1
|
Pinheiro LW, Martins FP, De Paulo GA, Contini MLC, Ferrari AP, Della Libera E. Endoscopic therapy using a self-expandable metallic stent with an anti-migration system for postorthotopic liver transplantation anastomotic biliary stricture. World J Gastrointest Endosc 2022; 14:547-554. [PMID: 36186946 PMCID: PMC9516474 DOI: 10.4253/wjge.v14.i9.547] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2022] [Revised: 04/19/2022] [Accepted: 08/05/2022] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Endoscopic therapy using multiple plastic stents (MPSs) is the standard therapy for postorthotopic liver transplantation (p-OLT) anastomotic biliary stricture (ABS). However, this approach demands repeated procedures. Recent studies using fully covered self-expandable metallic stents (FCSEMS) have shown encouraging results, but migration occurs in 10% to 40% of cases. The objective of this retrospective study was to evaluate the efficacy of endoscopic treatment using FCSEMS with an anti-migration system (Am-FCSEMS) in patients with p-OLT ABS.
AIM To evaluate the efficacy of endoscopic treatment using an Am-FCSEMS in patients with p-OLT ABS.
METHODS This study was conducted in a private tertiary care centre in São Paulo, Brazil and was approved by our institution's Human Research Committee. From April 2018 to October 2020, regardless of previous endoscopic treatment (MPS or FCSEMS), 17 patients with p-OLT ABS and indications for endoscopic therapy were included in this study. The exclusion criteria were pregnancy, nonanastomotic biliary or hilar stricture, hepatic artery stenosis/thrombosis, isolated biliary fistulae, a distance shorter than 2 cm from the stricture to the hepatic hilum, and patient refusal. The primary endpoint was the efficacy of p-OLT ABS endoscopic treatment using an Am-FCSEMS that remained in place for a 12-mo period. Biliary sphincterotomy was performed in patients with native papilla, and an Am-FCSEMS (10 mm in final diameter and 60 or 80 mm in length) was placed (HanarostentTM MI Tech, Co). Balloon stricture dilation was performed only if necessary to introduce the stent.
RESULTS Three patients were excluded due to loss to follow-up before stent removal. Among the 14 patients included and followed, 7 were women, and the average age was 56 years (range: 28-76). The average period of Am-FCSEMS placement was 362 ± 109 d. Technical success occurred in all 14 patients (100%). There were no cases of distal stent migration. Complete resolution of the stricture occurred in 13/14 patients (92.85%). Adverse events occurred in 3/14 patients (21.42%): 2 patients with mild acute pancreatitis (14.28%) and 1 patient (7.14%) with stent dysfunction (occlusion by biliary sludge and stones, which was treated endoscopically without the need for stent removal). No deaths occurred related to therapy. All stents were removed using foreign body forceps or snares without difficulty. After Am-FCSEMS removal, all 13 patients who had ABS resolution were followed-up for an average of 411 ± 172 d, and there was no stricture recurrence or need for further endoscopic therapy.
CONCLUSION In this retrospective study, endoscopy therapy using an Am-FCSEMS for p-OLT ABS was safe and effective, with a high stricture resolution rate that was probably due to the absence of stent migration.
