Rogerio Kuga

ERCP Using Double-Balloon Enteroscopy in Patients with Roux-en-Y Anatomy

Double-balloon enteroscopy (DBE) is a useful method for endoscopic retrograde cholangiopancreatography (ERCP) in patients with Roux-en-Y anatomy. Depending on the distorted anatomy, endoscopic therapies with conventional scopes were very difficult or impossible before the advent of DBE and patients had to be submitted to a percutaneous or surgical approach. The case of 6 patients with different types of Roux-en-Y-altered anatomy in which DBE-ERCP was performed with 83.3% successful rate (5/6) is reported confirming recent data in the literature on the feasibility of this method.

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.

Symptomatic Pneumoperitoneum after Endoscopic Removal of Adjustable Gastric Band

Endoscopic removal of an adjustable gastric band is a feasible procedure with few complications, according to our series of 8 patients. We report the case of a 56year-old woman who underwent endoscopic removal of a gastric band which had eroded through the gastric wall; this procedure was performed under general anesthesia, while the surgical group removed the subcutaneous port. The patient developed a large pneumoperitoneum after the procedure, and complained of back, shoulder and epigastric pain. A plain abdominal X-ray confirmed the pneumoperitoneum, and esophagogastric radiography with water-soluble contrast did not show a perforation. The treatment approach was conservative. This experience demonstrates an expected complication of endoscopic removal of an adjustable gastric band, and that the treatment may be conservative. The technique of band removal and the mechanism of pneumoperitoneum are discussed.

Gastric volvulus: A review of 38 cases

RACIONAL: O volvo gastrico e frequentemente condicao assintomatica e diagnosticado em exame radiologico feito por outras causas. A forma aguda, no entanto, pode ter consequencias graves e letais. Ele e definido como rotacao anomala do estomago nele proprio e classificado de acordo com o tipo, extensao, direcao, causa e apresentacao clinica. OBJETIVO: Apresentar aspectos clinicos e morfologicos de volvos gastricos. em 38 pacientes. METODOS: Analise retrospectiva onde foram coletadas informacoes registradas sobre 38 pacientes a cerda da idade, surgimento do primeiro sintoma, genero, principais achados clinicos, de exames complementares, tipo do volvo, causa, procedimentos terapeuticos, recidivas e evolucao tardia. RESULTADOS: Em 75,8% o volvo foi secundario Na maioria dos pacientes a opcao de tratamento foi cirurgica. Ele era cronico em 29 e agudo em quatro pacientes. O tratamento conservador foi indicado somente aos sem condicoes clinicas para operacoes. Gastropexia anterior foi associada a alta taxa de recidiva. A sutura da pequena curvatura gastrica a capsula hepatica e colon transverso na fossa subfrencia esquerda (operacao de Tanner) parece ser o tratamento de escolha nos volvos primarios. CONCLUSAO: O tratamento do volvo gastrico deve ser feito sob medida caso a caso e de acordo com a causa da doenca.

DOUBLE-BALLOON ENTEROSCOPY IN THE DIAGNOSIS OF AN ADENOCARCINOMA OF THE FOURTH PORTION OF THE DUODENUM: REPORT OF A CASE

due to a coincident bariatric jejunum-ileal bypass sur-gery at that time.Upper gastrointestinal endoscopy showed antral ery-thematous gastritis, and no alteration was noted in the firstor second portions of the duodenum. Fecal stool occultblood testing was positive (3+), but colonoscopy showedno alterations. Scintigraphy with 99 Tc and marked eryth-rocytes was performed and revealed positivity for intesti-nal bleeding, probably at the proximal small bowel.DBE demonstrated first, second and third portions ofthe duodenum with no abnormalities. In the fourth portionof the duodenum a vegetative, infiltrative and friable le-sion was noted, extending about 10 cm, involving almostall the circumference and the lumen of the organ, allow-ing however the transposition of the double-balloonenteroscope. Multiple biopsies were performed. Histologi-cal examination demonstrated moderately differentiatedadenocarcinoma of the duodenum. The immunohistochemi-cal evaluation was consistent with adenocarcinoma. Afterthe diagnosis, the patient and his family elected treatmentat a private hospital and we lost the follow-up.

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.

Comparison between Enteroscopy-Based and Laparoscopy-Assisted ERCP for Accessing the Biliary Tree in Patients with Roux-en-Y Gastric Bypass: Systematic Review and Meta-analysis

Although balloon-assisted enteroscopy-endoscopic retrograde cholangiopancreatography (BAE-ERCP) is a well-described means of accessing the duodenal papilla in patients with Roux-en-Y gastric bypass (RYGB), it is associated with modest clinical success rates. Laparoscopy-assisted ERCP (LA-ERCP)—performed by advancing a standard duodenoscope through a gastrostomy into the excluded stomach and duodenum—has emerged as a viable alternative to BAE-ERCP, with apparently higher success rates. In this systematic review, we compare LA-ERCP with enteroscopy-based techniques in post-RYGB patients, including 22 case series that provided data on papilla identification, papilla cannulation, and complications. We found that LA-ERCP was superior to the enteroscopy-based techniques in its capacity to reach the duodenal papilla, although complication rates were lower for the latter. Comparative studies are needed in order to corroborate our findings.

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.