Mauricio Minata

Narrow band imaging versus lugol chromoendoscopy to diagnose squamous cell carcinoma of the esophagus: a systematic review and meta-analysis

BackgroundIn the early stage esophageal cancer, changes in the mucosa are subtle and pass unnoticed in endoscopic examinations using white light. To increase sensitivity, chromoscopy with Lugol’s solution has been used. Technological advancements have led to the emergence of virtual methods of endoscopic chromoscopy, including narrow band imaging (NBI). NBI enhances the relief of the mucosa and the underlying vascular pattern, providing greater convenience without the risks inherent to the use of vital dye. The purpose of this systematic review and meta-analysis was to evaluate the ability of NBI to diagnose squamous cell carcinoma of the esophagus and to compare it to chromoscopy with Lugol’s solution.MethodsThis systematic review included all studies comparing the diagnostic accuracy of NBI and Lugol chromoendoscopy performed to identify high-grade dysplasia and/or squamous cell carcinoma in the esophagus. In the meta-analysis, we calculated and demonstrated sensitivity, specificity, and positive and negative likelihood values in forest plots. We also determined summary receiver operating characteristic (sROC) curves and estimates of the areas under the curves for both per-patient and per-lesion analysis.ResultsThe initial search identified 7079 articles. Of these, 18 studies were included in the systematic review and 12 were used in the meta-analysis, for a total of 1911 patients. In per-patient and per-lesion analysis, the sensitivity, specificity, and positive and negative likelihood values for Lugol chromoendoscopy were 92% and 98, 82 and 37%, 5.42 and 1.4, and 0.13 and 0.39, respectively, and for NBI were 88 and 94%, 88 and 65%, 8.32 and 2.62, and 0.16 and 0.12, respectively. There was a statistically significant difference in only specificity values, in which case NBI was superior to Lugol chromoendoscopy in both analyses. In the per-patient analysis, the area under the sROC curve for Lugol chromoendoscopy was 0.9559. In the case of NBI, this value was 0.9611; in the per-lesion analysis, this number was 0.9685 and 0.9587, respectively.ConclusionsNBI was adequate in evaluating the esophagus in order to diagnose high-grade dysplasia and squamous cell carcinoma. In the differentiation of those disorders from other esophageal mucosa alterations, the NBI was shown to be superior than Lugol.

Stents and surgical interventions in the palliation of gastric outlet obstruction: a systematic review.

Background and study aims: Palliative treatment of gastric outlet obstruction can be done with surgical or endoscopic techniques. This systematic review aims to compare surgery and covered and uncovered stent treatments for gastric outlet obstruction (GOO). Patients and methods: Randomized clinical trials were identified in MEDLINE, Embase, Cochrane, LILACs, BVS, SCOPUS and CINAHL databases. Comparison of covered and uncovered stents included: technical success, clinical success, complications, obstruction, migration, bleeding, perforation, stent fracture and reintervention. The outcomes used to compare surgery and stents were technical success, complications, and reintervention. Patency rate could not be included because of lack of uniformity of the extracted data. Results: Eight studies were selected, 3 comparing surgery and stents and 5 comparing covered and uncovered stents.The meta-analysis of surgical and endoscopic stent treatment showed no difference in the technical success and overall number of complications. Stents had higher reintervention rates than surgery (RD: 0.26, 95 % CI [0.05, 0.47], NNH: 4). There is no significant difference in technical success, clinical success, complications, stent fractures, perforation, bleeding and the need for reintervention in the analyses of covered and uncovered stents. There is a higher migration rate in the covered stent therapy compared to uncovered self-expanding metallic stents (SEMS) in the palliation of malignant GOO (RD: 0.09, 95 % CI [0.04, 0.14], NNH: 11). Nevertheless, covered stents had lower obstruction rates (RD: – 0.21, 95 % CI [-0.27, – 0.15], NNT: 5). Conclusions: In the palliation of malignant GOO, covered SEMS had higher migration and lower obstruction rates when compared with uncovered stents. Surgery is associated with lower reintervention rates than stents.

Efficacy and Safety of Stents in the Treatment of Fistula After Bariatric Surgery: a Systematic Review and Meta-analysis

Fistula development is a serious complication after bariatric surgery. We performed a systematic review and meta-analysis to assess the efficacy of fistula closure and complications associated with endoscopic stent treatment of fistulas, developed after bariatric surgeries, particularly Roux-en-Y gastric bypass (RYGB) and gastric sleeve (GS). Studies involving patients with fistula after RYGB or GS and those who received stent treatment only were selected. The analyzed outcomes were overall success rate of fistula closure, mean number of stents per patient, mean stent dwelling time, and procedure-associated complications. Current evidence from identified studies demonstrates that, in selected patients, endoscopic stent treatment of fistulas after GS or RYGB can be safe and effective.

