Unusual Findings in the Small Bowel

AbstractSmall bowel endoscopy has now become a routine investigation. The most common methods to visualize the small bowel are balloon-assisted enteroscopy and capsule endoscopy. Currently, the most common indications for small bowel endoscopy are obscure gastrointestinal bleeding and suspected or established Crohn's disease. Common findings of small bowel endoscopy include arteriovascular malformations, erosions, ulcers, and edema in the mucosa. However, there are myriad uncommon small bowel conditions which can now be visualized endoscopically. These include vasculitis, neuroendocrine tumors, familial polyposis syndromes such as Peutz–Jeghers syndrome; ulcerative celiac disease; enteropathy-associated T-cell lymphoma; and infections such as Whipple's disease, tuberculosis, and blastomycosis. The aim of this video is to demonstrate the endoscopic characteristics of various unusual but very important small bowel diseases. This article is part of an expert video encyclopedia

Duplo Piloro: Estudo de caso e revisão da literatura

Duplo piloro é condição rara em que se forma dupla comunicação entre o antro gástrico e o bulbo duodenal. Pode ser congênito ou adquirido como complicação de doença cloridropéptica. Apresentamos caso de duplo piloro adquirido em paciente masculino com epigastralgia e história prévia de úlcera péptica. A pesquisa do Helicobacter pylori foi positiva em amostras de tecido gástrico. Foi realizada revisão da literatura e discutido o papel de doenças associadas e do Helicobacter pylori na etiopatogenia desta afecção.Double pylorus is an unusual condition in which a double communication between the gastric antrum and the duodenal bulb occurs. It may be congenital, or it may be acquired complication of peptic ulcer disease. We present a case of double pylorus in a gentleman with epigastric pain and previous history of peptic ulcer disease. The relationship between Helicobacter pylori and this disease was assessed. A review of the literature, the role of associated diseases and the role of H. pylori are discussed

Economic evaluations of colorectal cancer screening: A systematic review and quality assessment

Colorectal Cancer (CRC) is the third most common type of cancer worldwide and ranks second in mortality. Screening programs for early detection and treatment have been implemented in several countries. Economic evaluations are an important tool to support decision-making about reimbursement and coverage decisions in health systems and, therefore, to support efficient resource allocation. The article aims to review the up-to-date evidence on economic evaluations of CRC screening strategies. MEDLINE, EMBASE, Web of Science, SCOPUS, SciELO, Lilacs, CRD databases, and lists of references were reviewed to identify relevant literature regarding full economic evaluations of CRC screening in asymptomatic average-risk individuals over 40 years old. Searches were conducted with no restriction to language, setting, or date. Qualitative syntheses described CRC screening strategies and comparators (baseline context), study designs, key parameter inputs and incremental cost-effectiveness ratios. Seventy-nine articles were included. Most of the studies were from high-income countries and a third-party payer perspective. Markov models were predominantly used, although microsimulation has been increasingly adopted in the last 15 years. The authors found 88 different screening strategies for CRC, which differed in the type of technique, the interval of screening, and the strategy, i.e., isolated or combined. The annual fecal immunochemical test was the most predominant screening strategy. All studies reported cost-effective results in their scenarios compared to no screening scenarios. One-quarter of the publications reported cost-saving results. It is still necessary to develop future economic evaluations in Low- and Middle-Income Countries (LMICs), which account for the high burden of disease

Validation of classic and expanded criteria for endoscopic submucosal dissection of early gastric cancer: 7 years of experience in a Western tertiary cancer center

OBJECTIVE: Our aim was to evaluate the Japan Gastroenterological Endoscopy Society criteria for endoscopic submucosal resection of early gastric cancer (EGC) based on the experience in a Brazilian cancer center. METHODS: We included all patients who underwent endoscopic submucosal resection for gastric lesions between February 2009 and October 2016. Demographic data and information regarding the endoscopic resection, pathological report and follow-up were obtained. Statistical calculations were performed with Fisher’s exact test and chi-square tests, with 95% confidence intervals. RESULTS: In total, 76% of the 51 lesions were adenocarcinomas, 16% were adenomas, and 8% had other diagnoses. The average size was 19.9 mm (±11.7). The average procedure length was 113.9 minutes (±71.4). The complication rate was 21.3%, with only one patient who needed surgical treatment (transmural perforation). Among the adenocarcinomas, 39.5% met the classic criteria for curability, 31.6% met the expanded criteria and 28.9% met the criteria for noncurative resection. Analysis of the indication criteria and curability revealed differences among cases with ‘‘only-by-size’’ expanded criteria (64.28%), other expanded criteria (40%) and classic criteria (89.47%), with a p-value of 0.049. During follow-up (15.8 months; ±14.3), 86.1% of the EGC patients had no recurrence. When well-differentiated and poorly differentiated lesions or lesions included in the classic and expanded criteria were compared, there were no differences in recurrence. The noncurative group presented a higher recurrence rate than the classic group (p=0.014). CONCLUSION: These results suggest that the Japanese endoscopic submucosal resection criteria might be useful for endoscopic treatment of EGC in Western countries

