Marta Salgado

Multicenter survey on the use of device-assisted enteroscopy in Portugal

Background Device-assisted enteroscopies (DAEs) are recent endoscopic techniques that enable direct endoscopic small-bowel evaluation. Objective The objective of this article is to evaluate the implementation of DAEs in Portugal and assess the main indications, diagnoses, diagnostic yield, therapeutic yield and complication rate. Methods We conducted a multicenter retrospective series using a national Web-based survey on behalf of the Portuguese Small-Bowel Study Group. Participants were asked to fill out two online databases regarding procedural data, indications, diagnoses, endoscopic therapy and complications using prospectively collected institutional data records. Results A total of eight centers were enrolled in the survey, corresponding to 1411 DAEs. The most frequent indications were obscure gastrointestinal bleeding (OGIB), inflammatory bowel disease and small-bowel tumors. The pooled diagnostic yield was 63%. A relation between the diagnostic yield and the indications was clear, with a diagnostic yield for OGIB of 69% (p = 0.02) with a 52% therapeutic yield. Complications occurred in 1.2%, with a major complication rate of 0.57%. Perforations occurred in four patients (0.28%). Conclusion DAEs are safe and effective procedures, with complication rates of 1.2%, the most serious of which is perforation. Most procedures are performed in the setting of OGIB. Diagnostic and therapeutic yields are dependent on the indication, hence appropriate patient selection is crucial.

Anorectal Melanoma: An Uncommon and Aggressive Disease

Department of Gastroenterology, Centro Hospitalar do Porto – Hospital de Santo Antonio, Porto, Portugal Correspondence: Dr Maria Joao Magalhaes, Rua Dr Manuel Rodrigues de Sousa, 21 5o D, 4450-181 Matosinhos, Porto, Portugal. Telephone 351-93-312-8979, e-mail mj.magalhaes@gmail.com Received for publication August 1, 2014. Accepted August 4, 2014 CASE PRESENTATION A 74-year-old woman was admitted to hospital in August 2010 for community-acquired pneumonia. Laboratory investigations revealed iron deficiency anemia (hemoglobin 104 g/L) and a thoracic computed tomography scan revealed scattered bilateral nodular opacities compatible with pulmonary metastasis of unknown primary site. In the diagnostic workup, the colonoscopy revealed a 40 mm vegetating lesion with a brownish surface at the distal rectum involving the anorectal transition (Figures 1 and 2). Histological analysis revealed an ulcerated malignancy with pleomorphic epithelioid cells and abundant melanophages (Figures 3 and 4). Immunohistochemical staining was positive for S-100, HMB-45 and Melan-A proteins, establishing the diagnosis of anorectal melanoma. She also had brain metastases. Due to the global status, symptomatic treatment was proposed. The patient died six months later.

successful endoscopic closure of gastrocutaneous fistula using an over-the-scope clip

1Department of Gastroenterology, Hospital Santo Antonio, Centro Hospitalar Porto, Porto; 2Department of Gastroenterology, Hospital de Braga; 3Life and Health Sciences Research Institute (ICVS), School of Health Sciences, University of Minho, Braga; 4ICVS/3B’s – PT Government Associate Laboratory, Braga/Guimaraes; 5Department of Surgery, Hospital Santo Antonio, Centro Hospitalar Porto, Porto, Portugal Correspondence: Dr Ricardo Kuttner Magalhaes, Rua Dr. Eduardo Santos Silva, 59, 5o Dto, 4200-282, Porto, Portugal. Telephone 96-411-9825, e-mail rkuttner@gmail.com Received for publication January 28, 2014. Accepted February 7, 2014 Case Presentation A 49-year-old man with heavy alcoholic habits was diagnosed with invasive squamous cell carcinoma of the amygdala (T4aN1Mx) for approximately one year. At that time, a percutaneous endoscopic gastrostomy (PEG) was performed, with placement of a 24 Fr tube using the Pull method, before chemotherapy and radiotherapy. The PEG tube was maintained for eight months, although the patient removed it accidentally several times, leading to successive replacements until it was not considered to be necessary and not reintroduced thereafter. During the following five months, the gastrocutaneous tract remained patent, with leakage of gastric contents, in spite of dietary precautions, omeprazole and domperidone. The external orifice of the fistula was apparent in the transition of the epigastrium to the left hypochondrium and the inner orifice on the anterior aspect of the medium/distal gastric body. A colostomy wafer was placed and bag adjusted to the external orifice, with consequent reduction of fistula output one week before endoscopic treatment was conducted. Argon plasma coagulation of the accessible part of the internal tract (Figure 1) followed by the application of an over-the-scope clip was performed (Figures 2 and 3). Post-procedure clinical success was achieved, with elimination of fistulous drainage. Complete closure of the internal opening of the fistula was confirmed at four weeks and three months, when an area of converging folds around the clip was observed (video [go to www.pulsus.com]). There was no recurrence over a 12-month follow-up period. DisCussion Performing temporary PEG is indicated when transiently poor oral intake is anticipated (1). This patient did not present classical factors for gastrocutaneous fistula persistence after tube removal and its closure with conservative measures was not successful. In these cases, surgery is the traditional option. Endoscopic approaches to persistent gastrocutaneous fistula, such as fistula tract cauterization, fibrin glue, cyanoacrylate and conventional endoclips, have been described (2-4); however, some are associated with a significant failure rate. Placement of a colostomy wafer and bag into the external orifice is not usually performed, although in our experience it helps to decrease fistula output, despite not being considered essential. Cautery of the tract with silver nitrate from the external orifice and with electrocoagulation from the inner orifice is intended to ablate the epithelial lining of the tract (a factor that is considered to be crucial in the pathogenesis of persistent gastrocutaneous fistula) and to promote scar formation. In the present case, the use of silver nitrate was not warranted, and we chose argon plasma for coagulation of the tract. We did not believe it was necessary to use ancillary devices designed to approximate the defect edges before deploying the clip. Compared with conventional endoclips, over-thescope clips have the advantage of a higher rate of full-thickness closure (5), and appear to be a safe and effective alternative in gastrocutaneous fistula closure. imageS of the month