Collapse
Affiliation(s)
- Larissa Wermelinger Pinheiro
- Department of Gastroenterology, Federal University of São Paulo/Escola Paulista de Medicina, São Paulo 04023-900, Brazil
| | - Fernanda Prata Martins
- Department of Endoscopy Unit, Hosp Israelita Albert Einstein, São Paulo 04042033, Brazil
| | | | | | - Angelo Paulo Ferrari
- Department of Gastroenterology, Federal University of São Paulo/Escola Paulista de Medicina, São Paulo 04023-900, Brazil
- Department of Endoscopy Unit, Hosp Israelita Albert Einstein, São Paulo 04042033, Brazil
| | - Ermelindo Della Libera
- Department of Gastroenterology, Federal University of São Paulo/Escola Paulista de Medicina, São Paulo 04023-900, Brazil
- Department of Endoscopy Unit, Hosp Israelita Albert Einstein, São Paulo 04042033, Brazil
| |
Collapse
|
2
|
de Sousa GB, Machado RS, Nakao FS, Libera ED. Efficacy and safety of endoscopic ultrasound-guided drainage of pancreatic pseudocysts using double-pigtail plastic stents: A single tertiary center experience. Clinics (Sao Paulo) 2021; 76:e2701. [PMID: 34378728 PMCID: PMC8311639 DOI: 10.6061/clinics/2021/e2701] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2021] [Accepted: 06/16/2021] [Indexed: 11/18/2022] Open
Abstract
OBJECTIVES Pancreatic pseudocysts (PPC) are fluid collections with a well-defined wall that persist for more than 4 weeks inside or around the pancreas as a result of pancreatic inflammation and/or a ductal lesion. PPC have been successfully treated with endoscopic ultrasound (EUS)-guided drainage using different stents. This study aimed to evaluate the safety and efficacy of EUS-guided drainage of PPC using double-pigtail plastic stents in a tertiary hospital. METHODS Patients with PPC referred for EUS-guided drainage between May 2015 and December 2019 were included in this case series. The primary endpoint was to evaluate the efficacy (clinical success) and safety (adverse events and mortality) of EUS-guided drainage of PPC. Secondary endpoints included technical success and pseudocyst recurrence. RESULTS Eleven patients (mean age, 44.5±18.98 years) were included in this study. The etiologies for PPC were acute biliary pancreatitis, chronic alcoholic pancreatitis, and blunt abdominal trauma. The mean pseudocyst size was 9.4±2.69 cm. The clinical success rate was 91% (10/11). Adverse events occurred in three of 11 patients (27%). There were no cases of mortality. The technical success rate was 100%. Pseudocyst recurrence was identified in one of 11 patients (9%) at 12 weeks after successful clinical drainage and complete pseudocyst resolution. CONCLUSION EUS-guided transmural drainage of PPC using double-pigtail plastic stents is safe and effective with high technical and clinical success rates.
Collapse
Affiliation(s)
- Giovana Biasia de Sousa
- Departamento de Endoscopia, Hospital Universitario, Universidade Federal de Sao Paulo (UNIFESP), Sao Paulo, SP, BR
| | - Rodrigo Strehl Machado
- Departamento de Endoscopia, Hospital Universitario, Universidade Federal de Sao Paulo (UNIFESP), Sao Paulo, SP, BR
| | - Frank Shigueo Nakao
- Departamento de Endoscopia, Hospital Universitario, Universidade Federal de Sao Paulo (UNIFESP), Sao Paulo, SP, BR
| | - Ermelindo Della Libera
- Departamento de Endoscopia, Hospital Universitario, Universidade Federal de Sao Paulo (UNIFESP), Sao Paulo, SP, BR
- Corresponding author. E-mail:
| |
Collapse
|
3
|
Franco MC, Nakao FS, Rodrigues R, Maluf-Filho F, Paulo GAD, Libera ED. PROPOSAL OF A CLINICAL CARE PATHWAY FOR THE MANAGEMENT OF ACUTE UPPER GASTROINTESTINAL BLEEDING. Arq Gastroenterol 2016; 52:283-92. [PMID: 26840469 DOI: 10.1590/s0004-28032015000400007] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/29/2015] [Accepted: 08/25/2015] [Indexed: 01/16/2023]
Abstract
BACKGROUND Upper gastrointestinal bleeding implies significant clinical and economic repercussions. The correct establishment of the latest therapies for the upper gastrointestinal bleeding is associated with reduced in-hospital mortality. The use of clinical pathways for the upper gastrointestinal bleeding is associated with shorter hospital stay and lower hospital costs. OBJECTIVE The primary objective is the development of a clinical care pathway for the management of patients with upper gastrointestinal bleeding, to be used in tertiary hospital. METHODS It was conducted an extensive literature review on the management of upper gastrointestinal bleeding, contained in the primary and secondary information sources. RESULTS The result is a clinical care pathway for the upper gastrointestinal bleeding in patients with evidence of recent bleeding, diagnosed by melena or hematemesis in the last 12 hours, who are admitted in the emergency rooms and intensive care units of tertiary hospitals. In this compact and understandable pathway, it is well demonstrated the management since the admission, with definition of the inclusion and exclusion criteria, passing through the initial clinical treatment, posterior guidance for endoscopic therapy, and referral to rescue therapies in cases of persistent or rebleeding. It was also included the care that must be taken before hospital discharge for all patients who recover from an episode of bleeding. CONCLUSION The introduction of a clinical care pathway for patients with upper gastrointestinal bleeding may contribute to standardization of medical practices, decrease in waiting time for medications and services, length of hospital stay and costs.
