Sílvia Mansur Reimão

Fecal microbiota transplant by push enteroscopy to treat diarrhea caused by Clostridium difficile

ABSTRACT Clostridium difficile is the major etiological agent of pseudomembranous colitis and is found in up to 20% of adult inpatients. The recommended treatment is antibiotic therapy with metronidazole and/or vancomycin. However, the recurrence rate may reach up to 25% and it increases in each episode. The newest alternative to treat diarrhea due to recurrent Clostridium difficile is fecal microbiota transplantation. The procedure was performed in 12 patients, with a 6-month follow-up on 10 of them. Of the ten cases, bacterial recurrence was diagnosed in only one patient, after a course of antibiotic to treat urinary tract infection, without presenting with diarrhea. The particularity of our study, besides being an unprecedented event in South America, is the way to perform the infusion of fecal microbiota by enteroscopy.

Endoscopic treatment of large pancreatic fluid collections (PFC) using self-expanding metallic stents (SEMS) – a two-center experience

Background/study aim: During the last several years, endoscopic ultrasound (EUS)-guided pancreatic fluid collections’ (PFC) drainage has evolved into the preferred drainage technique. Recently, self-expanding metallic stents (SEMS) have been used as an alternative to double pigtail stents, with the advantage of providing a larger diameter fistula, thereby decreasing the risk of early obstruction and also allowing for direct endoscopic exploration of the cavity. The aim of this study was to evaluate the technical and clinical success, safety, and outcome of patients undergoing EUS-guided drainage of complex PFC using SEMS. Patients/materials and methods: The study was conducted at two tertiary hospitals from January 2010 to January 2013. All patients with PFC referred for endoscopic drainage were enrolled in a prospective database. The inclusion criteria were: (1) patients with pseudocysts or walled-off necrosis based on the revised Atlanta classification; (2) symptomatic patients with thick PFC; (3) PFC that persisted more than 6 weeks; and (4) large PFC diameter (≥ 9 cm). The exclusion criteria consisted of coagulation disorders, PFC bleeding or infection, and failure-to-inform written consent. Results: A total of 16 patients (9 females, 7 males; mean age 52.6, range 20 – 82) underwent EUS drainage with SEMS. There were 14 cases of pseudocysts and 2 cases of walled-off necrosis. The etiologies of the PFC were mainly gallstones (8 of 16 patients, 50 %) and alcohol (5 of 16 patients, 31 %). Technical success was achieved in 100 % of the cases. All patients had a complete resolution of the PFC. Conclusion: Transmural EUS-guided drainage of complex PFC using SEMS is feasible, appears safe, and is efficacious. However, the exchange of the UC (uncovered)-SEMS for plastic stents is mandatory within 1 week. Future prospective studies, preferably multicenter studies, comparing SEMS versus traditional plastic stents for the drainage of PFC are warranted.

Reply to Letter to Editor: Comment on “Improvement of Body Composition and Quality of Life Following Intragastric Balloon”

Dear Editor, Thank you for the opportunity to respond this Letter to the Editor. We would like to inform that all usual procedures were taken to avoid errors during the bioimpedance analysis (BIA). All tests were done early morning, at the same time with constant temperature to keep the testing environment and methodology adequacy. The patients were carefully advised to avoid physical activities, alcohol, food, and medications before the test that was performed with 12-h-fasting and empty bladder. As all these procedures are usual in clinical practice, they were not included due to the limited words of our article published as Brief Communication, but they are really very important to perform and evaluate the research. To the best of our knowledge, BIA can be a feasible alternative tool to assess body composition because of its simplicity and noninvasiveness and had been validated with dualenergy X-ray absorptiometry (DXA) [1]. Comparing the amount of body and trunk fat mass measured by DXA to magnetic resonance imaging [2] or measured by BIA compared with X-ray computed tomography [3], it had been closely related. Furthermore, the same patients were evaluated with the same device and in the same environmental conditions before and after treatment, which certainly helps to minimize small differences and validate our results.

What are the benefits of endoscopic ultrasound in the staging of pancreatic cancer

Female patient, 73 years old, with a history of jaundice, epi-gastric pain radiating to the back, and weight loss of 15 kg in three months. She was referred to our hospital with a possible diagnosis of cancer in the head of the pancreas, with evidence of increased pancreatic head and dilatation of intra- and extra-hepatic biliary ducts on abdominal com-puted tomography and magnetic resonance cholangiogra-phy. Due to obstructive jaundice, a retrograde cholangio-pancreatography was performed, showing partial stenosis of the distal common bile duct with dilatation of bile ducts, which was drained by inserting two biliary plastic stents. An endoscopic ultrasound was requested to further study the pancreas and adjacent structures. During the investigation, a hypoechoic heterogeneous lesion measuring 35 x 30 mm and presenting ill-defined margins was seen in the pancreatic head. There were also signs of vascular involvement, with loss of acoustic inter -face with the wall of the portal vein and absence of vas-cular flow (thrombosis). Furthermore, dilatation of the main pancreatic duct (6 mm) in the regions of body and tail of the pancreas upstream to the lesion described abo-ve was observed. Echo-guided punctures were performed in the lesion for histological clarification.