Risk Factors for Bleeding After Gastric Endoscopic Submucosal Dissection: a Systematic Review and Meta-Analysis

BACKGROUND AND AIMS: Postprocedural bleeding (PPB) is the most common adverse event associated with endoscopic resection. Several studies have tried to identify risk factors for PPB after gastric EMR and endoscopic submucosal dissection (ESD), with controversial results. This systematic review and meta-analysis aimed to identify significant risk factors for PPB after gastric EMR and ESD. METHODS: Three online databases were searched. Pooled odds ratio (OR) was computed for each risk factor using a random-effects model, and heterogeneity was assessed by Cochran's Q test and I(2). RESULTS: Seventy-four articles were included. Pooled PPB rate was 5.1% (95% confidence interval, 4.5%-5.7%), which did not vary according to different study designs. Male sex (OR, 1.25), cardiopathy (OR, 1.54), antithrombotic drugs (OR, 1.63), cirrhosis (OR, 1.76), chronic kidney disease (OR, 3.38), tumor size > 20 mm (OR, 2.70), resected specimen size > 30 mm (OR, 2.85), localization in the lesser curvature (OR, 1.74), flat/depressed morphology (OR, 1.43), carcinoma histology (OR, 1.46), and ulceration (OR, 1.64) were identified as significant risk factors for PPB, whereas age, hypertension, submucosal invasion, fibrosis, and localization (upper, middle, or lower third) were not. Procedure duration > 60 minutes (OR, 2.05) and the use of histamine-2 receptor antagonists instead of proton pump inhibitors (OR, 2.13) were the procedural factors associated with PPB, whereas endoscopist experience and preprocedural proton pump inhibitors were not. Second-look endoscopy was not associated with decreased PPB (OR, 1.34; 95% confidence interval, .85-2.12). CONCLUSIONS: Risk factors for PPB were identified that can help to guide management after gastric ESD, namely adjusting further management. Second-look endoscopy is not associated with decreased PPB.info:eu-repo/semantics/publishedVersio

Multifunctional magnetoelectric sensing and bending actuator response of polymer-based hybrid materials with magnetic ionic liquids

With the evolution of the digital society, the demand for miniaturized multifunctional devices has been increasing, particularly for sensors and actuators. These technological translators allow successful interaction between the physical and digital worlds. In particular, the development of smart materials with magnetoelectric (ME) properties, capable of wirelessly generating electrical signals in response to external magnetic fields, represents a suitable approach for the development of magnetic field sensors and actuators due to their ME coupling, flexibility, robustness and easy fabrication, compatible with additive manufacturing technologies. This work demonstrates the suitability of magnetoelectric (ME) responsive materials based on the magnetic ionic liquid (MIL) 1-butyl-3-methylimidazolium tetrachloroferrate ([Bmim][FeCl4]) and the polymer poly(vinylidene fluoride-co-trifluoroethylene) (P(VDF-TrFE) for magnetic sensing and actuation device development. The developed sensor works in the AC magnetic field and has frequency-dependent sensitivity. The materials show voltage responses in the mV range, suitable for the development of magnetic field sensors with a highest sensitivity (s) of 76 mV·Oe−1. The high ME response (maximum ME voltage coefficient of 15 V·cm−1·Oe−1) and magnetic bending actuation (2.1 mm) capability are explained by the magnetoionic (MI) interaction and the morphology of the composites.This work was supported by the Portuguese Foundation for Science and Technology (FCT) in the framework of the Strategic Funding UID/FIS/04650/2020, UID/QUI/00686/2020, LA/P/0008/2020, UIDB/50006/2020 and UIDP/50006/2020. The authors are grateful for funds through FCT under the projects 2022.05932.PTDC, PTDC/BTM-MAT/28237/2017 and PTDC/EMD-EMD/28159/2017 and grant SFRH/BD/145345/2019 (L.C.F). D.M.C. and P.M. thank FCT—Fundação para a Ciência e Tecnologia for the contract under the Stimulus of Scientific Employment, Individual Support 2020.02915.CEECIND and CEECIND/03975/2017, respectively. This study forms part of the Advanced Materials programme and was supported by MCIN with funding from European Union NextGenerationEU (PRTR-C17.I1) and by the Basque Government under the IKUR program. Funding from the Basque Government Industry Departments under the ELKARTEK program is also acknowledged. Technical and human support provided by IZO-SGI, SGIker (UPV/EHU, MICINN, GV/EJ, ERDF and ESF) is gratefully acknowledged