Collapse
Affiliation(s)
| | - Frank Shigueo Nakao
- Hospital Universitário, Universidade Federal de São Paulo, São Paulo, SP, Brasil
| | - Rodrigo Rodrigues
- Departamento de Endoscopia, Fleury Medicina e Saúde, São Paulo, SP, Brasil
| | - Fauze Maluf-Filho
- Departamento de Endoscopia, Instituto de Câncer de São Paulo, São Paulo, SP, Brasil
| | | | | |
Collapse
|
4
|
Lenz L, Felipe-Silva A, Nakao F, Miyajima N, Della Libera E, Chaves DM, Sugai BM, Rohr MRDS. Pyloric Brunner's gland hamartoma with atypical hyperplasia. Autops Case Rep 2013; 3:49-51. [PMID: 28584807 PMCID: PMC5453661 DOI: 10.4322/acr.2013.039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2013] [Accepted: 12/03/2013] [Indexed: 11/23/2022] Open
Abstract
Brunner's gland hamartoma (BGH) is an extremely rare benign digestive tumor, generally located in the duodenal bulb. We report the case of a 51-year-old asymptomatic man with a large pedunculated BGH arising from the pylorus. It was successfully removed en bloc by endoscopic resection.
Collapse
Affiliation(s)
- Luciano Lenz
- Fleury Medicina e Saúde, São Paulo/SP - Brazil.,Department of Endoscopy - Universidade Federal de São Paulo, São Paulo/SP - Brazil
| | - Aloísio Felipe-Silva
- Fleury Medicina e Saúde, São Paulo/SP - Brazil.,Anatomic Pathology Service - Hospital Universitário - Universidade de São Paulo, São Paulo/SP - Brazil
| | - Frank Nakao
- Fleury Medicina e Saúde, São Paulo/SP - Brazil.,Department of Endoscopy - Universidade Federal de São Paulo, São Paulo/SP - Brazil
| | - Nelson Miyajima
- Fleury Medicina e Saúde, São Paulo/SP - Brazil.,Gastrointestinal Endoscopy Service - Hospital das Clínicas - Faculdade de Medicina - Universidade de São Paulo, São Paulo/SP - Brazil
| | - Ermelindo Della Libera
- Fleury Medicina e Saúde, São Paulo/SP - Brazil.,Department of Endoscopy - Universidade Federal de São Paulo, São Paulo/SP - Brazil
| | - Dalton Marques Chaves
- Fleury Medicina e Saúde, São Paulo/SP - Brazil.,Gastrointestinal Endoscopy Service - Hospital das Clínicas - Faculdade de Medicina - Universidade de São Paulo, São Paulo/SP - Brazil
| | | | - Maria Rachel da Silveira Rohr
- Fleury Medicina e Saúde, São Paulo/SP - Brazil.,Department of Endoscopy - Universidade Federal de São Paulo, São Paulo/SP - Brazil
| |
Collapse
|
5
|
Rezende M, Montero EFDS, Salomão R, Brunialti M, Rodrigues R, Gomes G, Libera AD, Ferrari A, Libera ED. Acute inflammatory response to transgastric natural orifice transluminal endoscopic surgery peritoneoscopy: an experimental study in swine. Clinics (Sao Paulo) 2013; 68:1433-9. [PMID: 24270956 PMCID: PMC3812549 DOI: 10.6061/clinics/2013(11)09] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2013] [Accepted: 05/19/2013] [Indexed: 11/23/2022] Open
Abstract
OBJECTIVE To investigate the impact of transgastric peritoneal access on plasma biomarkers of acute inflammatory response in comparison to laparoscopy. METHODS This was a prospective and comparative study in a porcine model. Transgastric peritoneal access performed by natural orifice transluminal endoscopic surgery was compared with laparoscopy. Laparotomy and sham groups were used as positive and negative controls, respectively. Thirty-four pigs were assigned to receive transgastric natural orifice transluminal endoscopic surgery (n = 12), laparoscopy (n = 8), laparotomy (n = 8) or a sham procedure involving only anesthesia (n = 6). In the natural