Walton Albuquerque

Clinical and Laboratory Predictors of Esophageal Varices in Children and Adolescents With Portal Hypertension Syndrome

Objectives: To determine the clinical and laboratory parameters that may predict the presence of esophageal varices in children and adolescents with portal hypertension. Patients and Methods: Overall, 111 patients with portal hypertension and no previous history of digestive bleeding underwent esophagogastroduodenoscopy for detection of esophageal varices. A univariate analysis initially was carried out, followed by a logistic regression analysis to identify the independent variables associated with the presence of esophageal varices. Sensitivity and specificity rates, positive predictive value, negative predictive value, and the accuracy of the predictive variables identified among cirrhotic patients were calculated with the esophagogastroduodenoscopy as the reference test. Results: Sixty percent of patients had esophageal varices on the first esophagogastroduodenoscopy. Patients with portal vein thrombosis and congenital hepatic fibrosis were 6.15-fold more likely to have esophageal varices than cirrhotic patients. When we analyzed 85 cirrhotic patients alone, splenomegaly and hypoalbuminemia remained significant indicators of esophageal varices. Only spleen enlargement showed appropriate sensitivity and negative predictive value (97.7% and 91.7%, respectively) to be used as a screening test for esophageal varices among cirrhotic patients. Conclusions: In reference services and research protocols, endoscopic screening should be performed in all patients with portal vein thrombosis and congenital hepatic fibrosis. Among cirrhotic patients, the indication should be conditioned to clinical evidence of splenomegaly or hypoalbuminemia. For clinicians, the recommendation is to emphasize the orientations given to guardians of patients with portal vein thrombosis and congenital hepatic fibrosis as to the risk of digestive bleeding. Cirrhotic patients with hypoalbuminemia and splenomegaly should receive the same orientations.

Botulinum A Toxin Injected into the Gastric Wall for the Treatment of Class III Obesity: A Pilot Study

Background: Obesity represents a major public health problem in western countries. Initial studies suggest that injection of botulinum A toxin (Btx-A) into the antropyloric region inhibits propulsive contractions of the antral pump, with delay in gastric emptying, early satiety and weight loss. Methods: After approval by the University Ethics Committee, we prospectively evaluated 12 patients with class III obesity divided into 4 groups of 3 patients each. In groups I and II, 200 U Btx-A were injected into the antropyloric region at 8 and 16 sites, respectively. Groups III and IV received 300 U Btx-A into the antropyloric region at 16 and 24 sites, respectively. Body weight and gastric emptying time (GET) of solids and semi-solids using 13C-octanoic acid breath test and 13C-acetic acid breath test, respectively, were determined before and after injection over a period of 12 weeks. Results: Pre- and post-treatment body weight or solid and semi-solid GET did not differ significantly between groups (P>0.05). All patients reported a feeling of early satiety. No adverse effects related to BtxA or complications resulting from the endoscopic procedure were observed. Conclusion: The injection of different doses of BtxA at different sites in the antropyloric region of patients with class III obesity did not interfere significantly with the solid and semi-solid GET or body weight of these individuals. However, early satiety was reported by all patients, the procedure was safe and no side-effects of the treatment were observed. Further controlled studies involving different methodologies regarding dosage of Btx-A and sites of injection are necessary.

Standardized endoscopic submucosal tunnel dissection for management of early esophageal tumors (with video).

Endoscopic submucosal dissection (ESD) was first developed to remove en bloc early gastric neoplasms. Later, this technique was proposed for the management of esophageal and colorectal superficial tumors, and currently ESD is performed routinely in Asia. ESD is indicated for esophageal cancer with no or minimal risk of lymph node metastasis. When the lesions are classified according to the depth of invasion as intraepithelial carcinoma (M1), restricted within the proper mucosal layer (M2), adjacent to or invading but not beyond the muscularis mucosa (M3), invading the submucosal (SM) layer to a depth of one third (SM1) or more than one third (SM2 and SM3) of the layer thickness, then the incidence of lymph node metastasis was reported to be 0%, 0% to 5.6%, 8% to 18%, 11% to 53%, and 30% to 54%, respectively. Therefore, under the 2002 Japan Esophageal Society guidelines for the treatment of esophageal cancer, the absolute indication for endoscopic resection is defined as M1-M2 esophageal cancer as well as two thirds or less extension of the circumference, whereas the relative indication is defined as M3-SM1 esophageal cancer with as much as three fourths or more mucosal defect after resection. ESD with complete resection can only be considered curative for M1-M2 esophageal squamous cell

Endoscopic repair of a large colonoscopic perforation with clips

We report a patient with a large colonic perforation that occurred in a screening colonoscopy, successfully repaired with endoclips, although the safety and efficacy of this approach is not entirely established. Endoscopic clip placement can be used to treat iatrogenic colonic perforation, when the defect is readily recognized and is easily accessible for closure, and the bowel preparation is excellent.