Common bile duct intussusception during ERCP for stone removal

Figure 2. Basket with the gallstone captured in the middle third of the mortality in 0.33%. The most common adverse events are pancreatitis (3.47%), bleeding (1.34%), sepsis (1.44%), and perforation (0.6%). Rare adverse events after ERCP occur in 1% of cases and could put the patient in critical condition requiringurgent surgical intervention.We report the first case of a common bile duct (CBD) intussusception during ERCP for stone removal in a patient with ulcerative colitis (UC) and primary sclerosing cholangitis (PSC). A 66-year-old man was referred for a second ERCP attempt at stone removal a week after cannulation of the CBD had failed. He had experienced jaundice and abdominal pain for the previous month, and US and CT showed cholecystolithiasis, choledocholithiasis, and dilatation of the intrahepatic bile ducts. His medical history included UC, rheumatoid arthritis, type 2 diabetes, and placement of a coronary stent after a myocardial infarction. The CBD was cannulated with a guidewired sphincterotome (Video 1, available online at www.VideoGIE.org). The intrahepatic bile ducts showed segmental strictures and

Increased Gastric Retention Capacity, Assessed by Scintigraphy, after APC Treatment of Dilated Gastrojejunal Anastomosis

Background: Weight regain occurs in about 20% of patients after Roux-en-Y gastric bypass (RYGB). Studies have reported that in most cases this regain is associated with dilatation of the gastrojejunal anastomosis. To correct this dilatation, one of the methods used is the application of argon plasma coagulation (APC). Case: The authors report the case of a 39-year-old woman submitted to RYGB who had weight regain. In the endoscopic evaluation, the patient presented with dilatation of the gastrojejunal anastomosis, for which treatment with APC and an adjusted diet was proposed. After 3 sessions of APC, the patient presented with a reduction of the anastomosis diameter, weight loss, and increased satiety to food, with an increased gastric emptying time evidenced by scintigraphy. Conclusion: APC proved to be a safe and efficacious method.

Carbon dioxide versus air insufflation enteroscopy: a systematic review and meta-analysis based on randomized controlled trials

Objectives  To compare the insufflation of CO 2 and ambient air in enteroscopy. Search sources  The investigators researched the electronic databases MedLine, Cochrane Library, Central, LILACS, BVS, Scopus and Cinahl. The grey search was conducted in the base of theses of the University of São Paulo, books of digestive endoscopy and references of selected articles and in previous systematic revisions. Study eligibility criteria  The evaluation of eligibility was performed independently, in a non-blind manner, by two reviewers, firstly by title and abstract, followed by complete text. Disagreements between the reviewers were resolved by consensus. Data collection and analysis method  Through the spreadsheet of data extraction, where one author extracted the data and a second author checked the extraction. Disagreements were resolved by debate between the two reviewers. The quality analysis of the studies was performed using the Jadad score. The software RevMan 5 version 5.3 was used for the meta-analysis. Results  Four randomized clinical trials were identified, totaling 473 patients submitted to enteroscopy and comparing insufflation of CO 2 and ambient air. There was no statistical difference in the intubation depth between the two groups. When CO 2 insufflation was reduced, there was a significant difference in pain levels 1 hour after the procedure (95 % IC, –2.49 [–4.72, –0.26], P : 0.03, I 2 : 20%) and 3 hours after the procedure (95% IC, –3.05 [–5.92, –0.18], P : 0.04, I 2 : 0 %). There was a usage of lower propofol dosage in the CO 2 insufflation group, with significant difference (95 % IC, –67.68 [–115.53, –19.84], P : 0.006, I 2 : 0 %). There was no significant difference between the groups in relation to the use of pethidine and to the oxygen saturation. Limitations  Restricted number of randomized clinical trials and nonuniformity of data were limitations to the analysis of the outcomes. Conclusion  The use of CO 2 as insufflation gas in enteroscopy reduces the pain levels 1 hour and 3 hours after the procedure, in addition to the reduction of the sedation (propofol) dosage used.

