Ricardo S. Uemura

Small Bowel Endoscopy Using the Double-Balloon Technique: Four-Year Results in a Tertiary Referral Hospital in Brazil

Background: Double-balloon enteroscopy (DBE) allows evaluation and therapy for various small bowel diseases. In this series the outcome of a 4-year experience in a tertiary hospital school in Brazil is reported. Methods: A total of 457 consecutive DBE were performed in 418 patients from August 2004 to August 2008. 93 patients with several indications, whose aim was not the evaluation of suspected diseases of the small bowel mucosa, were excluded, therefore leaving 364 DBE in 325 patients for analysis. Data were retrospectively collected with regard to clinical, endoscopic findings, therapy and complications. Results: Among the 364 DBE performed in 325 patients, 143/325 were males (44%) and 182/325 females (56%) with a mean age of 48.6 ± 15.7 years (range 17–89). Mean investigation time was 64 ± 22 min (range 35–135). The depth of insertion beyond the ligament of Treitz was 230 ± 85 cm (range 30–500) by the antegrade approach and 140 ± 75 cm (range 0–320) by the retrograde approach. Total enteroscopy was achieved in 41.66% of the attempts (30 of 72 patients). Overall diagnostic yield was 54.95% (200 of 364 procedures) ranging from 0 to 100% in this series, depending on the indication. Angiodysplasia was the main diagnosis in 24.5% (49 of 200 procedures) and endoscopic treatment, including biopsies, hemostasis, tattooing and polypectomy were performed in 65.38% (238 of 364 procedures). No major complications were reported. Conclusions: DBE is a feasible, safe and well-tolerated procedure allowing endoscopic therapy. Selection of indications increases its diagnostic yield.

Predictive Factors for Local Recurrence and Incomplete Resection of Early Gastric Cancer Treated by Endoscopic Resection: A Western Experience

BACKGROUND Early gastric cancer (EGC) is defined as adenocarcinoma limited to the mucosa or submucosa regardless of lymph node involvement. Local EGC recurrence rates have been described in up to 6% of cases. OBJECTIVES To evaluate predictive factors for incomplete resection and local recurrence of EGC treated by endoscopic mucosal resection (EMR) that was followed up for at least one year. METHODS From June 1994 to December 2005, 46 patients with EGC underwent EMR. Possible predictive factors for incomplete endoscopic resection and local recurrence were identified by medical chart analysis. Demographic, endoscopic and histopathological data were retrospectively evaluated. EMR was considered complete or incomplete. Patients from the complete resection group were divided into subgroups (with and without local EGC recurrence). RESULTS Complete resection was possible in 36 cases (76.6%). Predictive factors for incomplete resection were tumour location (P=0.035), histological type (P=0.021), lesion size (P=0.022) and number of resected fragments (P=0.013). On multivariate analysis, undifferentiated histological type (OR 0.8; 95% CI 0.036 to 0.897) and number of resected fragments (OR 7.34; 95% CI 1.266 to 42.629) were independent predictive factors for incomplete resection. In the complete resection group, a larger lesion size was associated with a higher the number of resected fragments (P=0.018). Local recurrence occurred in nine cases (25%). Use of the cap technique was the only predictive factor for local recurrence in five of seven cases (71.4%) (P=0.006). CONCLUSIONS A larger lesion size was associated with a higher number of resected fragments. Undifferentiated adenocarcinoma and piecemeal resection were predictive factors for incomplete resection. Technique type was a predictive factor for local EGC recurrence.

Endoluminal appendectomy: the first description in humans for acute appendicitis

Appendix inversion into the cecal lumen can be demonstrated, and its endoluminal appendectomy is feasible [1]. We describe the first procedure to remove the appendix using colonoscopy during acute appendicitis presentation. A video colonoscope (Pentax Medical, Tokyo, Japan) and a handmade doublechannel colonoscope prototype with an adapted 20Fr nasogastric tube were used for the colonoscopy (▶Fig. 1). Shark Tooth grasping forceps (Olympus Medical Systems, Tokyo, Japan), an endoloop (Olympus), a standard diathermic snare wire loop (Boston Scientific Corp., Marlborough, Massachusetts, USA), and endoclips (Olympus) were also used. Owing to such an unconventional procedure, informed consent was obtained from the patient’s wife and from his surgeon after the colonoscopic findings during the same procedure. A 67-year-old man with transverse colostomy secondary to surgical resection of a prior obstructive sigmoid neoplasm, presented with vague lower abdominal pain and fever. Two days earlier, an ultrasonography showed an enlarged appendix. A colonoscopy was performed to investigate synchronic lesions and showed only a purulent discharge from the appendiceal orifice. The endoloop from the attached nasogastric tube was opened and positioned close to the appendiceal orifice. The Shark Tooth grasping forceps was passed through the endoloop and gently into the appendix until tissue resistance was detected. The appendix tip was grasped and inverted back into the lumen in a single pull-through motion (▶Video1). The appendix presented with a reddish orange mucosa in its tail. A diathermic snare wire loop (Blend 1, 30W) was then placed over the inverted appendix to cut. Another endoloop was loaded, and then endoclips were used to fix the ligating loop into position and close the ligated appendix base (▶Fig. 2, ▶Video1). No bleeding was observed. Pathological assessment confirmed acute appendicitis (▶Fig. 3). The patient experienced abdominal discomfort and low-grade fever on the first postoperative day. He received ceftriaxone 2g/day and metronidazole 1.5 g/day for 2 days; oral diet was started on the same day. On the second postoperative day, the patient’s condition improved, without any report of pain.

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.

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.

Endoscopic Zenker's Diverticulotomy with a Harmonic Scalpel

Abstract The video of this article demonstrates a clinical case of Zenkers diverticulum (ZD) treated by flexible endoscopy using a harmonic scapel and soft diverticuloscope. The endoscopic aspect of follow-up at 1 month is also illustrated. Also demonstrated is the use of an articulated stapler in association with a soft diverticuloscope for the treatment of ZD in a pig model. This article is part of an expert video encyclopedia.