Submucosal Injection of 0.4% Hydroxypropyl Methylcellulose Facilitates Endoscopic Mucosal Resection of Early Gastrointestinal Tumors

Background and Aims Submucosal injection of a viscoelastic solution prolongs submucosal lift, thus, facilitating endoscopic mucosal resection. Our objective was to assess the safety and clinical effectiveness of 0.4% hydroxypropyl methylcellulose (HPMC) as a submucosal injectant for endoscopic mucosal resection. Patients and Methods A prospective, open-label, multicenter, phase 2 study was conducted at 2 academic institutions in Brazil. Eligible participants included patients with early gastrointestinal tumors larger than 10 mm. Outcomes evaluated included complete resection rates, volume of HPMC injected, duration of the submucosal cushion as assessed visually, histology of the resected leisons, and complication rates. Results Over a 12-month period, 36 eligible patients with superficial neoplastic lesions (stomach 14, colon 11, rectum 5, esophagus 3, duodenum 3) were prospectively enrolled in the study. The mean size of the resected specimen was 20.4 mm (10 to 60 mm). The mean volume of 0.4% HPMC injected was 10.7 mL (range 4 to 35 mL). The mean duration of the submucosal fluid cushion was 27 minutes (range 9 to 70 min). Complete resection was successfully completed in 89%. Five patients (14%) developed immediate bleeding requiring endoclip and APC application. Esophageal perforation occurred in 1 patient requiring surgical intervention. There were no local or systemic adverse events related to HPMC use over the follow-up period (mean 2.2 mo). Conclusion HPMC solution (0.4%) provides an effective submucosal fluid cushion and is safe for endoscopic resection of early gastrointestinal neoplastic lesions.

Effectiveness of unsedated transnasal endoscopy with white-light, flexible spectral imaging color enhancement, and lugol staining for esophageal cancer screening in high-risk patients.

Background and Aims: Transnasal endoscopy (TNE) has been proposed to screen for esophageal squamous cell cancer (ESCC) in Asia. This study aimed to assess the feasibility and tolerance of Brazilian patients to undergo unsedated TNE for screening, the prevalence of ESCC in this population, and the effectiveness of white-light endoscopy (WLE) and digital chromoendoscopy [flexible spectral imaging color enhancement (FICE)] to diagnose esophageal neoplasia. Patients and Methods: This was a diagnostic test study that enrolled patients with head and neck squamous cell cancer (HNSCC) referred to ESCC screening. Patients’ tolerance was rated by a numeric pain intensity scale. Interventions included unsedated TNE with WLE and FICE examination of the esophagus, in a tandem manner with blinded operators, followed by lugol chromoscopy. Performance of WLE and FICE for neoplasia detection was compared with the reference standard (lugol chromoscopy plus histology). Results: A total of 106 patients were recruited. TNE was feasible in 99.1%, and 92% of the patients rated the discomfort as absent or minimal. Thirteen ESCC were detected (12.3%), with 10 early cancers (77%). The tests showed an excellent performance and there was no difference between WLE (sensitivity 92.3%, specificity 98.9%, accuracy 98.1%, area under curve 0.995) and FICE (sensitivity 100%, specificity 98.9%, accuracy 99%, area under curve 0.956) for esophageal neoplasia detection. Conclusions: Unsedated TNE is a feasible, well accepted, and efficient diagnostic tool for the screening of ESCC. The elevated rate of esophageal neoplasia strengthens the recommendations to screen patients with HNSCC. The yields of WLE and FICE were similar for ESCC detection.