orifice transluminal endoscopic surgery group, peritoneoscopy was performed with a gastroscope via transgastric access. Blood samples were collected at baseline and 1, 3, 6, 9 and 24 h after the surgical procedure for measurement of interleukins 1β, 6 and 10 and tumor necrosis factor-α. A complete blood count was performed, and C-reactive protein levels were measured at baseline and at 24 h. RESULTS All surgical and endoscopic procedures were performed without major complications. Peritoneal cavity inventory showed no signs of peritonitis in any animal. Interleukin 1β, interleukin 10 and tumor necrosis factor-α levels were below the threshold of detection. The mean level of interleukin 6 was statistically significantly higher in the laparotomy group than in the other groups (p<0.05), with no significant differences among the sham, laparoscopy and natural orifice transluminal endoscopic surgery groups (p>0.05). C-reactive protein analysis indicated significant increases in all groups, with no differences among the groups. Complete blood count analysis showed no differences among the groups. CONCLUSIONS Based on the observed interleukin 6 patterns, the systemic inflammatory response resulting from transgastric peritoneal access by natural orifice transluminal endoscopic surgery is similar in intensity to the response that occurs after laparoscopy.
Collapse
Affiliation(s)
- Marcelo Rezende
- Gastroenterology Division, São Paulo Federal University (UNIFESP), São PauloSP, Brazil
| | | | | | | | | | | | | | | | | |
Collapse
|
6
|
Forones NM, Lima JM, Teixeira Y, Pimenta CAM, Murray H, Donizetti T, Felipe AV, Oliveira J, Vidigal V, Libera ED, Saad SS. Detection of DNA stool mutations in colorectal cancer patients. J Clin Oncol 2013. [DOI: 10.1200/jco.2013.31.15_suppl.e22074] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
e22074 Background: Colorectal cancer (CRC) is the third leading cause of cancer in the world. Noninvasive screening tests have higher compliance. Changes in tumoral cells are also found in the stools after cancer cell exfoliation. Aim: to detect mutations in the stools of CRC patients and compare to mutations found in CRC tissue Methods: Patients referred for colonoscopy were divided into 3 groups: control, cancer, and polyp. The DNA was extracted from tissue and stool and it was analysed by two microarrays, the KRAS/BRAF/PIK3CA Array and the RanplexCRC Array (Randox Laboratories Ltd). Both based on the simultaneous detection of 20 mutations in KRAS, BRAF and PIK3CA and 28 mutations in KRAS, BRAF, TP53 and APC respectively. Positive tissue sample mutations were confirmed by Sanger sequencing. Results: 90 stools and 112 tissue biopsies were studied. Analysis of tissue samples was initially performed using the KRAS/BRAF/PIK3CA Array. In total mutations were detected in 16(55%) CRC, 12(45%) polyp and 2(6%) control samples. Mutations were confirmed via Sanger sequencing (76%). In the stool the frequency were 17(35%) in CRC, 10(71%) in polyp and 1(4%) in the control. Inconclusive tests were higher among the controls (32.5%) and polyps (22%), being less frequent in the CRC patients (6%). Excluding the inconclusive tests, WT genes were common in the controls (96%). The most common mutation was within KRAS codon 12. Stools samples from 48 subjects were compared to the results obtained by the RanplexCRC Array and mutations were found in 50% of