Fábio Yuji Hondo

Surgery or Endoscopy for Palliation of Biliary Obstruction Due to Metastatic Pancreatic Cancer

BACKGROUND AND AIMS:Both endoscopic and surgical drainage procedures are effective palliative methods for malignant biliary obstruction. Surgical drainage is still preferred in developing countries due to the high cost of procuring metal biliary stents. The aim of this study was to evaluate the quality of life and the cost of care in patients with metastatic pancreatic cancer after endoscopic biliary drainage and surgical drainage.PATIENTS AND METHODS:This is a prospective, randomized controlled trial conducted in a tertiary referral center in Brazil. Patients with biliary obstruction due to metastatic pancreatic cancer and liver metastasis, but without gastric outlet obstruction, were included in the study. Endoscopic biliary drainage with the insertion of a metal stent into the bile duct was compared with the surgical drainage procedure (choledochojejunostomy and gastrojejunostomy). Quality of life was assessed before, and 30 days, 60 days, and 120 days after the drainage procedure. The cost of drainage procedure, cost during the first 30 days and the total cost from drainage procedure to death were calculated.RESULTS:Of the 273 patients with pancreatic malignancy seen at our hospital between July 2001 and October 2004, 35 patients were eligible for the study, and 30 agreed to participate in the study. Both surgical and endoscopic drainage procedures were successful, without any mortality in the first 30 days. The cost of biliary drainage procedure (US

Kras mutation analysis of fine needle aspirate under EUS guidance facilitates risk stratification of patients with pancreatic mass

2,832 ± 519 vs 3,821 ± 1,181, p = 0.031), the cost of care during the first 30 days after drainage (US

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

3,122 ± 877 vs 6,591 ± 711, p = 0.001), and the overall total cost of care that included initial care and subsequent interventions and hospitalizations until death (US

Endoscopic treatment of Roux-en-Y gastric bypass-related gastrocutaneous fistulas using a novel biomaterial

4,271 ± 2,411 vs 8,321 ± 1,821, p = 0.0013) were lower in the endoscopy group compared with the surgical group. In addition, the quality of life scores were better in the endoscopy group at 30 days (p = 0.042) and 60 days (p = 0.05). There was no difference between the two groups in complication rate, readmissions for complications, and duration of survival.CONCLUSIONS:Endoscopic biliary drainage is cheaper and provides better quality of life in patients with biliary obstruction and metastatic pancreatic cancer.

Transgastric access By balloon overtube for intraperitoneal surgery

Objectives The accuracy of endoscopic ultrasound-fine needle aspiration cytology (EUS-FNAC) for the diagnosis of pancreatic cancer is suboptimal. Mutational activation of the kras oncogene is almost universally present in pancreatic cancer tissue. We, therefore, investigated if analysis for mutant kras gene in the EUS-FNAC aspirates supplements cytopathology for the diagnosis of pancreatic adenocarcinoma (PAC). Methods EUS-FNAC specimens obtained from 74 patients with pancreatic masses were analyzed for the presence of kras mutation on codon 12 using polymerase chain reaction-restriction fragment length polymorphism and MvaI restriction enzyme. Definitive diagnosis was based on surgical pathology or long-term follow-up (median 27.8 mo); 57 patients had PAC, 11 patients chronic pancreatitis, and 9 patients nonfunctioning neuroendocrine tumors. Results Analysis of mutant kras gene in addition to cytopathology allowed the detection of PAC in 4 additional patients as compared with cytopathology alone. Cytopathology and kras mutant analysis were negative for PAC in 17 patients of whom 6 patients (35%) had PAC. The respective sensitivity (90.9% vs. 82.5%), specificity (47.6% vs. 97.9%), positive predictive value (89.5% vs. 83.8%), negative predictive value (98.1% vs. 94.1%), accuracy (89.2% vs. 58.8%) of cytopathology plus kras mutation versus cytopathology were numerically superior but did not reach statistical significance. Conclusions Analysis for the presence of mutant kras gene supplements conventional cytopathology for the diagnosis of PAC even without a cytopathologist in attendance and using only 3 needle passes. Among patients with negative cytopathology, the presence of kras mutation represents pancreatic cancer while the absence of kras mutation increases the possibility of benign lesion.

Symptomatic Pneumoperitoneum after Endoscopic Removal of Adjustable Gastric Band

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.

