Thiago Souza

Echoguided hepatico-gastrostomy: a case report

and maybe seen as a variation of the intrahepatic approach, butwithout selective drainage through the ampulla.In terms of a minimally invasive concept and low com-plication rate, this is the first presentation of hepatico-gas-trostomy drainage using both endoscopic ultrasound andfluoroscopy guidance performed at the Gastrointestinal En-doscopy Unit in the Hospital das Clinicas – University ofSao Paulo School of Medicine.

Deep sedation during gastrointestinal endoscopy: Propofol-fentanyl and midazolam-fentanyl regimens

AIM To compare deep sedation with propofol-fentanyl and midazolam-fentanyl regimens during upper gastrointestinal endoscopy. METHODS After obtaining approval of the research ethics committee and informed consent, 200 patients were evaluated and referred for upper gastrointestinal endoscopy. Patients were randomized to receive propofol-fentanyl or midazolam-fentanyl (n = 100/group). We assessed the level of sedation using the observers assessment of alertness/sedation (OAA/S) score and bispectral index (BIS). We evaluated patient and physician satisfaction, as well as the recovery time and complication rates. The statistical analysis was performed using SPSS statistical software and included the Mann-Whitney test, χ² test, measurement of analysis of variance, and the κ statistic. RESULTS The times to induction of sedation, recovery, and discharge were shorter in the propofol-fentanyl group than the midazolam-fentanyl group. According to the OAA/S score, deep sedation events occurred in 25% of the propofol-fentanyl group and 11% of the midazolam-fentanyl group (P = 0.014). Additionally, deep sedation events occurred in 19% of the propofol-fentanyl group and 7% of the midazolam-fentanyl group according to the BIS scale (P = 0.039). There was good concordance between the OAA/S score and BIS for both groups (κ = 0.71 and κ = 0.63, respectively). Oxygen supplementation was required in 42% of the propofol-fentanyl group and 26% of the midazolam-fentanyl group (P = 0.025). The mean time to recovery was 28.82 and 44.13 min in the propofol-fentanyl and midazolam-fentanyl groups, respectively (P < 0.001). There were no severe complications in either group. Although patients were equally satisfied with both drug combinations, physicians were more satisfied with the propofol-fentanyl combination. CONCLUSION Deep sedation occurred with propofol-fentanyl and midazolam-fentanyl, but was more frequent in the former. Recovery was faster in the propofol-fentanyl group.

GASTROPLASTIA VERTICAL ENDOSCÓPICA - TERAPÊUTICA MINIMAMENTE INVASIVA PARA TRATAMENTO PRIMÁRIO DA OBESIDADE

Racional: Procedimentos menos invasivos e complexos tem sido desenvolvidos para o tratamento da obesidade. A gastroplastia vertical endoscopica com uso de OverStitch(r) (Apollo Endosurgery, Austin, TX, EUA) ja foi relatada com sucesso na literatura. Objetivo: Apresentar detalhes tecnicos do procedimento e seu resultado cirurgico/endoscopico preliminar. Metodo: O equipamento foi utilizado para realizar plicaturas ao longo da grande curvatura gastrica, objetivando tubulizacao do estomago semelhante a gastrectomia vertical. Resultado: O metodo foi aplicado em paciente com IMC 35,17 kg/m2, sendo realizadas quatro plicaturas, preservando o fundo gastrico. O procedimento foi realizado com sucesso em 50 min, sem sangramento ou outras complicacoes. O paciente evoluiu com dor abdominal leve, e teve boa aceitacao de dieta liquida. Conclusao: A realizacao da gastroplastia endoscopica foi segura, com viabilidade tecnica aceitavel e reprodutivel, com curto tempo de procedimento, sem complicacoes precoces.

