiectasia detected by double balloon enteroscopy. The patients were diagnosed with South American blastomycosis, tuberculosis and primary small bowel lymphangioma.

Comparison of the pull and introducer percutaneous endoscopic gastrostomy techniques in patients with head and neck cancer

Background and study aims Percutaneous endoscopic gastrostomy (PEG) in head and neck cancer (HNC) patients is associated with higher complication and mortality rates when compared to a general patient population. The pull technique is still the preferred technique worldwide but it has some limitations. The aim of this study is to compare the pull and introducer PEG techniques in patients with HNC. Patients and methods This study is based on a retrospective analysis of a prospectively collected database of 309 patients with HNC who underwent PEG in the Cancer Institute of São Paulo. Results The procedure was performed with the standard endoscope in 205 patients and the introducer technique was used in 137 patients. There was one procedure-related mortality. Age, sex and albumin level were similar in both groups. However in the introducer technique group, patients had a higher tumor stage, a lower Karnofsky status, and presented more frequently with tracheostomy and trismus. Overall, major, minor, immediate and late complications and 30-day mortality rates were similar but the introducer technique group presented more minor bleeding and tube dysfunctions. Conclusion The push and introducer PEG techniques seem to be both safe and effective but present different complication profiles. The choice of PEG technique in patients with HNC should be made individually.

Complete therapeutic response of a large tubulovillous adenoma after chemotherapy

We describe the case of a woman who underwent urgent right hemicolectomy for obstructive advanced neoplasia. Histopathologic examination revealed poorly differentiated mucinous adenocarcinoma with invasion to the subserosa without vascular or perineural invasion. Seven of 28 resected regional lymph nodes were metastatic (pT3pN2M0). Immunohistochemical study showed microsatellite instability. Adjuvant chemotherapy with oxalipla-

Sa1643 Self-Expanding Metallic Stents for the Treatment of Malignant Colorectal Obstruction Are Effective and Safe

Sa1642 Ascending Colon Exploration by Retroviewing: Technical Feasibility and Diagnosis Performance Alba L. Vargas*, Marco Alburquerque, Montserrat Figa, Ferran GonzaLez-Huix Endoscopy, Clinica Girona, Girona, Spain Introduction: The right colon lesions not visualized during the standard colonoscopy have been associated to interval cancer. The proximal fold side exploration of the ascending colon by retroviewing reduces the likely of losing those lesions. The shorter colonoscope diameter would make easier the cecal retroflexion with lower complication rate. Objective: To determine the technical feasibility of the cecal retroflexion, the diagnosis performance and complication rate of the ascending colon exploration by retroviewing with a shorter colonoscope diameter. Methods: Prospective study. There were included all the consecutive total colonoscopies performed by an expert endoscopist during four months. Technique: 1) Usual exploring of the ascending colon: colonoscope insertion and colonoscope withdrawal in forward view from the cecum until the hepatic flexure, 2) colonoscope reinsertion and cecal retroflexion maneuver, and 3) colonoscope withdrawal in retroviewing until the hepatic flexure. We collected the visualized and resected lesions on conventional and retroviewing colonoscopy. Exclusion criteria: incomplete endoscopies by any cause (obstruction, endoscopic therapy, right colon resection). All procedures were done with a Colonoscope PENTAX-i10L EC34 (Insert O: 11.6, Channel: 3.8, Deflection up/down: 180/180, left/right: 160/160). Results: There were included 323 colonoscopies and were excluded 20 by incomplete examination. The cecal retroflexion was feasible in 76.6% (n Z 232). In these procedures, in the right colon, were detected 42 (29.4%) polyps: 40 Paris Is (32 sessile and 8 subpedunculated) and 2 Ip; in 142 colonoscopies. Histology: 32 adenomas and 10 sessile serrated polyps without dysplasia. 14 polyps (9.8% of the total and 33.3% of the ascending colon) were detected only by withdrawal colonoscopy in retroviewing: sessile polyps Is, between 3-15 mm; 8 were resected in retroflexion. There were not complications. Conclusion: The cecal retroflexion was feasible in over 75% of colonoscopies and were not registered associated complications. Over 30% of the ascending colon polyps were detected only by colonoscope withdrawal in retroviewing. Cecal retroflexion maneuver has the potential to improve colorectal polyps detection.

Sa1668 Results of Two Different Techniques of Percutaneous Endoscopic Gastrostomy in Patients With Head and Neck Cancer - Experience of a Tertiary Referral Academic Center

Results of Two Different Techniques of Percutaneous Endoscopic Gastrostomy in Patients With Head and Neck Cancer Experience of a Tertiary Referral Academic Center Felipe A. Retes, Fauze Maluf-Filho, Fabio S. Kawaguti, Carla Z. Neves, Bruno C. Martins, Fabio Y. Hondo, Marcelo S. Lima, Ulysses Ribeiro, Paulo Sakai Surgery of the Alimentary Tract, Cancer Institute of Sao Paulo, Sao Paulo, Brazil Introduction: Most of the patients with head and neck cancer (HNC) present with dysphagia caused by the malignant digestive stenosis usually aggravated by the treatment. In most of them, prolonged nutritional support will be needed. Percutaneous endoscopic gastrostomy (PEG) is considered the method of choice to provide nutritional support to these patients. On the other hand, severe complications related to PEG placement such as acute respiratory distress, metastasis to the gastrostomy site and increased rate of peristomal infection have been associated with HNC patients. Objective: describe the safety profile and the efficacy of two PEG techniquespull and introducer/gastropexy in HNC patients. Methods: retrospective review of prospectively collected data in an academic tertiary referral center. From December 2008 to May 2010, 77 HNC patients (84% male, median age 58,6 y, range 28 to 89 y) were referred to PEG placement. Patients with trismus or severe aerodigestive stenosis were submitted to the introducer technique with gastropexy (Frexapexat-Fresenius Germany) with the aid of a slim (4.9mm) scope (GIF-N180 Olympus Co, Japan). The remaining pts were submitted to standard PEG by the pull technique with a 24 or 20Fr feeding tube (PEGflow Cook, USA). The rates of technical success, complications, morbidity and mortality were determined. Results: PEG placement was possible in 76 patients (98.7%). The absence of transillumination and previous gastrectomy prevented PEG in one pt (1.3%). The pull technique was employed in 65 patients (85.5%) and the introducer technique with gastropexy with a 15 Fr tube, in 11 patients (14.5%). Major complications were observed in 6 (7.8%) and minor complications in 11 (14.4%) of the 76 patients. All the major complications were observed in the pull technique group (6/65pts-9.2%) and included acute respiratory distress in three pts (4,6%) with fatal outcome in one of them (1.5% mortality rate), one case of bleeding (1,5%), one case with buried bumper syndrome (1,5%) and inadvertent early withdrawn of the tube in one pt (1,5%). Minor complications were observed in 5 patients in the pull technique (7,6%) and included granuloma at the PEG site in two pts (3%), peristomal infection in two pts (3%) and local pain in one pt (1,5%). In the introducer/gastropexy technique group minor complications were observed in six pts (54,5%) and included tube dislodgment in four (36,3%), dermatitis in one (9%) and local pain in one pt (9%). Conclusions: PEG is a feasible, safe and effective procedure in HNC patients. Our preliminary data suggest that the pull technique is related to higher rates of severe complications and the introducer/gastropexy technique is associated with more frequent tube dysfunction. Randomized trials are needed to compare the push and introducer/gastropexy techniques in HNC pts.