Endoscopic dilatation of esophageal strictures in children and adolescents

OBJECTIVE To assess the causes of esophageal stricture in pediatric patients and their response to endoscopic dilatation. METHODS Retrospective analysis of clinical and endoscopic data obtained from children and adolescents with esophageal stricture submitted to endoscopic dilatation between July 1993 and January 2003. RESULTS A total of 125 patients aged between 1 month and 16 years were included in the study. Among the types of stenosis, postoperative (43.2%), corrosive (27.2%) and peptic (21.6%) strictures were the most prevalent. Those patients with corrosive esophageal stricture needed more dilatation sessions. Five cases of esophageal perforation and one case of hemorrhage occurred due to complications during the procedure. Good response to endoscopic treatment was described in 74.4% of cases, but better results were obtained from patients with peptic esophageal stricture. CONCLUSIONS Endoscopic treatment of esophageal strictures in children and adolescents yields good results and has a low rate of complications. Corrosive esophageal strictures have a higher morbidity and require more dilatation sessions.

INITIAL EXPERIENCE OF ENDOSCOPIC SUBMUCOSAL DISSECTION IN BRAZIL TO TREAT EARLY GASTRIC AND ESOPHAGHEAL CANCER: a multi-institutional analysis

OBJECTIVE This study aimed to evaluate the feasibility and clinicopathological characteristics of early gastric and esophageal cancers treated with endoscopic submucosal dissection (ESD) at five centers in Brazil. METHODS Five centers in Brazil reported their initial experience with ESD. The cases reported had already been collected by each center before pooled analysis. RESULTS Were resected 62 gastric lesions; 52(83,8%) of the gastric lesions were well-differentiated adenocarcinoma, 31(50%) from the antrum, 24 (38.7%) type IIa. 51 (82.2%) lesions had en-block resection with three showing lateral margin compromise. Concerning invasion, 25 (40.3%) tumors were M1. Mean tumor diameter was 18.9 mm (range, 0.6-5.0 cm) and mean procedure duration was 119.45 minutes. Gastric perforation occurred in three (4.8%) patients. Mean follow-up duration was 11.3 months, with two local recurrences and one death from pneumonia Seven months after treatment. Of the 16 esophageal lesions resected, 14 (87.4%) were squamous cell carcinoma, 10 (62.5%) were located proximally and 8 (50.0%) type IIa. Mean tumor diameter was 23.8 mm (range, 6-60 mm). Thirteen (81.2%) lesions had en-block resection with five cases of lateral margin compromise. Eight (50.0%) lesions were M1. Mean procedure duration was 78 minutes (range, 20-150 min). Complications included pneumomediastinum in two (12.5%) patients and stenosis in one (6.2%). Mean duration of follow-up was 8.6 months, with no local recurrence despite the presence of lateral margin compromise. CONCLUSION Different centers in Brazil feasibly perform ESD with a high success rate.

Tratamento das estenoses esofágicas por dilatação endoscópica em crianças e adolescentes

OBJETIVO: Avaliar as causas de estenose esofagica em pacientes pediatricos e a resposta ao tratamento por dilatacao endoscopica nos diferentes grupos estudados. METODOS: Analise retrospectiva dos dados clinicos e endoscopicos de criancas e adolescentes com estenose esofagica tratadas por dilatacao endoscopica entre julho de 1993 e janeiro de 2003. RESULTADOS: Foram incluidos no estudo 125 pacientes, com idade entre 1 mes e 16 anos. Houve predominio das estenoses de causas cirurgica (43,2%), caustica (27,2%) e peptica (21,6%). O grupo com estenose esofagica caustica necessitou de maior numero de sessoes de dilatacao endoscopica. Cinco casos de perfuracao esofagica e um caso de hemorragia foram observados como complicacoes do procedimento. Houve boa resposta ao tratamento endoscopico em 74,4% dos casos, com melhores resultados nos pacientes com estenose esofagica peptica. CONCLUSOES: O tratamento endoscopico das estenoses esofagicas em criancas e adolescentes apresenta bons resultados e baixo indice de complicacoes. A estenose esofagica de etiologia caustica e a de morbidade mais elevada e com necessidade de maior numero de sessoes de dilatacao esofagica.

Cisto de duplicação gástrica com parênquima pancreático ectópico em adulto assintomático

The authors describe a rare case of a gastric duplication cyst in a 55-year-old man. The past history revealed that the patient was treated one year before for gastroduodenal ulcer. The cyst was discovered incidentally at upper gastrointestinal endoscopy. Biopsies showed inflammation without evidence of tumor. On abdominal ultrasonography and CT scan, a left upper quadrant mass was noted. At laparotomy, a mass measuring 6,0 cm in contact with the stomach was excised. Histopathology showed a gastric duplication cyst containing pancreatic mucosa.