Rodrigo Rocha

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.

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

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.

Single-guidewire double-tip cannulation for difficult biliary access: the DTC technique

The double-guidewire technique (DGT) for difficult biliary cannulation was first described by Dumonceau et al. in 1998 [1]. Over recent years, DGT has become an important advanced technique after unsuccessful standard retrograde cannulation (guidewire-assisted or contrast-assisted), especially when unintentional pancreatic duct cannulation occurs [2]. The success rate of DGT for biliary cannulation in randomized controlled trials ranges from 66.6% to 92.5% [3]. We describe a similar alternative to DGT using a single guidewire with two hydrophilic tips. A 75-year-old man was admitted to the hospital with non-severe pancreatitis. Physical examination was unremarkable except for mild jaundice. Abdominal ultrasound showed gallstones inside the common bile duct, and laboratory studies revealed total bilirubin of 4.8mg/dL (direct bilirubin 3.5mg/dL). After resolution of the pancreatitis, the patient was referred for endoscopic retrograde cholangiopancreatography with stone extraction. During the procedure, we encountered difficult biliary access, with three pancreatic duct cannulations (▶Fig. 1). In our unit, we routinely employ sphincterotome-assisted guidewire cannulation. In this case, we used a Hydra Jagwire (Boston Scientific, Marlborough, Massachusetts, USA), which offers two hydrophilic tips. After the third pancreatic duct cannulation, the first tip was kept inside the main pancreatic duct. We removed the sphincterotome, reinserted the second tip through its guidewire channel (▶Fig. 2), and successfully performed biliary cannulation similarly to DGT (▶Fig. 3, ▶Video1). Finally, we performed the sphincterotomy and balloon sweeping. At follow-up, the patient presented neither abdominal pain nor hyperamylasemia and was referred to a gastrointestinal surgeon for laparoscopic cholecystectomy. DGT for difficult biliary access is effective and widespread but carries high related costs owing to the need for an extra guidewire. The single-guidewire doubletip cannulation (DTC) technique is as ef▶ Fig. 1 First guidewire tip inside the main pancreatic duct.