Management of Colorectal Laterally Spreading Tumors: a Systematic Review and Meta-Analysis

Objective and study aims  To evaluate the efficacy and safety of different endoscopic resection techniques for laterally spreading colorectal tumors (LST). Methods  Relevant studies were identified in three electronic databases (PubMed, ISI and Cochrane Central Register). We considered all clinical studies in which colorectal LST were treated with endoscopic resection (endoscopic mucosal resection [EMR] and/or endoscopic submucosal dissection [ESD]) and/or transanal minimally invasive surgery (TEMS). Rates of en-bloc/piecemeal resection, complete endoscopic resection, R0 resection, curative resection, adverse events (AEs) or recurrence, were extracted. Study quality was assessed with the Newcastle-Ottawa Scale and a meta-analysis was performed using a random-effects model. Results  Forty-nine studies were included. Complete resection was similar between techniques (EMR 99.5 % [95 % CI 98.6 %-100 %] vs. ESD 97.9 % [95 % CI 96.1 - 99.2 %]), being curative in 1685/1895 (13 studies, pooled curative resection 90 %, 95 % CI 86.6 - 92.9 %, I 2  = 79 %) with non-significantly higher curative resection rates with ESD (93.6 %, 95 % CI 91.3 - 95.5 %, vs. 84 % 95 % CI 78.1 - 89.3 % with EMR). ESD was also associated with a significantly higher perforation risk (pooled incidence 5.9 %, 95 % CI 4.3 - 7.9 %, vs. EMR 1.2 %, 95 % CI 0.5 - 2.3 %) while bleeding was significantly more frequent with EMR (9.6 %, 95 % CI 6.5 - 13.2 %; vs. ESD 2.8 %, 95 % CI 1.9 - 4.0 %). Procedure-related mortality was 0.1 %. Recurrence occurred in 5.5 %, more often with EMR (12.6 %, 95 % CI 9.1 - 16.6 % vs. ESD 1.1 %, 95 % CI 0.3 - 2.5 %), with most amenable to successful endoscopic treatment (87.7 %, 95 % CI 81.1 - 93.1 %). Surgery was limited to 2.7 % of the lesions, 0.5 % due to AEs. No data of TEMS were available for LST. Conclusions  EMR and ESD are both effective and safe and are associated with a very low risk of procedure related mortality.info:eu-repo/semantics/publishedVersio

Management of epithelial precancerous conditions and lesions in the stomach (MAPS II): European Society of Gastrointestinal Endoscopy (ESGE), European Helicobacter and Microbiota Study Group (EHMSG), European Society of Pathology (ESP), and Sociedade Portuguesa de Endoscopia Digestiva (SPED) guideline update 2019