CRC. KRAS/BRAF/PIK3CA Array stool results had a correlation with RanplexCRC Array in 64% of CRC patients and in 47% of polyp patients. The average human DNA in the stools was 15ng/ul in CRC patients and 0.46ng/ul in the controls (p=0.0001). Conclusions: Both arrays had a good correlation and a sensitivity between 30-50% with a high specificity (95-100%). The KRAS/BRAF/PIK3CA Array is currently optimized and recommended for assessment of tissue samples. This initial set of data however does indicate its potential applicability to stool specimens. Inconclusive tests are likely as a result of limited human DNA content within stool control samples. FAPESP (Sao Paulo Research Foundation) project 09/16618-8.
Collapse
Affiliation(s)
| | | | | | | | - Helena Murray
- Randox Laboratories, Ltd., Crumlin, Northern Ireland
| | | | | | | | | | | | | |
Collapse
|
7
|
Rodrigues R, Rezende M, Gomes G, Souza F, Blagitz M, Libera AD, Taha M, Ferrari A, Libera ED. Effect of transgastric peritoneal access on peritoneal innate cellular immunity: experimental study in swine. Surg Endosc 2012; 27:964-70. [PMID: 23239288 DOI: 10.1007/s00464-012-2541-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2012] [Accepted: 08/04/2012] [Indexed: 10/27/2022]
Abstract
BACKGROUND One of the main concerns of natural orifice surgery is the local and systemic impact on physiology. Few studies have compared natural orifice transluminal endoscopic surgery (NOTES) with other surgical modalities. Most studies are based on systemic variables such as postoperative serum cytokines, with conflicting results. Surgical trauma induces an early inflammatory response, release of cytokines, and local leukocyte activation and oxidative burst. Major surgical trauma is related to impairment of phagocytic function and an increase in production of active oxygen species by phagocytes. The aim of this study was to evaluate the impact of transgastric peritoneoscopy on peritoneal innate immune response compared with laparoscopy and laparotomy in swine. METHODS Thirty-four male Sus scrofa domesticus swine were assigned to four groups: transgastric peritoneoscopy (13), laparoscopy (7), laparotomy (7), and sham procedure (7). Twenty-four hours after the procedure, peritoneal fluid cells were harvested by peritoneal washing after necropsy. Flow cytometry analysis of labeled S. aureus and E. coli phagocytosis by peritoneal neutrophils and macrophages was blindly performed. Oxidative burst activity measured by H(2)O(2) production under different challenges was also evaluated. RESULTS Total operative time varied between all groups. The transgastric, laparoscopy, and laparotomy groups required 56, 17.2, and 40.3 min of mean operative time, respectively (p < 0.05). Even though the mean percentage and intensity of phagocytosis by peritoneal phagocytes were higher in the sham, transgastric, and laparoscopy groups, there was no significant difference between these groups and laparotomy. Macrophage production of H(2)O(2) has been shown to be similar among the transgastric, laparoscopy, and sham groups, and smaller than that in laparotomy (p < 0.05), either under basal conditions, while performing E. coli phagocytosis, or challenged by the presence of E. coli membrane lipopolysaccharide. CONCLUSION Under the conditions of this study, transgastric peritoneoscopy has been shown to have minimal impact on peritoneal innate immune response.
