Vitor Brunaldi

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.

Response to “The Forgotten Fundus—Obesity Treatment with Botulinum Toxin-A Is Not Effective: a Systematic Review and Meta-Analysis”

Dear colleagues, Firstly, we would like to thank for your comments and compliments about our article [1]. In our point of view, discussions on scientific articles always benefit science and patients, ultimately. Our group has been publishing systematic reviews on GI endoscopy and abdominal surgery over the last 4 years. We always perform a comprehensive and very sensitive search that aims at avoiding missing any study. This strategy guarantees that our manuscripts represent the literature as a whole. Also, we draw conclusions based on the results found in our meta-analysis. However, explanations for specific findings are usually hypothetical and based on personal experiences and are not meant to convey steady scientific assurance. Regarding our article, we hypothesized the reasons why Foschi D et al. showed a significant superiority of botulinum toxin-A (BTA) versus placebo while the other three RCT did not [2–5]. Surely, there are many other differences between those trials and all of themmay have led to the aforementioned superiority. Foschi D et al. were the only ones who oriented strict diet. Foschi D et al. have included only patients with BMI greater than 35 kg/m while the others enrolled also Bless obese^ individuals (BMI > 30 kg/m). Foschi D et al. employed a stricter follow-up regimen: weekly assessment for 2 months (Gui D et al.: day 10 and 5 weeks; Mittermair R et al.: monthly; Topazian M: weekly for 1 month, biweekly for 3 more months, and final assessment at sixth month). Finally, Foschi D et al. injected BTA into the fundus while the others did not. Regardless of the explanations we find, Foschi D et al. would still be considered an outlier. That is, their results are not in accordance with the rest of the literature. They would still be extracted from meta-analysis after funnel plot assessment; otherwise, the high heterogeneity would impair conclusions. Ultimately, the result would be the same. As to the outlined physiological pathways for BTA action in the gastric fundus, we comprehend your rationale. However, we have some concerns about the scientific data used as reference. Firstly, Foschi D et al. assessed maximal gastric capacity for liquids, not solids. Secondly, this analysis is completely limited by a significant baseline difference between groups: 545 ± 48 kcal (BTA) vs 475.8 ± 28 kcal (placebo)—p < 0.001. Since the populations present substantial differences, they might not be comparable and, therefore, one should not draw conclusions based on their outcomes. As to the gastric emptying test, the authors did not provide baseline results which impair a critical appraisal [2]. In our point of view, this selective lack of data points out to another baseline difference. Even though we agree with the biological plausibility of your rationale, it remains to be proven. Finally, we think that if an untested rationale exists, it should be addressed by a specifically designed trial. Your suggestion seems remarkable but we would include an adequate gastric emptying and maximal gastric capacity assessment. That would support the proposed pathway and surely contribute to a more evidence-based practice. * Vitor Ottoboni Brunaldi vbrunaldi@gmail.com; vitor.brunaldi@usp.br

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.

Endoscopic Dilation with Bougies versus Balloon Dilation in Esophageal Benign Strictures: Systematic Review and Meta-Analysis

Background The use of bougies and balloons to dilate benign esophageal strictures (BES) is a consolidated procedure. However, the amount of evidence available in scientific literature supporting which is the best technique is very low, despite the great prevalence and importance of such pathology. This systematic review with meta-analysis aims at comparing both techniques, providing good quality of evidence. Methods We searched for randomized clinical trials (RCTs) published from insertion to November 2017, using MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials, LILACS, and grey literature. After the data extraction, a meta-analysis was performed. The main outcomes were symptomatic relief and recurrence rate. The secondary outcomes were bleeding, perforation, and postprocedure pain. Results We included 5 randomized clinical trials (RCTs), totalizing 461 patients. Among them, 151 were treated with bougie dilation and 225 underwent balloon dilation. Regarding symptomatic relief, recurrence, bleeding, and perforation rates, there were no differences between the methods. Concerning postprocedure pain, patients submitted to balloon dilation had less intense pain (RD 0.27, 95% IC −0.42 to −0.07, P = 0.007). Conclusion We conclude that there is no difference between bougie and balloon dilation of BESs regarding symptomatic relief, recurrence rate at 12 months, bleeding, and perforation. Patients undergoing balloon dilation present less severe postprocedure pain.

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.

Stent migration requiring surgical removal: a serious adverse event after bariatric megastent placement

Leaks are serious complications after sleeve gastrectomy, with an incidence rate up to 7% [1]. Currently, stent placement and other endoscopic techniques are recommended for the treatment of post-bariatric leaks (PBLs) [2]. Bariatric stents are a feasible, effective and lifesaving method [3]. They achieve leak closure rates between 72.8% and 87.8% but are associated with significant migration rates (16.9%–28.2%) [1, 4]. The large bariatric-specific stent (LBSS) has been developed as an important device to fit bariatric anatomy and avoid migration because of its long length with the distal edge being placed in the duodenum [5]. We report the case of 34-year-old woman who underwent sleeve gastrectomy. On the 5th post-operative day (POD), she developed abdominal pain and purulent output from the drain. Computed tomography (CT) scanning showed a leak at the angle of His without any collections. We opted to place an LBSS (24 cm× 28mm; Hanarostent, MITECH) to bypass the whole stomach (▶Fig. 1). The LBSS was removed 4 weeks later (33th POD), but the leak persisted. We then placed two single-pigtail stents (▶Fig. 2) and kept them in place for 10 days, but this was also unsuccessful. On the 43 rd POD, we removed the pigtail stents, performed a septotomy, and placed a second LBSS (▶Fig. 3). After 3 weeks (64th POD), the patient again presented with abdominal pain. On this occasion, esophagogastroduoE-Videos

Hemostatic powder: a new ally in the management of postsphincterotomy bleeding

ERCP with sphincterotomy is the criterion standard treatment for the management of choledocholithiasis because it has low morbidity and mortality rates and excellent outcomes; however, adverse events are not uncommon. Postsphincterotomy bleeding has an estimated incidence of less than 2%, but it represents a serious adverse event of ERCP. The management of postsphincterotomy bleeding is challenging, and the main therapeutic modality is endoscopic treatment. The most commonly performed hemostatic procedure is epinephrine injection, which is effective in most cases. Nevertheless, some cases demand combined therapy. It is known that endoscopic clipping with the use of a side-view endoscope is a laborious procedure; therefore, the development of new hemostatic procedures is imperative. Hemospray (Cook Medical, Winston-Salem, NC) is a new endoscopic accessory and consists of a mineral powder that absorbs water when applied to an actively bleeding lesion, forming a mechanical barrier over the bleeding site. We offer a video in which Hemospray application successfully controlled postsphincterotomy bleeding. A 69-year-old man was referred to our department with a diagnosis of choledocholithiasis. ERCP confirmed the latter, and sphincterotomy, followed by calculi extraction,