ENDOSCOPIC SLEEVE GASTROPLASTY - MINIMALLY INVASIVE THERAPY FOR PRIMARY OBESITY TREATMENT

ABSTRACT Background: Less invasive and complex procedures have been developed to treat obesity. The successful use of Endoscopic Sleeve Gastroplasty using OverStitch(r) (Apollo Endosurgery, Austin, Texas, USA) has been reported in the literature. Aim: Present technical details of the procedure and its surgical/ endoscopic preliminary outcome. Method: The device was used to perform plications along the greater curvature of the stomach, creating a tubulization similar to a sleeve gastrectomy. Result: A male patient with a BMI of 35.17 kg/m2 underwent the procedure, with successful achievement of four plications, and preservation of gastric fundus. The procedure was successfully performed in 50 minutes, time without bleeding or other complications. The patient presented mild abdominal pain and good acceptance of liquid diet. Conclusions: The endoscopic gastroplasty procedure was safe, with acceptable technical viability, short in duration and without early complications.

Endoscopic Aspects of Gastric Syphilis

Introduction. Considered as a rare event, gastric syphilis (GS) is reported as an organic form of involvement. Low incidence of GS emphasizes the importance of histopathological analysis. Objective. We aim to characterize GS endoscopic aspects in an immunocompetent patient. Case Report. A 23-year-old man presented with epigastric pain associated with nausea, anorexia, generalized malaise and 11 kg weight loss that started 1 month prior to his clinical consultation. Physical examination was normal except for mild abdominal tenderness in epigastrium. Endoscopy observed diminished gastric expandability and diffuse mucosal lesions, from cardia to pylorus. Gastric mucosa was thickened, friable, with nodular aspect, and associated with ulcers lesions. Gastric biopsies were performed, and histopathological analysis resulted in dense inflammatory infiltration rich in plasmocytes. Syphilis serologies were positive for VDRL and Treponema pallidum reagents. Immunohistochemical tests were positive for Treponema pallidum and CD138. The patient was treated with penicillin, leading to resolution of his clinical complaints and endoscopic findings. Conclusion. Diagnosis suspicion of GS is important in view of its nonspecific presentation. Patients with gastric symptoms that mimic neoplastic disease should be investigated thoroughly based on the fact that clinical, endoscopic, and histological findings can easily be mistaken for lymphoma or plastic linitis.

Plasmocytoma of the jejunum: diagnosis by double-balloon enteroscopy

Multiple myeloma (MM) or Kahler’s disease is a malignant neoplasia of the lymphoplasmocyte lineage, characterized by uncontrolled and progressive proliferation of an abnormal plasmocyte clone within the bone marrow (BM) with subsequent production of monoclonal immunoglobulin. On the other hand, focal plasmocyte tumors (plasmocytomas) with formation of tumorous masses without medullary involvement may rarely affect the gastrointestinal tract (GIT) and are denominated solitary extramedullary plasmocytomas. The main extramedullary site of plasmocytoma is the jejunum. We report a patient who presented with jejunal plasmocytoma and emphasize the importance of the double-balloon endoscope for diagnosis of the lesion. 2

Efficacy and Safety of Stents in the Treatment of Fistula After Bariatric Surgery: a Systematic Review and Meta-analysis

Fistula development is a serious complication after bariatric surgery. We performed a systematic review and meta-analysis to assess the efficacy of fistula closure and complications associated with endoscopic stent treatment of fistulas, developed after bariatric surgeries, particularly Roux-en-Y gastric bypass (RYGB) and gastric sleeve (GS). Studies involving patients with fistula after RYGB or GS and those who received stent treatment only were selected. The analyzed outcomes were overall success rate of fistula closure, mean number of stents per patient, mean stent dwelling time, and procedure-associated complications. Current evidence from identified studies demonstrates that, in selected patients, endoscopic stent treatment of fistulas after GS or RYGB can be safe and effective.

