Endoscopic submucosal dissection for the treatment of early esophageal and gastric cancer - initial experience of a western center

BACKGROUND: Endoscopic submucosal dissection is a new Japanese technique characterized by en-bloc resection of the entire lesion irrespective of size, with lower local recurrence when compared to endoscopic mucosal resection. OBJECTIVE: To evaluate the feasibility, early results and complications of the endoscopic submucosal dissection technique for treating early gastric and esophageal cancer at the Endoscopic Unit of Clinics Hospital and Cancer Institute of the São Paulo University. MATERIALS AND METHODS: Twenty patients underwent endoscopic resection using the endoscopic submucosal dissection technique for early gastric or esophageal cancer. The patients were evaluated prospectively as to the executability of the technique, the short-term results of the procedure and complications. RESULTS: Sixteen gastric adenocarcinoma lesions and six esophageal squamous carcinoma lesions were resected. In the stomach, the mean diameter of the lesions was 16.2 mm (0.6-3.5 mm). Eight lesions were type IIa + IIc, four were type IIa and four IIc, with thirteen being well differentiated and three undifferentiated. Regarding the degree of invasion, five were M2, seven were M3, two were Sm1 and one was Sm2. The mean duration of the procedures was 85 min (20-160 min). In the esophagus, all of the lesions were type IIb, with a mean diameter of 17.8 mm (6-30 mm). Regarding the degree of invasion, three were M1, one was M2, one was M3 and one was Sm1. All had free lateral and deep margins. The mean time of the procedure was 78 min (20-150 min). CONCLUSION: The endoscopic submucosal dissection technique was feasible in our service with a high success rate

A comparison of the efficiency of 22G versus 25G needles in EUS-FNA for solid pancreatic mass assessment: A systematic review and meta-analysis

Our aim in this study was to compare the efficiency of 25G versus 22G needles in diagnosing solid pancreatic lesions by EUS-FNA. We performed a systematic review and meta-analysis. Studies were identified in five databases using an extensive search strategy. Only randomized trials comparing 22G and 25G needles were included. The results were analyzed by fixed and random effects. A total of 504 studies were found in the search, among which 4 randomized studies were selected for inclusion in the analysis. A total of 462 patients were evaluated (233: 25G needle/229: 22G needle). The diagnostic sensitivity was 93% for the 25G needle and 91% for the 22G needle. The specificity of the 25G needle was 87%, and that of the 22G needle was 83%. The positive likelihood ratio was 4.57 for the 25G needle and 4.26 for the 22G needle. The area under the sROC curve for the 25G needle was 0.9705, and it was 0.9795 for the 22G needle, with no statistically significant difference between them (p=0.497). Based on randomized studies, this meta-analysis did not demonstrate a significant difference between the 22G and 25G needles used during EUS-FNA in the diagnosis of solid pancreatic lesions

Randomized controlled trial comparing propofol and fentanyl versus midazolam and fentanyl for sedation in upper gastrointestinal endoscopy

Introdução: o uso da sedação na rotina endoscópica tem sido empregado praticamente de maneira universal. O emprego de propofol parece se relacionar a exame mais confortável, com aumento da satisfação com o exame, pelo médico e pelo paciente. Entretanto, o uso do propofol está associado ao maior risco de sedação profunda e às complicações a ela associadas. Objetivo: comparar dois esquemas de sedação para a realização de endoscopia digestiva alta diagnóstica, grupo midazolam (midazolam e fentanil) com o grupo propofol (propofol e fentanil) quanto ao nível de sedação profunda e, como desfechos secundários, o grau de satisfação, o tempo de recuperação e a frequência de complicações entre os grupos. Método: foi realizado estudo experimental, prospectivo, randômico, cego com 200 pacientes, 100 no grupo midazolam e 100 no grupo propofol. Resultado: utilizando a escala OAA/S e o índice bispectral (BIS), respectivamente 11% e 7% dos pacientes do grupo midazolam e 25% e 19 % do grupo propofol apresentaram níveis de sedação profunda, sendo significativamente mais frequente neste último grupo. Houve boa correlação do nível de sedação da escala clínica OAA/S com o índice bispectral (BIS) para os dois grupos (k=0,63 para o grupo midazolam e k=0,71 para o grupo propofol). Quarenta e dois por cento dos pacientes do grupo propofol e 26% dos pacientes do grupo midazolam precisaram de oferta suplementar de oxigênio (p=0,025). O tempo médio de recuperação dos pacientes do grupo midazolam foi de 44,13 min e do grupo propofol foi de 28,82 min (p<0,001). O grau de satisfação dos pacientes foi semelhante entre os grupos e os médicos deram preferência ao uso da associação propofol/fentanil. Não se observaram complicações graves decorrentes da sedação em ambos os grupos. Conclusão: ambos os esquemas de sedação levam à sedação profunda. O grupo propofol utilizando o propofol e fentanil apresentou eventos de sedação profunda mais frequentemente. Por outro lado, os dois esquemas são seguros. Os pacientes do grupo propofol apresentaram tempo de indução da sedação, de recuperação e de liberação menoresIntroduction: the use of sedation is almost universal for the practice of upper gastrointestinal (GI) endoscopy. The use of propofol seems to be associated with higher physician and patient satisfaction. However there is a higher risk of deep sedation and its related complication when propofol is used. Objective: compare the frequency of deep sedation events with two drug associations for the sedation in upper GI endoscopy. The OAA/S score and the bispectral index monitoring (BIS) were employed for the assessment of consciousness level. Secondarily we compared patient and physician satisfaction, recovery time and the complication rates between the two groups. Methods: two hundred patients sent for upper GI endoscopy were randomized in two groups: midazolam and propofol, each of them with 100 patients. Results: Deep sedation events occurred in 11% (OAA/S score) and 7% (BIS) in group midazolam and significantly more frequent in group propofol (25%- OAA/S score and 19% - BIS). There was a good agreement between the OAA/S score and the bispectral index (BIS) in both groups (k=0.63 and K=0.71 for groups midazolam and propofol, respectively). Forty two per cent of group propofol patients and 26% of group midazolam patients needed oxygen supplementation (p=0.025). The mean recovery time for groups midazolam and propofol patients were 44.13 min and 28.82 min, respectively (p<0.001). While patients were equally satisfied with both drug associations, physicians were more satisfied with the propofol/fentanyl association. We did not record any severe complications related with sedation. Conclusion: both drug associations are associated with deep sedation events. The propofol/fentanyl association causes deep sedation events more frequently when compared with midazolam/fentanyl association. Both associations are safe. The induction sedation, recovery and discharge times were shorter with propofol/fentanyl associatio