Collapse
Affiliation(s)
- Rodrigo Rodrigues
- Clinical Gastroenterology Division, Department of Medicine, São Paulo Federal University, São Paulo, Brazil,
| | | | | | | | | | | | | | | | | |
Collapse
|
8
|
Bonilha DQ, Correia LM, Monaghan M, Lenz L, Santos M, Libera ED. Prospective study of bacteremia rate after elective band ligation and sclerotherapy with cyanoacrylate for esophageal varices in patients with advanced liver disease. Arq Gastroenterol 2011; 48:248-51. [DOI: 10.1590/s0004-28032011000400006] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/26/2011] [Accepted: 05/24/2011] [Indexed: 02/22/2023]
Abstract
CONTEXT: Band ligation (BL) is the most appropriate endoscopic treatment for acute bleeding or prophylaxis of esophageal variceal bleeding. Sclerotherapy with N-butyl-2-cyanoacrylate (CY) can be an alternative for patients with advanced liver disease. Bacteremia is an infrequent complication after BL while the bacteremia rate following treatment with CY for esophageal varices remains unknown. OBJECTIVES: To evaluate and compare the incidence of transient bacteremia between cirrhotic patients submitted to diagnostic endoscopy, CY and BL for treatment of esophageal varices. METHODS: A prospective study comprising the period from 2004 to 2007 was conducted at Hospital of Universidade Federal de São Paulo, UNIFESP, SP, Brazil. Cirrhotic patients with advanced liver disease (Child-Pugh B or C) were enrolled. The patients were divided into two groups according treatment: BL Group (patients undergoing band ligation, n = 20) and CY Group (patients receiving cyanoacrylate injection for esophageal variceal, n = 18). Cirrhotic patients with no esophageal varices or without indication for endoscopic treatment were recruited as control (diagnostic group n = 20). Bacteremia was evaluated by blood culture at baseline and 30 minutes after the procedure. RESULTS: After 137 scheduled endoscopic procedures, none of the 58 patients had fever or any sign suggestive of infection. All baseline cultures were negative. No positive cultures were observed after CY or in the control group - diagnostic endoscopy. Three (4.6 %) positive cultures were found out of the 65 sessions of band ligation (P = 0.187). Two of these samples were positive for coagulase-negative staphylococcus, which could be regarded as a contaminant. The isolated microorganism in the other case was Klebsiella oxytoca. The patient in this case presented no evidence of immunodeficiency except liver disease. CONCLUSIONS: There was no significant difference in bacteremia rate between these three groups. BL or CY injection for non-bleeding esophageal varices may be considered as low-risk procedures regarding bacteremia even when performed on patients with advanced liver disease.
Collapse
Affiliation(s)
| | | | | | - Luciano Lenz
- Universidade Federal de São Paulo, Brasil; Laboratório Fleury, Brasil
| | | | | |
Collapse
|
9
|
Correia LM, Bonilha DQ, Gomes GF, Brito JR, Nakao FS, Lenz L, Rohr MRS, Ferrari AP, Libera ED. Sedation during upper GI endoscopy in cirrhotic outpatients: a randomized, controlled trial comparing propofol and fentanyl with midazolam and fentanyl. Gastrointest Endosc 2011; 73:45-51, 51.e1. [PMID: 21184869 DOI: 10.1016/j.gie.2010.09.025] [Citation(s) in RCA: 48] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2010] [Accepted: 09/14/2010] [Indexed: 02/08/2023]
Abstract
BACKGROUND Patients with liver cirrhosis frequently undergo diagnostic or therapeutic upper GI endoscopy (UGIE), and the liver disease might impair the metabolism of drugs usually administered for sedation. OBJECTIVE AND SETTING To compare sedation with a combination of propofol plus fentanyl and midazolam plus fentanyl in cirrhotic outpatients undergoing UGIE. DESIGN A prospective, randomized, controlled trial was conducted between February 2008 and February 2009. MAIN OUTCOMES MEASUREMENTS Efficacy (proportion of complete procedures using the initial proposed sedation scheme), safety (occurrence of sedation-related complications), and recovery time were measured. RESULTS Two hundred ten cirrhotic patients referred for UGIE were randomized to 2 groups: midazolam group (0.05 mg/kg plus fentanyl 50 μg intravenously) or propofol group (0.25 mg/kg plus fentanyl 50 μg intravenously). There were no differences between groups regarding age, sex, weight, etiology of cirrhosis, and Child-Pugh or American Society of Anesthesiologists classification. Sedation with propofol was more efficacious (100% vs 88.2%; P < .001) and had a shorter recovery time than sedation with midazolam (16.23 ± 6.84 minutes and 27.40 ± 17.19 minutes, respectively; P < .001). Complication rates were similar in both groups (14% vs 7.3%; P = .172). LIMITATIONS Single-blind study; sample size. CONCLUSION Both sedation schemes were safe in this setting. Sedation with propofol plus fentanyl was more efficacious with a shorter recovery time compared with midazolam plus fentanyl. Therefore, the former scheme is an alternative when sedating cirrhotic patients undergoing UGIE.