Instabilidade de microsatelites no cancer gástrico solitário e esporádico

Recently, the presence of microsatellite instability (MSI) has been reported in gastric cancer and associated with older age of presentation, distal tumor location, early disease staging, and better overall prognosis. Different characteristics in presentation and in tumor behavior may be explained by different genetic alterations during carcinogenesis of gastric cancer. Identification of specific genetic pathways in gastric cancer may have direct impact on prognosis and selection of treatment strategies. PATIENTS AND METHODS: All 24 patients were treated by radical surgery. Fragments of normal and tumor tissues were extracted from the specimen and stored at -80ºC before DNA purification and extraction. PCR amplification utilizing microsatellite markers was performed. Tumors presenting PCR products of abnormal sizes were considered positive for microsatellite instability (MSI+). RESULTS: Five patients (21%) had tumors that were MSI+ in at least 1 marker. In the group of patients with Lauren's intestinal-type gastric carcinoma, 3 had tumors that were MSI+ (23%), while in the group of diffuse-type gastric cancer, 2 patients had tumors that were MSI+ (19%). The mean age of presentation and the male:female ratio was similar in both groups. Tumors that were MSI+ were more frequently located in proximal portion of the stomach compared to microsatellite-stable (MSS) tumors (40% vs. 16%). Although there was a trend of patients with MSI+ tumors towards a proximal gastric tumor location, early staging, and negative lymph node metastasis, there was no statistical significance compared to those with MSS tumors (P >;.1). Comparison of overall and disease-free survival between gastric tumors that were MSI+ and those that were MSS found no statistically significant differences (P >;.1). CONCLUSIONS: Microsatellite instability is a frequent event in gastric carcinogenesis and shows a trend towards distinct clinical and pathological characteristics of gastric cancer.A presença de Instabilidade de microsatellites (IMS) tem sido relatada no cancer gastrico e associada a pacientes com idade mais avançada, localização mais distal do tumor, estadios mais precoces e melhor prognostico. Relatamos neste prospectivo estudo envolvendo 24 pacientes com cancer gastrico solitario e esporadico, a incidencia de IMS, sua correlação com parametros epidemiologicos, clinicos e anatomo patológicos e o seu impacto sobre a sobrevida geral e livre de doença. PACIENTES E MÉTODOS: Todos os pacientes haviam sido tratados com cirurgia radical. Fragmentos de tecido normal e tumoral eram extraidos das peças e armazenados a -80ºC antes da extração e purificação DNA. Realizava-se então a amplificação com PCR utilizando marcadores específicos de microsatelites. Os tumores que apresentavam produtos de amplificação anormais foram considerados positivos para IMS. RESULTADOS: Cinco pacientes (21%) apresentaram Instabilidade de microsatelites (IMS+) com pelo menos um marcador (primer) No grupo de pacientes com adenocarcinomas gástricos do tipo histológico de Lauren, três apresentavam IMS (23%) enquanto no grupo portador de cancar gástrico difuso, dois pacientes mostraram IMS (19%).. Embora haja uma tendência dos pacientes IMS+ apresentarem tumores de localização mais proximal, estadios mais precoces e ausência de metástases linfonodais, não se observou diferenças estatisticamente significativas (p >; 0,1). A comparação entre as taxas de sobrevida geral e livre de doença não mostrou significância estatistica (p >; 0,1). CONCLUSÕES: IMS é um evento frequente na carcinogese gástrica e pode estar associado a caracteristicas clinicas e anátomo-patológicas do câncer gástrico

THE VALUE OF PREOPERATIVE PROGNOSTIC NUTRITIONAL INDEX IN GASTRIC CANCER AFTER CURATIVE RESECTION

ABSTRACT BACKGROUND: Predicting short- and long-term outcomes of oncological therapies is crucial for developing effective treatment strategies. Malnutrition and the host immune status significantly affect outcomes in major surgeries. AIMS: To assess the value of preoperative prognostic nutritional index (PNI) in predicting outcomes in gastric cancer patients. METHODS: A retrospective cohort analysis was conducted on patients undergoing curative-intent surgery for gastric adenocarcinoma between 2009 and 2020. PNI was calculated as follows: PNI=(10 x albumin [g/dL])+(0.005 x lymphocytes [nº/mm3]). The optimal cutoff value was determined by the receiver operating characteristic curve (PNI cutoff=52), and patients were grouped into low and high PNI. RESULTS: Of the 529 patients included, 315 (59.5%) were classified as a low-PNI group (PNI<52) and 214 (40.5%) as a high-PNI group (PNI≥52). Older age (p=0.050), male sex (p=0.003), American Society of Anesthesiologists score (ASA) III/IV (p=0.001), lower hemoglobin level (p<0.001), lower body mass index (p=0.001), higher neutrophil-lymphocyte ratio (p<0.001), D1 lymphadenectomy, advanced pT stage, pN+ and more advanced pTNM stage were related to low-PNI patient. Furthermore, 30-day (1.4 vs. 4.8%; p=0.036) and 90-day (3.3 vs. 10.5%; p=0.002) mortality rates were higher in low-PNI compared to high-PNI group. Disease-free and overall survival were worse in low-PNI patients compared to high-PNI (p<0.001 for both). ASA III/IV score, low-PNI, pT3/T4, and pN+ were independent risk factors for worse survival. CONCLUSIONS: Preoperative PNI can predict short- and long-term outcomes of patients with gastric cancer after curative gastrectomy. Low PNI is an independent factor related to worse disease-free and overall survival