Técnica modificada para realização da gastro-jejunostomia endoscópica percutânea

RESUMO A realização da gastro-jejunostomia endoscópica percutânea (PEG-J) proporciona nutrição além do ângulo de Treitz, e está associada à diminuição das complicações relacionadas à gastroparesia, como a pneumonia por aspiração. Existem diversas técnicas para realização da PEG-J descritas na literatura, com graus variáveis de sucesso técnico. Neste artigo propomos modificações na técnica de realização da PEG-J, a fim de reduzir o tempo do procedimento e minimizar o risco de insucesso

ENDOSCOPIC ULTRASOUND IN THE EVALUATION OF UPPER SUBEPITHELIAL LESIONS

BackgroundEndoscopic ultrasound is considered the best imaging test for the diagnosis and evaluation of subepithelial lesions of the gastrointestinal tract.ObjectiveThe present study aims to describe the endosonographic characteristics of upper gastric subepithelial lesions and our experience using endoscopic ultrasound for evaluation of such lesions.MethodsRetrospective data study of 342 patients who underwent endoscopic ultrasound evaluation of subepithelial lesions.ResultsLesions of the fourth layer were more common in the stomach (63.72%) than in the esophagus (44.68%) and duodenum (29.03%). In stomach, 81.1% of the lesions &#8805;2 cm, and 96.5% &#8805;3 cm, were from the fourth layer. Endosonographic signs that could be related to malignant behavior, such as irregular borders, echogenic foci, cystic spaces and/or size greater than 3 cm were identified in 34 (15.81%) lesions at the first endoscopic ultrasound evaluation. Endoscopic ultrasound-fine needle aspiration did the diagnosis in 21 (61.76%) patients who were submitted a puncture. Three (12.0%) lesions of 25 who were submitted to regular endoscopic ultrasound surveillance increased the size.ConclusionStomach is the organ most affected with subepithelial lesions of the gastrointestinal tract and the fourth layer was the most common layer of origin. More than 80% of gastric subepithelial lesions from the fourth layer are &#8805;2 cm. Endoscopic ultrasound evaluation of subepithelial lesions has been very important for stratification into risk groups and to determine the best management

EUS-guided percutaneous endoscopic gastrostomy for enteral feeding tube placement

Background: Patients without adequate abdominal-wall transillumination are at a high risk of developing complications after PEG. Objective: We evaluated the feasibility and utility of EUS to guide PEG in patients lacking abdominal-wall transillumination. Design: Single-center case series. Setting: Tertiary-referral center. Patients: Six patients who lacked adequate abdominal-wall transillumination and 2 patients with a large laparotomy scar deemed to be at high risk of developing complications after PEG. Interventions: Patients underwent EUS-guided PEG and deployment of a standard enteral feeding tube. Main Outcome Measurements: Technical success and complication rates. Results: PEG was Successful Under EUS guidance in 5 of 8 patients. Causes of failure included all inadequate EUS window because of a prior Billroth 1 gastrectomy in one and suspected bowel interposition in 2 patients. There were no complications. Limitations: A small number of patients, uncontrolled study, and short follow-up period. Conclusions: This technique may facilitate deployment of PEG in patients who lack adequate abdominal-wall transillumination