Comparison between endoscopic sclerotherapy and band ligation for hemostasis of acute variceal bleeding

BackgroundRoux-en-Y gastric bypass (RYGB) is amongst the commonest surgical intervention for weight loss in obese patients. Gastrocutaneous fistula, which usually occurs along the vertical staple line of the pouch, is amongst its most alarming complications. Medical management comprised of wound drainage, nutritional support, acid suppression, and antibiotics may be ineffective in as many as a third of patients with this complication. We present outcomes after endoscopic application of SurgiSIS®, which is a novel biomaterial for the treatment of this complication.DesignA case series of 25 patients.MethodsTwenty-five patients who had failed conservative medical management of gastrocutaneous fistula after RYGB underwent endoscopic application of SurgiSIS®—an acellular fibrogenic matrix biomaterial to help fistula healing.Main outcome measuresFistula closure as assessed by upper gastrointestinal imaging and endoscopic examination.Results In patients who had failed medical management lasting 4–25 (median, 7) weeks, closure of the fistulous tract was successful after one application in six patients (30%), two applications in 11 patients (55%), and three applications in three patients (15%). There were no procedure-related complications.ConclusionsEndoscopic application of SurgiSIS®—an acellular fibrogenic matrix—is safe and effective for the treatment of gastrocutaneous fistula after RYGB.

Experiência inicial no tratamento endoscópico de fístulas gastrocutâneas pós-gastroplastia vertical redutora através da aplicação de matriz acelular fibrogênica

The final frontier in endoscopy is the peritoneal cavity which was recently reached through natural orifice transluminal endoscopic surgery (NOTES). Endoscopic perforation caused by NOTES has been the major challenge for this procedure because of the risk of peritonitis and consequent complications. We describe in a dog model the use of an overtube system, one of them with a balloon, to access the peritoneal cavity by NOTES. It permits direct access to the peritoneal cavity from the mouth and also allows the performance of a controlled perforation and provides conditions for a safe closure of the gastric wall.

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

Endoscopic removal of an adjustable gastric band is a feasible procedure with few complications, according to our series of 8 patients. We report the case of a 56year-old woman who underwent endoscopic removal of a gastric band which had eroded through the gastric wall; this procedure was performed under general anesthesia, while the surgical group removed the subcutaneous port. The patient developed a large pneumoperitoneum after the procedure, and complained of back, shoulder and epigastric pain. A plain abdominal X-ray confirmed the pneumoperitoneum, and esophagogastric radiography with water-soluble contrast did not show a perforation. The treatment approach was conservative. This experience demonstrates an expected complication of endoscopic removal of an adjustable gastric band, and that the treatment may be conservative. The technique of band removal and the mechanism of pneumoperitoneum are discussed.

A new large-caliber trocar for percutaneous endoscopic gastrostomy by the introducer technique in head and neck cancer patients.

AIM To compare band ligation (BL) with endoscopic sclerotherapy (SCL) in patients admitted to an emergency unit for esophageal variceal rupture. METHODS A prospective, randomized, single-center study without crossover was conducted. After endoscopic diagnosis of esophageal variceal rupture, patients were randomized into groups for SCL or BL treatment. Sclerotherapy was performed by ethanolamine oleate intravascular injection both above and below the rupture point, with a maximum volume of 20 mL. For BL patients, banding at the rupture point was attempted, followed by ligation of all variceal tissue of the distal esophagus. Primary outcomes for both groups were initial failure of bleeding control (5 d), early re-bleeding (5 d to 6 wk), and complications, including mortality. From May 2005 to May 2007, 100 patients with variceal bleeding were enrolled in the study: 50 SCL and 50 BL patients. No differences between groups were observed across gender, age, Child-Pugh status, presence of shock at admission, mean hemoglobin levels, and variceal size. RESULTS No differences were found between groups for bleeding control, early re-bleeding rates, complications, or mortality. After 6 wk, 36 (80%) SCL and 33 (77%) EBL patients were alive and free of bleeding. A statistically significant association between Child-Pugh status and mortality was found, with 16% mortality in Child A and B patients and 84% mortality in Child C patients (P<0.001). CONCLUSION Despite the limited number of patients included, our results suggest that SCL and BL are equally efficient for the control of acute variceal bleeding.