Collapse
Affiliation(s)
- Lucianna Motta Correia
- Disciplina de Gastroenterologia Clínica, Universidade Federal de São Paulo, São Paulo, Brasil
| | | | | | | | | | | | | | | | | |
Collapse
|
10
|
Novis M, Ardengh JC, Libera ED, Nakao FS, Ornellas LC, Santo GC, Venco F, Ferrari AP. Estudo prospectivo e comparativo do escovado obtido pela CPER à ecoendoscopia associada à punção aspirativa com agulha fina (EE-PAAF) no diagnóstico diferencial das estenoses biliares. Rev Col Bras Cir 2010; 37:190-8. [DOI: 10.1590/s0100-69912010000300006] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2009] [Accepted: 05/20/2009] [Indexed: 01/15/2023] Open
Abstract
OBJETIVO: Avaliar o desempenho diagnóstico da citologia obtida pela CPER, aquele obtido pela EE-PAAF e a concordância entre patologistas gerais (PG) e especialistas (PE) em pacientes com estenose biliar. MÉTODOS: Incluímos pacientes com estenose biliar identificados pela CPER. A EE-PAAF foi realizada apenas em áreas com efeito de massa ou da parede espessada do ducto biliar. O padrão-ouro foi a cirurgia, histologia e/ou o seguimento. As amostras teciduais foram consideradas: malignas, suspeitas, atípicas, insuficientes ou benignas. Os espécimes obtidos por cada método foi interpretado (cego) por um PG e outro PE. RESULTADO: 46 pacientes foram incluídos (37 malignos e 9 benignos). O diagnóstico final foi de tumor pancreático (26), biliar (11), pancreatite crônica (8) e estenose inflamatória do ducto biliar (1). Sensibilidade e acurácia da CPER foram 43,2% e 52,2% para o PG e 51,4% e 58,7% para o PE. Sensibilidade e acurácia da EE-PAAF foi 52,8% e 58,5% para o PG e 69,4% e 73,2% para o PE. A combinação entre a CPER e EE-PAAF demonstrou maior sensibilidade e acurácia para ambos PG (64,9% e 69,6%) e PE (83,8% e 84,8%), respectivamente. CONCLUSÃO: A citologia obtida pelo escovado da via biliar durante a CPER e as amostras teciduais colhidas pela EE-PAAF tem rendimento semelhante para o diagnóstico das estenoses biliares. No entanto, a combinação dos métodos resulta em uma maior acurácia. Além disso, espera-se que a interpretação das amostras ocorra com maior precisão pelo PE se comparado ao PG.
