Liliana Carvalho

Endoscopic Submucosal Dissection for Gastrointestinal Superficial Lesions: Initial Experience in a Single Portuguese Center

Introduction Endoscopic submucosal dissection (ESD) is a minimally invasive organ-sparing endoscopic technique which allows en bloc resection of premalignant and early malignant lesions of the gastrointestinal tract regardless of size. In spite of the promising results, mainly from Japanese series, ESD is still not being widely used in western countries. This study aims to report the feasibility, safety and effectiveness of ESD technique for treating premalignant and early malignant gastrointestinal (GI) lesions (esophagus, gastric and rectum) in a Portuguese center. Patient and Methods From December 2011 to November 2014, 34 GI lesions were treated by ESD. The location, en bloc and pathological complete resection (R0) rates, procedure time, complications and local recurrence were retrospectively evaluated. Results From 34 resected lesions, 18 were gastric (GL), 15 were rectal (RL) and one esophageal (EL). En bloc resection for each location was 17/18 (94%), 11/15 (73%) and 1/1 respectively. R0 was achieved in 16/18 (89%) GL, 9/15 (60%) RL and 1/1 EL. Mean resection time was 67 min for GL, 142 min for RL and 40 min for EL. Complications included immediate (6%) and delayed (3%) minor bleeding but no perforation. One local residual lesion from a RL was reported in the follow-up, effectively treated with an endoscopic technique. Disease-specific survival was 100% over a mean follow-up period of 14 months. Conclusion ESD has shown to be a safe and feasible resection method, achieving high R0, low recurrence and complication rates. Our results are similar to those reported in other international series.

Endoscopic Management of Foreign Bodies in the Upper Gastrointestinal Tract: An Evidence-Based Review Article

Gastrointestinal foreign bodies (FB) are comprised of food bolus impaction and intentionally or unintentionally ingested or inserted true FB. Food bolus impaction and true FB ingestion represent a recurrent problem and a true challenge in gastrointestinal endoscopy. More than 80–90% of the ingested true FB will pass spontaneously through the gastrointestinal tract without complications. However, in 10–20% of the cases an endoscopic intervention is deemed necessary. True FB ingestion has its greatest incidence in children, psychiatric patients and prisoners. On the other hand, food bolus impaction typically occurs in the elderly population with an underlying esophageal pathology. The most serious situations, with higher rates of complications, are associated with prolonged esophageal impaction, ingestion of sharp and long objects, button batteries and magnets. Physicians should recognize early alarm symptoms, such as complete dysphagia, distressed patients not able to manage secretions, or clinical signs of perforation. Although many papers are yearly published regarding this subject, our knowledge is mainly based on case-reports and retrospective series. Herein, the authors summarize the existing evidence and propose an algorithm for the best approach to FB ingestion.

An Extremely Rare Cause of Dysphagia

68 69 70 71 72 73 74 75 76 77 78 79 80 81 82 83 84 85 86 87 88 89 90 91 92 93 94 95 96 97 98 99 100 101 102 103 104 105 106 107 108 109 110 111 112 113 114 115 116 Question: A 52-year-old woman presented to our department with a 1-month history of progressive dysphagia for solids and weight loss (<10% of total weight). Her past medical history included cigarette smoking (15 pack-years) without medication, alcohol, or drug consumption, nor familiar risk factors. The patient denied other symptoms like anorexia, nausea, heartburn, retrosternal chest pain, abdominal pain, and gastrointestinal bleeding. On physical examination, she presented with a global decrease of the breath sounds. Laboratory data had no changes, like anemia or increased inflammatory parameters. Upper endoscopy revealed extensive submucosal blebs that collapsed with insufflation and were distributed over the esophagus circumference, especially in the medial and distal portions (Figure A–D), without involvement of the stomach or duodenum. To confirm and complete this rare diagnose, a computed tomography (CT) scan