Hepatitis B virus reactivation after chemotherapy in an HIV-positive patient.

To the Editor: Reactivation of hepatitis B virus (HBV) is a recognized complication in patients with prior HBV infection undergoing cytotoxic or immunomodulatory therapy. In addition, human immunodeficiency virus (HIV) infection facilitates HBV reactivation.1,2 We report the case of a 46-year-old female patient, with HIV infection diagnosed in 2005 that was being treated with darunavir, ritonavir, and raltegravir for the past 6 months, after modification of her previous therapy that included lamivudine, according to the antiretroviral test resistance. She had an isolated positive anti-HBc for the last 5 years and she had been diagnosed with cecal non-Hodgkin diffuse large B-cell lymphoma 5 months before, for which 6 cycles of chemotherapy with cyclophosphamide, doxorubicin, vincristine, and prednisone had been completed. The patient visited the hospital for asthenia, anorexia, jaundice, ascites, and diffuse abdominal pain for the previous 7 days. She had no fever or hepatic encephalopathy. Laboratory results showed a total bilirubin of 16.5mg/dL, an aspartate aminotransferase of 1452U/L, an alanine aminotransferase of 831U/L, an alkaline phosphatase of 114U/L, a g-glutamyl transferase of 213U/L and an international normalized ratio of 2.9. Abdominal Doppler ultrasound showed a large volume septated ascites, without changes in the pattern of arterial or venous flows. The peritoneal fluid was characteristic of portal hypertension, with no evidence of infection or malignant cells. She had a positive HBsAg, a positive anti-HBs, a positive anti-HBc with negative IgM, a negative HBeAg, a positive anti-HBe, a negative anti-HCV, and a negative anti-HDV. HAV IgM, EBV IgM, HSV IgM, and CMV IgM were negative. HBV DNA tests revealed a genotype D HBV with a viral load of 29,900UI/mL. It was assumed to be a severe reactivation of hepatitis B, and antiviral therapy with emtricitabine (200mg) and tenofovir (300mg) was started. Jaundice and coagulopathy worsened during the subsequent days and the patient died by the 11th day of hospitalization (Fig. 1). Thus, we report the case of an HIV patient with probable occult HBV infection, which after chemotherapy and lamivudine suspension developed a severe acute hepatitis leading to death. It is prudent to test all HIVinfected patients for HbsAg and for anti-Hbc, and if any of these are positive, HBV DNA testing is warranted. Moreover, we underline the universal need to assess HBV serological markers in all patients before undergoing cytotoxic or immunomodulatory therapy. We stress the importance of prophylaxis and monitoring patients at risk because of the possibility of HBV

An unsuspicious duodenal foreign body

A 56-year-old woman with Peutz–Jeghers syndrome, who underwent a laparoscopic right hemicolectomy for colon adenocarcinoma 19 months earlier, presented for elective single-balloon antegrade enteroscopy to remove a 25mm jejunal polyp previously identified on video capsule endoscopy. During duodenal intubation, a foreign body was found wedged into the wall of the second portion of the duodenum (▶Fig. 1 a). An attempt to gently pull the foreign body with grasping forceps was not successful. An abdominal computed tomography scan showed a moderately radiopaque foreign body (suggesting a bone), 20mm in size, perforating the wall of the second duodenal portion to the retroperitoneum, with no associated inflammation, fluid collections or free air in the peritoneum (▶Fig. 2). As the patient was asymptomatic, with normal vital signs and no systemic inflammation on blood tests, an elective upper endoscopy in the operating room with surgeon support was performed the following day (▶Fig. 1b – d; ▶Video1). Through cap-assisted endoscopy, the foreign body was successfully retrieved using grasping forceps. Endoscopic review showed edematous duodenal mucosa with granulation tissue. On close inspection, the foreign body was a plastic clip.On review of the patient’s surgical notes, it was discovered that Hem-o-lok clips (Weck Closure Systems, Research Triangle Park, North Carolina, USA) had been used in the previous laparoscopic surgery for ileocolonic vessel ligation. The Hem-o-lok clip is a nonabsorbable polymer locking clip that is used frequently during laparoscopic procedures. Despite their well known safety [1], a few case reports of clip migration have been published [2–5]. The management of these cases remains controversial; both spontaneous detachment of these clips [3–5] and endoscopic removal [2] have been described. In our case, the patient was asymptomatic and the clip was found on routine upper endoscopy. Hem-o-lok clip retrieval was possible using grasping forceps, without complications. The patient was discharged 2 days later with proton pump inhibitors.