Endoscopic polymer injection and endoluminal plication in treatment of gastroesophageal reflux disease: evaluation of long-term results

Background and study aims  Us of proton pump inhibitors (PPIs) has made endoscopic treatment of gastroesophageal reflux disease (GERD) more efficient, with reduction in morbidity and complications. However, some patients persist with symptoms despite medical treatment and some are not compliant with it or cannot afford it for financial reasons, and thus they require non-pharmacological therapeutic options such as surgical fundoplication. Surgery may be effective in the short term, but there is related morbidity and concern about its long-term efficacy. The possibility of minimally invasive endoluminal surgeries has resulted in interest in and development of newly endoscopic devices. Good short-term results with surgical fundoplication lack of studies of is with long follow-up justify our interest in this study. The aim of this study was to investigate the efficacy of endoscopic polymer injection and endoluminal full-thickness plication in the long-term control of GERD. Patients and methods  Forty-seven patients with GERD who underwent an endoscopic procedure were followed up for 60 months and evaluated for total response (RT), partial response (RP) and no response (SR) to endoscopic treatment with reintroduction of PPIs. Results  Twenty-one patients received polymer injection (G0) and 26 endoluminal plication (G1). The number of patients with no response to endoscopic treatment with reintroduction of PPIs increased in time for both techniques (G0 P  = 0.006; G1 P  < 0.001). There was symptomatic improvement up to 12 months, with progressive loss of this trending up to 60 months in G0 and G1 ( P  < 0.001). Health-related quality of life score (GERD-HRQL) demonstrated TR in G0 and G1 at 1, 3, 6 and 12 months. The 60-month analysis showed an increased number of patients with SR in both groups. The quality of life assessment (SF-36) showed benefit in G0 up to 3 months. G0 showed a higher rate of complications. There were no deaths. There was healing of esophagitis at 3 months in 45 % of patients in G0 and 40 % in G1. There was no improvement in manometric or pH findings. Conclusion  Endoscopic therapies were ineffective in controlling GERD in the long term.

Massive bleeding after plastic stent removal during ERCP: what’s next?

Portal biliopathy or portal cavernoma cholangiopathy refers to cholangiographic abnormalities, which occur in patients with portal cavernoma. These include shallow bile duct impressions and indentations causing wall irregularity, smooth strictures with upstream dilatation, and luminal filling defects (▶Fig. 1, ▶Fig. 2). These changes occur as a result of pressure on bile ducts from bridging tortuous paracholedochal, epicholedochal, and cholecystic veins [1]. Symptoms of portal cavernoma cholangiopathy include longstanding jaundice due to chronic cholestasis, or biliary pain with or without cholangitis due to biliary stones [2]. We present the case of a 41-year-old man with portal biliopathy secondary to noncirrhotic portal vein thrombosis, who was admitted with obstructive jaundice and cholangitis. He had a biliary plastic stent placed 2months earlier for obstructive jaundice. The previous stent had become blocked and was removed. A sudden spurt of massive bleeding from the ampulla was noticed. A fully covered self-expandable metal stent (fcSEMS; Wallflex biliary fcSEMS, 10×60mm; Boston Scientific, Marlborough, Massachusetts, USA) was deployed, with resolution of the hemorrhage (▶Video 1). The second case involves endoscopic retrograde cholangiopancreatography (ERCP) in a 54-year-old woman with portal hypertension and cholangitis. Hemobilia was noticed after balloon sweeping. A fcSEMS was used with success (▶Video 1). ERCP with plastic stent exchanges is the first-line intervention for jaundice or cholangitis due to biliary strictures. If E-Videos

Endoscopic treatment of sigmoid volvulus

This video demonstrates the endoscopic treatment of a sigmoid volvulus. An 80-year-old man who was receiving palliative treatment for metastatic head and neck cancer presented with abdominal distension and pain. There was no evidence of hemodynamic instability or peritonitis on examination. The medical history included ischemic cardiomyopathy and a previous sigmoid volvulus, treated with endoscopic detorsion (Figs. 1A-D). This patient was not a candidate for surgical resection because of severe comorbidities. A CT scan was done to exclude other causes of obstruction. We observed a distended sigmoid loop in an inverted U position, also known as the “coffee bean” sign (Fig. 1E). The water immersion technique is an option for sigmoid volvulus treatment and can be done without sedating the patient. In this case, this was a good choice because of the patient’s poor clinical condition. The procedure was initiated with a standard colonoscope, equipped with carbon dioxide insufflation and a water pump. No air insufflation was used. First, we noticed a torsion in the