Marcelo Simas de Lima

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

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.

Unusual clinical presentation of annular pancreas in the adult

Annular pancreas (AP) is a rare congenital anomaly, usually present in childhood, with symptoms due to duodenal obstruction; however, this condition can manifest in adulthood with abdominal pain, pancreatitis and pancreatic head mass. The authors present a case of AP observed in a 22-year-old patient that presented an unusual dual-phase clinical manifestation of duodenal obstruction in infancy that was treated by a duodenojejunostomy, and abdominal pain due to chronic pancreatitis in the adult age. MRI with cholangiopancreatography played a decisive role in achieving the correct diagnosis. The patient was treated by a pylorus-preserving Whipple procedure, with resection of the previous duodenojejunostomy. Pancreatic changes characteristic of chronic pancreatitis were demonstrated both in the AP and in the resected pancreatic segment. A marked biliopancreatic ductal anomaly not previously described in the literature was demonstrated by radiologic examination of the surgical specimen. The pathogenesis of AP, the importance of its association with benign and malignant pancreatic disease and the treatment alternatives are discussed by the authors.

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

BACKGROUND: Roux-en-Y gastric bypass is one of the most commonly performed bariatric surgeries in Brazil. Gastric leaks are relatively uncommon and potentially dangerous complications. The initial management of gastric leaks consists in adequate drainage, nutritional support, antibiotics and acid suppression. In almost 30% of the cases the fistula will become chronic. AIM: A novel peroral endoscopic treatment of gastric leaks in Roux-en-Y gastric bypassed patients is presented. METHODS: An acellular biomaterial was endocopically placed in the fistulous orifice in order to promote healing and avoid surgery in 25 patients. The time between fistula diagnosis and endoscopic treatment varied from 4 to 25 weeks (median: 7 weeks). RESULTS: Endoscopic treatment was successful in 20 (80%) patients. Fistula closure was obtained after one, two and three sessions in 6 (30%), 11 (55%) and 3 (15%) patients, respectively. No procedure related complications were observed. CONCLUSION: Endoscopic repair of gastric leak after Roux-en-Y gastric bypass by using an acellular biomaterial is safe and effective. However two or three endoscopic sessions are usually needed.

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

Background The source and outcomes of upper gastrointestinal bleeding (UGIB) in oncologic patients are poorly investigated. Objective The study aimed to investigate these issues in a tertiary academic referral center specialized in cancer treatment. Methods This was a retrospective study including all patients with cancer referred to endoscopy due to UGIB in 2010. Results UGIB was confirmed in 147 (of 324 patients) referred to endoscopy for a suspected episode of GI bleeding. Tumor was the most common cause of bleeding (N = 35, 23.8%), followed by varices (N = 30, 19.7%), peptic ulcer (N = 29, 16.3%) and gastroduodenal erosions (N = 16, 10.9%). Among the 32 patients with cancer of the upper GI tract, the main causes of bleeding were cancer (N = 27, 84.4%) and peptic ulcer (N = 5, 6.3%). Forty-one patients (27.9%) presented with bleeding from the primary tumor or from a metastatic lesion, and seven received endoscopic therapy, with successful initial hemostasis in six (85.7%). Rebleeding and mortality rates were not different between endoscopically treated (N = 7) and non-treated (N = 34) patients (28.6% vs. 14.7%, p = 0.342; 43.9% vs. 44.1%, p = 0.677). Median survival was 20 days, and the overall 30-day mortality rate was 44.9%. There was no predictive factor of mortality or rebleeding. Conclusion Tumor bleeding is the most common cause of UGIB in cancer patients. UGIB in cancer patients correlates with a high mortality rate regardless of the bleeding source. Current endoscopic treatments may not be effective in preventing rebleeding or improving survival.

Argon plasma coagulation for the endoscopic treatment of gastrointestinal tumor bleeding: A retrospective comparison with a non-treated historical cohort