Miliary Tuberculosis in a Crohn’s Disease Patient: The Risk beyond the Screening

Tumor necrosis factor alpha (TNFα) antagonist is recognized as an effective treatment to achieve clinical remission and healing mucosal in patients with moderate to severe active Crohn’s disease. Considering that it plays a central role in immune-mediated modulation, there are some obvious concerns about its long-term safety. There is evidence that it may increase the risk of opportunistic infections such as tuberculosis, particularly reactivation of previous latent infection. Due to the global high incidence of tuberculosis and its frequent severity in immunocompromised patients, the exclusion of latent infection is currently part of the screening prior to anti-TNFα therapy. Only a few cases of life-threatening disseminated tuberculosis have been reported in immunocompromised patients probably related to widespread use of higher-accuracy screening tests, such as interferon-γ release assays. However, despite negative screening, the risk of active tuberculosis infection remains during treatment. In that instance, tuberculosis infection becomes considerably more difficult to diagnose due to its altered pattern presentation (extrapulmonary and disseminated infection) and is harder to treat because of the high rate of resistance and its associated relevant morbidity and mortality. We report an enigmatic case of a miliary tuberculosis despite negative latent infection screening, using interferon-γ release assays, in a Crohn’s disease patient undergoing treatment with infliximab and azathioprine, focusing on the screening and diagnostic and therapeutic challenge. This case enhances the awareness of anti-TNFα therapy management and the need for strategies to diagnose and treat tuberculosis in this context.

Peroral Endoscopic Myotomy with Water Pump-Assisted Submucosal Tunnel Creation

Achalasia is an idiopathic motor disorder of the esophagus characterized by impaired lower esophageal sphincter relaxation and loss of esophageal peristalsis, which results in the classic presentation of dysphagia to solids and liquids associated with regurgitation of food and saliva [1]. From the available treatment options, endoscopic balloon dilatation and laparoscopic Heller myotomy have been the most frequently used. More recently, peroral endoscopic myotomy (POEM) was developed in Japan. This endoscopic technique requires the creation of a submucosal tunnel as an operating space to access the circular muscle layer for performance of the myotomy [2]. Short-term results from the available series are promising when compared to the alternative approaches. However, procedure length still varies greatly, and the use of devices has also not been standardized. Water jet-assisted POEM, which uses needleless submucosal injections to create a submucosal fluid cushion (usually using a hybrid knife), has been demonstrated to significantly decrease POEM procedure length and to facilitate reinjection, contributing to a lower rate of intraprocedural bleeding [3]. A modified technique with a method of injecting saline mixed with indigo car-

Endoscopic Submucosal Dissection of Gastric Adenocarcinoma Involving the Pylorus Circumference

plinary assessment suggested an endoscopic resection by endoscopic submucosal dissection (ESD) technique. The procedure was then performed under general anaesthesia using the ERBE ICC electrosurgical generator with Flush Knife (Fujifilm®) and IT knife nano (Olympus®). Carbon dioxide was used for insufflation. At first, small coagulation marks were made 2–5 mm around the lesion. Then, a sufficient lifting was obtained with submucosal solution injection of Voluven®, indigo carmine

Adenosquamous Carcinoma of the Ampulla of Vater: A Rare Cause of Obstructive Jaundice

Tumour markers CA19.9 and CEA were normal. Endoscopic ultrasound was performed using a linear scope and showed a subepithelial mass of the papilla (Fig. 1), corresponding to a hypoechogenic lesion of 22 mm, with submucosal growth, involving the muscularis propria of the duodenum (T2) (Fig. 2). This lesion caused marked dilation of the proximal common bile duct and intrahepatic ducts. A perilesional adenopathy was identified (N1). Endoscopic ultrasound-guided fine needle aspiration (EUSFNA) was performed using a 25-gauge needle and cytologic evaluation was consistent with adenocarcinoma. Computed tomography ruled out distant metastasis and the patient was referred for surgery (cephalic duodenopancreatectomy). Histological analysis of the surgical specimen documented an adenosquamous carcinoma of the ampulla of Vater (ASC AV; Fig. 3), involving the duodenal muscularis propria, with one regional lymph node metastasis (R0, pT2N1). Postoperative outcome was uneventful and the patient remains asymptomatic after a 10-month follow-up period. Adenocarcinomas account for most primary malignant tumors of the ampulla of Vater, while other histological types such as squamous or adenosquamous carcinomas are exceedingly rare [1]. Duodenoscopy in combi

