Robson K. Ishida

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.

ENDOSCOPIC AND ULTRASONOGRAPHIC EVALUATION BEFORE AND AFTER ROUX-EN-Y GASTRIC BYPASS FOR MORBID OBESITY

BACKGROUND Esophagogastric abnormalities are recognized prior and after bariatric procedures, but frequency and severity are debated. Liver and biliary tract findings are also of clinical importance, especially gallstones and liver steatosis. AIM To compare pre-operative findings of hepatobiliary ultrasound and upper digestive endoscopy with post-operative results in patients submitted to open Roux-en-Y gastric bypass for morbid obesity. METHODS A total of 80 patients were enrolled 16.8 +/- 12.1 months after operation, all of them on routine follow-up program, and 8 were excluded. Retrospective analysis aimed at pre-operative clinical, endoscopic and ultrasonographic examinations and were prospectively repeated. RESULTS Pre-operative endoscopical report was available in 42 cases, and 52 examinations were performed post-operatively. Frequency of esophagitis changed from 16.7% (7/42) to 15.4% (8/52), and of gastritis from 45.2% (19/42) to 21.2% (11/52). Gastric or gastrojejunal ulcers were initially present in 4.8% (2/42) and increased to 9.6% (5/52). Post-operatively, an unusual abnormality was silastic band erosion: 7.7% (4/52). Helicobacter pylori was present in 50.0% (21/42) before and 3.5% (2/52) after operation. Ultrasonographic study had been done before intervention in 63 subjects, and 57 were executed on follow-up. Liver steatosis occurred previously in 58.7% (37/63) and in 43.9% (25/57) later on. Only 12.7% (8/63) of the patients had undergone cholecystectomy before bariatric operation, 29.1%(16/55) suffered simultaneous resection of gallbladder because of stones during Roux-en-Y gastric bypass, and an additional 26.8% (10/36) developed gallstones post-operatively. CONCLUSIONS Liver steatosis did not statistically improve, nor did inflammatory conditions of the upper digestive tube, despite reduction of H. pylori infections; gallbladder stones requiring intervention were common.

Gastrointestinal Transcriptomic Response of Metabolic Vitamin B12 Pathways in Roux-en-Y Gastric Bypass

OBJECTIVES: Vitamin B12 (B12) deficiency after Roux‐en‐Y gastric bypass (RYGB) is highly prevalent and may contribute to postoperative complications. Decreased production of intrinsic factor owing to gastric fundus removal is thought to have a major role, but other components of B12 metabolism may also be affected. We evaluated changes in the expression levels of multiple B12 pathway‐encoding genes in gastrointestinal (GI) tissues to evaluate the potential roles in contributing to post‐RYGB B12 deficiency. METHODS: During double‐balloon enteroscopy, serial GI biopsies were collected from 20 obese women (age, 46.9±6.2 years; body mass index, 46.5±5.3 kg/m2) with adult‐onset type 2 diabetes (fasting plasma glucose ≥126 mg/dl; hemoglobin A1c≥6.5%) before and, at the same site, 3 months after RYGB. Gene expression levels were assessed by the Affymetrix Human GeneChip 1.0 ST microarray. Findings were validated by real‐time quantitative PCR (RT–qPCR). RESULTS: Gene expression levels with significant changes (P≤0.05) included: transcobalamin I (TCN1) in remnant (−1.914‐fold) and excluded (−1.985‐fold) gastric regions; gastric intrinsic factor (GIF) in duodenum (−0.725‐fold); and cubilin (CUBN) in duodenum (+0.982‐fold), jejunum (+1.311‐fold), and ileum (+0.685‐fold). Validation by RT–qPCR confirmed (P≤0.05) observed changes for TCN1 in the remnant gastric region (−0.132‐fold) and CUBN in jejunum (+2.833‐fold). CONCLUSIONS: RYGB affects multiple pathway‐encoding genes that may be associated with postoperative B12 deficiency. Decreased TCN1 levels seem to be the main contributing factor. Increased CUBN levels suggest an adaptive genetic reprogramming of intestinal tissue aiming to compensate for impaired intestinal B12 delivery.

The SURMetaGIT study: Design and rationale for a prospective pan-omics examination of the gastrointestinal response to Roux-en-Y gastric bypass surgery

Objective To describe the protocol of the SURgically induced Metabolic effects on the Human GastroIntestinal Tract (SURMetaGIT) study, a clinical pan-omics study exploring the gastrointestinal tract as a central organ driving remission of type 2 diabetes mellitus (T2DM) after Roux-en-Y gastric bypass (RYGB). The main points considered in the study’s design and challenges faced in its application are detailed. Methods This observational, longitudinal, prospective study involved collection of gastrointestinal biopsy specimens, faeces, urine, and blood from 25 obese women with T2DM who were candidates for RYGB (20 patients for omics assessment and 5 for omics validation). These collections were performed preoperatively and 3 and 24 months postoperatively. Gastrointestinal transcriptomics; faecal metagenomics and metabolomics; plasma proteomics, lipidomics, and metabolomics; and biochemical, nutritional, and metabolic data were assessed to identify their short- and long-term correlations with T2DM remission. Results Data were collected from 20 patients before and 3 months after RYGB. These patients have nearly completed the 2-year follow-up assessments. The five additional patients are currently being selected for omics data validation. Conclusion The multi-integrated pan-omics approach of the SURMetaGIT study enables integrated analysis of data that will contribute to the understanding of molecular mechanisms involved in T2DM remission after RYGB.

Computed tomography colonography versus colonoscopy for the diagnosis of colorectal cancer: a systematic review and meta-analysis

Colorectal cancer (CRC) is a significant cause of morbidity and mortality. Optical colonoscopy (OC) is the first choice of investigation for assessing the state of the colon and it is excellent for CRC screening. Newer technologies such as computed tomography colonography (CTC) may also be useful in CRC screening. This systematic review compares the benefits of CTC and OC for CRC screening. This review includes all the available randomized clinical trials comparing CTC and OC for CRC screening in asymptomatic patients. Three studies were included in the systematic review and were submitted for meta-analysis. In the analysis of participation rates, only 2,333 of 8,104 (29%) patients who were invited for screening underwent the CTC, and only 1,486 of the 7,310 (20%) patients who were invited for screening underwent OC. The absolute risk difference in participation rate in the two procedures was 0.1 (95% CI, 0.05–0.14) in favor of CTC. In the analysis of advanced colorectal neoplasia (ACN) detection rates, 2,357 patients undergoing CTC and 1,524 patients undergoing OC were included. Of these, 135 patients (5.7%) who underwent a CTC and 130 patients (8.5%) who underwent an OC were diagnosed with ACN. The absolute risk difference in ACN detection rate in the two procedure types was −0.02 (with a 95% CI between −0.04 and −0.00) in favor of OC. CTC is an option for CRC screening in asymptomatic patients. However, as CTC was inferior in detecting ACN, it should not replace OC, which remains the gold standard.

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.