Background The endoscopic use of argon plasma coagulation (APC) to achieve hemostasis for upper gastrointestinal tumor bleeding (UGITB) has not been adequately evaluated in controlled trials. This study aimed to evaluate the efficacy of APC for the treatment of upper gastrointestinal bleeding from malignant lesions. Methods Between January and September 2011, all patients with UGITB underwent high-potency APC therapy (up to 70 Watts). This group was compared with a historical cohort of patients admitted between January and December 2010, when the endoscopic treatment of bleeding malignancies was not routinely performed. Patients were stratified into two categories, grouping the Eastern Cooperative Oncology Group (ECOG) performance status scale: Category I (ECOG 0–2) patients with a good clinical status and Category II (ECOG 3–4) patients with a poor clinical status. Results Our study had 25 patients with UGITB whom underwent APC treatment and 28 patients whom received no endoscopic therapy. The clinical characteristics of the groups were similar, except for endoscopic active bleeding, which was more frequently detected in APC group. We had 15 patients in the APC group whom had active bleeding, and initial hemostasis was obtained in 11 of them (73.3%). In the control group, four patients had active bleeding. There were no differences in 30-day re-bleeding (33.3% in the APC group versus 14.3% in the control group; p = 0.104) and 30-day mortality rates (20.8% in the APC group, versus 42.9% in the control group; p = 0.091). When patients were categorized according to their ECOG status, we found that APC therapy had no impact in re-bleeding and mortality rates (Group I: APC versus no endoscopic treatment: re-bleeding p = 0.412, mortality p = 0.669; Group II: APC versus no endoscopic treatment: re-bleeding p = 0.505, mortality p = 0.580). Hematemesis and site of bleeding located at the esophagus or duodenum were associated with a higher 30-day mortality. Conclusions Endoscopic hemostasis of UGITB with APC has no significant impact on 30-day re-bleeding and mortality rates, irrespective of patient performance status.

Long-term result of endoscopic treatment of an ampullary adenoma with extension into the common bile duct

A 56-year-old man with chronic hepatic disease due to hepatitis C and esophageal varices was referred to our hospital with an elevated alpha-fetoprotein level and a solid lesion in the distal common bile duct (CBD) seen on computed tomography (CT) scanning. This lesion was protruding into the second part of the duodenum and causing dilatation of the biliary tree. An upper gastrointestinal endoscopy revealed a raised lesion at the major duodenal papilla (▶Fig. 1). Biopsies showed a tubular adenoma with low grade dysplasia. Endoscopic ultrasound (EUS) revealed thickening that was restricted to the mucosal layer and choledocholithiasis. The patient was not suitable for surgical treatment because of his portal hypertension. We therefore performed an endoscopic papillectomy, followed by a sphincterotomy and placement of a plastic pancreatic stent. A follow-up endoscopy 7 days later revealed a residual lesion with a filling defect in the distal CBD (▶Fig. 2). After 30 days, a cholangioscopy was performed using CO2 and a pediatric gastroscope passed over a guidewire (▶Fig. 3). Biopsies were taken and the residual lesion was treated with argon plasma coagulation (APC) at 20W and 1.5 L/min (▶Video1). The patient remains completely asymptomatic 5 years later, receiving annual follow-up, and having no residual lesions (▶Fig. 4). Ampullary adenomas can be found incidentally on endoscopic screening examinations and harbor a malignant potential [1]. In a retrospective study, 180 patients who had been treated for ampullary adenomas were followed up for a mean of 4.4 years [2]. There was no difference in endoscopic and operative resection of the ampullary adenomas in terms of local recurrence. However, intraductal E-Videos

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.

Self-expandable metal stent for malignant esophagorespiratory fistula: predictive factors associated with clinical failure

BACKGROUND AND AIMS Malignant esophagorespiratory fistulas (MERFs) usually are managed by the placement of self-expandable metal stents (SEMSs) but with conflicting results. This study aimed to identify risk factors associated with clinical failure after SEMS placement for the treatment of MERFs. METHODS This was a retrospective analysis of a prospectively maintained database used at a tertiary-care cancer hospital, with patients treated with SEMS placement for MERFs between January 2009 and February 2016. Logistic regression was used to identify predictive factors for clinical outcomes and to estimate the odds ratio (OR) and the 95% confidence interval (CI). The Kaplan-Meier method was used for survival analysis, and comparisons were made by using the log-rank test. RESULTS A total of 71 patients (55 male, mean age 59 years) were included in the study, and 70 were considered for the final analysis (1 failed stent insertion). Clinical failure occurred in 44% of patients. An Eastern Cooperative Oncology Group (ECOG) performance status of 3 or 4 and fistula development during esophageal cancer treatment were associated with an increased risk of clinical failure. ECOG status of 3 or 4, pulmonary infection at the time of SEMS placement, and prior radiation therapy were predictive factors associated with lower overall survival. Dysphagia scores improved significantly 15 days after stent insertion. The overall stent-related adverse event rate was 30%. Stent migration and occlusion caused by tumor overgrowth were the most common adverse events. CONCLUSION SEMS placement is a reasonable treatment option for MERFs; however, ECOG status of 3 or 4 and fistula development during esophageal cancer treatment may be independent predictors of clinical failure after stent placement.

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.