Endoscopic therapy of appendicular bleeding complicated by shock

A 57-year-old man, who was receiving antiplatelet therapy with acetylsalicylic acid for ischemic heart disease and had a recently diagnosed stage IV pulmonary adenocarcinoma (with liver and bone metastases), presented with hemorrhagic shock due to painless hematochezia. Total colonoscopy revealed active bleeding from the ileocecal appendix (▶Fig. 1 a). Initially epinephrine was injected at the appendicular base, but the bleeding was ongoing. Endoscopic therapy with hemostatic spray (Hemospray; Cook Medical, Winston-Salem, North Carolina, USA) was tried, with the achievement of immediate hemostasis (▶Fig. 1b, c; ▶Video1). No recurrent bleeding was reported during the follow-up period (3 months). Appendicular bleeding is an exceptional cause of lower gastrointestinal hemorrhage that can arise from various etiologies, including granulomatous appendicitis, inflammatory bowel disease, tuberculosis, benign erosions and ulcers, neoplastic disease, and aorto-appendicular fistula [1, 2]. Because of the difficult approach to the bleeding vessels endoscopically, emergent surgery has been necessary in most reported cases [3]. Hemospray is a hemostatic powder that forms a mechanical barrier when it comes into contact with an active bleeding site. Preliminary data have shown that it can be effective in the management of lower gastrointestinal bleeding [4]. In the case presented, because of the patient’s high surgical risk and considering the potential for the development of severe appendicitis after clip placement due to persistent blockage of the appendiceal lumen, the application of hemostatic spray was the best therapeutic option. Because of the dismal prognosis of the patient’s underlying neoplastic disease, no further intervention was performed, apart from stopping the antiplatelet therapy. To our knowledge, this is the first reported case of active bleeding from the ileocecal appendix that was successfully controlled with the application of hemostatic spray.

Radial artery pseudoaneurysm: rare complication of a frequent procedure.

The pseudoaneurysms of the radial artery are uncommon, generally secondary to trauma or invasive procedures such as arterial catheterisation (0.09%).1 ,2 Predisposing factors are advanced age, longer duration of catheterisation, coagulation disorders or use of anticoagulants/antiplatelet agents. A woman of 85 years, with history of ischaemic heart failure, chronic atrial fibrillation on anticoagulation, with labile International Normalisation Ratio, hypertension, peripheral …

Mixed cryoglobulinemia: a diagnostic and therapeutic challenge

Mixed cryoglobulinemia is frequently secondary to hepatitis C virus infection. Diagnosis and therapeutic management are challenging, depending on the spectrum and severity of manifestations, as well as on the presence of comorbidities. We describe a case of a 79-year-old woman with a non-cirrhotic hepatitis C virus infection presenting with weakness, arthralgias, purpuric rash with left leg ulcerative lesions, bilateral peripheral sensorimotor polyneuropathy, renal impairment and cardiac failure. The investigation was compatible with a severe type II mixed cryoglobulinemia with multisystemic involvement, including a low-grade B cell lymphoma and concomitant intestinal tuberculosis. Initial management with immunosuppressive therapy with glucocorticoids to control symptoms and simultaneous tuberculosis treatment was required. Unavailability of adequate antiviral treatment led to the need to control the severity of systemic manifestations with rituximab, before the effective aetiological treatment with sofosbuvir and ledipasvir was possible, allowing the definitive resolution of the disease.