Complex biliary stones management: cholangioscopy versus papillary large balloon dilation - a randomized controlled trial

Background and study aims  Endoscopic removal of biliary stones has high success rates, ranging between 85 % to 95 %. Nevertheless, some stones may be challenging and different endoscopic methods have evolved. Papillary large balloon dilation after sphincterotomy is a widely used technique with success rates ranging from 68 to 90 % for stones larger than 15 mm. Cholangioscopy allows performing lithotripsy under direct biliary visualization, either by laser or electrohydraulic waves, which have similar success rate (80 % – 90 %). However, there is no study comparing these 2 techniques. Patients and methods  From April 2014 to June 2016, 100 patients were enrolled and randomized in 2 groups, using a non-inferiority hypothesis: cholangioscopy + electrohydraulic lithotripsy (group 1) and endoscopic papillary large balloon dilation (group 2). The main outcome was complete stone removal. Adverse events were documented. Mechanical lithotripsy was not performed. Failure cases had a second session with crossover of the methods. Results  The mean age was 56 years. 74 (75.5 %) patients were female. The initial overall complete stone removal rate was 74.5 % (77.1 % in group 1 and 72 % in group 2, P  > 0.05). After second session the overall success rate achieved 90.1 %. Procedure time was significantly lower in group 2, – 25.2 min (CI95 % – 12.48 to – 37.91). There were no significant differences regarding technical success rate, radiologic exposure and adverse events. Conclusion  Single-operator cholangioscopy-guided lithotripsy and papillary large balloon dilation are effective and safe approaches for removing complex biliary stones.

Brazilian Intragastric Balloon Consensus Statement (BIBC): practical guidelines based on experience of over 40,000 cases

BACKGROUND Intragastric balloons (IGBs) are a minimally invasive option for obesity treatment, acting as a space-occupying device and leading to weight loss through increased satiety. This device has been growing in popularity owing to its safety profile and good weight loss results. However, there are no published guidelines that standardize the technical aspects of the procedure. OBJECTIVES To create a practical guideline for intragastric balloon usage. SETTING Private and Academic Settings, Brazil. METHODS A consensus meeting was held in São Paulo, Brazil, in June 2016, bringing together 39 Brazilian endoscopists with extensive experience in IGBs from all regions of the country. Topics on patient selection, indications, contraindications, multidisciplinary follow-up, technique, and adverse events were discussed in the form of questions. After electronic voting, a consensus was defined when there was ≥70% agreement. Experts were also requested to provide data on their experience with IGBs. RESULTS The selected experts discussed and reached a consensus on 76 questions, mainly concerning specific indications and contraindications for the procedure; technical details, such as patient preparation, minimum balloon-filling volume, techniques for implant and explant; patient follow-up and recommended medication for the adaptation period; and adverse event management. The overall Brazilian expert data encompassed 41,863 IGBs, with a mean percentage total weight loss of 18.4% ± 2.9%. The adverse event rate after the adaptation period was 2.5%, the most common being hyperinflation (.9%) and spontaneous deflation (.8%) of the device. The early removal rate due to intolerance was 2.2%. CONCLUSIONS The present consensus represents practical recommendations for performing IGB procedures and reflects Brazils significant experience with this device. The experience of over 40,000 cases shows that the device leads to satisfactory weight loss with a low rate of adverse events.

Increased Gastric Retention Capacity, Assessed by Scintigraphy, after APC Treatment of Dilated Gastrojejunal Anastomosis

Background: Weight regain occurs in about 20% of patients after Roux-en-Y gastric bypass (RYGB). Studies have reported that in most cases this regain is associated with dilatation of the gastrojejunal anastomosis. To correct this dilatation, one of the methods used is the application of argon plasma coagulation (APC). Case: The authors report the case of a 39-year-old woman submitted to RYGB who had weight regain. In the endoscopic evaluation, the patient presented with dilatation of the gastrojejunal anastomosis, for which treatment with APC and an adjusted diet was proposed. After 3 sessions of APC, the patient presented with a reduction of the anastomosis diameter, weight loss, and increased satiety to food, with an increased gastric emptying time evidenced by scintigraphy. Conclusion: APC proved to be a safe and efficacious method.