Patients with chronic atrophic gastritis or intestinal metaplasia (IM) are at risk for gastric adenocarcinoma. This underscores the importance of diagnosis and risk stratification for these patients. High definition endoscopy with chromoendoscopy (CE) is better than high definition white-light endoscopy alone for this purpose. Virtual CE can guide biopsies for staging atrophic and metaplastic changes and can target neoplastic lesions. Biopsies should be taken from at least two topographic sites (antrum and corpus) and labelled in two separate vials. For patients with mild to moderate atrophy restricted to the antrum there is no evidence to recommend surveillance. In patients with IM at a single location but with a family history of gastric cancer, incomplete IM, or persistent Helicobacter pylori gastritis, endoscopic surveillance with CE and guided biopsies may be considered in 3 years. Patients with advanced stages of atrophic gastritis should be followed up with a high quality endoscopy every 3 years. In patients with dysplasia, in the absence of an endoscopically defined lesion, immediate high quality endoscopic reassessment with CE is recommended. Patients with an endoscopically visible lesion harboring low or high grade dysplasia or carcinoma should undergo staging and treatment. H. pylori eradication heals nonatrophic chronic gastritis, may lead to regression of atrophic gastritis, and reduces the risk of gastric cancer in patients with these conditions, and it is recommended. H. pylori eradication is also recommended for patients with neoplasia after endoscopic therapy. In intermediate to high risk regions, identification and surveillance of patients with precancerous gastric conditions is cost-effective.info:eu-repo/semantics/publishedVersio

Endoscopic submucosal dissection techniques and technology: European Society of Gastrointestinal Endoscopy (ESGE) Technical Review

ESGE suggests conventional endoscopic submucosal dissection (ESD; marking and mucosal incision followed by circumferential incision and stepwise submucosal dissection) for most esophageal and gastric lesions. ESGE suggests tunneling ESD for esophageal lesions involving more than two-thirds of the esophageal circumference. ESGE recommends the pocket-creation method for colorectal ESD, at least if traction devices are not used. The use of dedicated ESD knives with size adequate to the location/thickness of the gastrointestinal wall is recommended. It is suggested that isotonic saline or viscous solutions can be used for submucosal injection. ESGE recommends traction methods in esophageal and colorectal ESD and in selected gastric lesions. After gastric ESD, coagulation of visible vessels is recommended, and post-procedural high dose proton pump inhibitor (PPI) (or vonoprazan). ESGE recommends against routine closure of the ESD defect, except in duodenal ESD. ESGE recommends corticosteroids after resection of  > 50 % of the esophageal circumference. The use of carbon dioxide when performing ESD is recommended. ESGE recommends against the performance of second-look endoscopy after ESD. ESGE recommends endoscopy/colonoscopy in the case of significant bleeding (hemodynamic instability, drop in hemoglobin > 2 g/dL, severe ongoing bleeding) to perform endoscopic hemostasis with thermal methods or clipping; hemostatic powders represent rescue therapies. ESGE recommends closure of immediate perforations with clips (through-the-scope or cap-mounted, depending on the size and shape of the perforation), as soon as possible but ideally after securing a good plane for further dissection

Um dia todos seremos Montag

Partindo de conversa comum em que a menção de Guernica causou constrangimento, pois as pessoas não conheciam o quadro, discutimos o caráter educacional especializado, em que os campos gerais do conhecimento não são valorizados. Isto denota falta de leitura que, quando praticada, é mero consumo. A escola tenta desenvolver esta prática, mas erra na concepção do ler e no não atendimento às necessidades do aluno. O professor não cumpre o papel de mediador, nem mostra a leitura como superação de dogmas. É urgente rever a política curricular, presa à cultura hegemônica. Assim, a escola deve abrir-se ao multiculturalismo, revelar a flutuação dos conceitos culturais. Na arte, tem de ensinar como esta não se faz cumprindo regras, mas rompendo-as, ao lado do que, o aluno aprenderá que cultura é crise. Percebendo isso, terá conhecimento de sua subjetividade como processo em construção e cultura como interdependência. Arte não é sagrada. Desmistificando mitos, o aluno está em condições de ser o modelador de sua história, não apenas consumidor de alheias. Verá a angústia como deflagradora de criatividade, impulso à superação de limites. Como a literatura perde espaço na sociedade, torna-se esotérica, recomendamos seu abandono, em nome de outras narrativas que ensinarão a sociedade como trançado de discursos. Sensibilizado e consciente disto, o aluno então pode trabalhar o literário como relação especial entre os discursos sociais