Collapse
|
11
|
Rodrigues RA, Correia LPDMP, Rohr MRDS, Nakao FS, dos Santos MMM, Ferrari AP, Della Libera E. Endoscopic resolution of pseudocyst infection and necrosis as a complication of endoscopic pseudocyst drainage. A case report. JOP 2008; 9:499-503. [PMID: 18648142] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/26/2023]
Abstract
CONTEXT Endoscopic therapy has recently gained importance as an option for the treatment of pancreatic necrosis. We report a case of transgastric endoscopic resolution of pseudocyst infection and necrosis as a complication of endoscopic pseudocyst drainage. CASE REPORT The patient underwent several sessions of endoscopic removal of debris and necrotic material, intercalated with daily lavage and aspiration through a nasocystic tube. CONCLUSIONS At the present time, fourteen months after pancreatic pseudocyst secondary infection, the patient remains asymptomatic with no radiographic signs of pseudocyst recurrence. Transmural endoscopic therapy followed by continuous drainage and necrosectomy is a reasonable option for treating the pancreatic pseudocyst secondary infection.
Collapse
|
12
|
Martins Santos MM, Correia LP, Rodrigues RA, Lenz Tolentino LH, Ferrari AP, Della Libera E. Splenic artery embolization and infarction after cyanoacrylate injection for esophageal varices. Gastrointest Endosc 2007; 65:1088-90. [PMID: 17451707 DOI: 10.1016/j.gie.2006.10.008] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2006] [Accepted: 10/05/2006] [Indexed: 12/13/2022]
|
13
|
Della Libera E, Rodrigues RA, Guimarães APR, Paulo GAD, Geocze S, Ferrari AP. Prevalence of sphincter of Oddi dysfunction in patients referred to endoscopic retrograde cholangiopancreatography. Arq Gastroenterol 2007; 44:18-21. [PMID: 17639177 DOI: 10.1590/s0004-28032007000100005] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/14/2006] [Accepted: 06/08/2006] [Indexed: 11/22/2022]
Abstract
BACKGROUND: Sphincter of Oddi manometry is the gold-standard method for sphincter of Oddi dysfunction. The prevalence of sphincter of Oddi dysfunction among patients referred to endoscopic retrograde cholangiopancreatography is largely unknown. AIM: To evaluate prospectively the prevalence of biliary sphincter of Oddi dysfunction (B-SOD) among Brazilian patients referred to endoscopic retrograde cholangiopancreatography and to study the safety of sphincter of Oddi manometry in this setting. METHODS: Biliary sphincter of Oddi manometry was intended in 110 patients referred to endoscopic retrograde cholangiopancreatography. The number of attempts to obtain deep cannulation with the manometry catheter was recorded and patients were divided into two groups: up to 5 (easy cannulation) and >5 attempts (difficult cannulation). RESULTS: Sphincter of Oddi manometry was successful in 71/110 patients (64.5%). Sphincter of Oddi dysfunction was found in 18/71 patients (25%). Endoscopic retrograde cholangiopancreatography findings were: normal in 16, biliary stones in 39, malignant biliary strictures in 9 and benign biliary strictures in 7. There was no statistical difference in sphincter of Oddi dysfunction prevalence regarding disease, gender or difficulty of cannulation. Only 2/71 patients developed post-procedure mild pancreatitis. CONCLUSIONS: We have found a high prevalence of sphincter of Oddi dysfunction in patients referred to endoscopic retrograde cholangiopancreatography. Gender, nature of disease or difficulty of cannulation did not influence the prevalence of sphincter of Oddi dysfunction among these patients. Sphincter of Oddi manometry is a safe procedure for the evaluation of sphincter of Oddi dysfunction in patients referred to endoscopic retrograde cholangiopancreatography.
Collapse
Affiliation(s)
- Ermelindo Della Libera
- Discipline of Gastroenterology, São Paulo Federal University, Escola Paulista de Medicina - UNIFESP/EPM, São Paulo, SP, Brazil
| | | | | | | | | | | |
Collapse
|
14
|
Ferrari AP, de Paulo GA, de Macedo CMF, Araújo I, Della Libera E. Efficacy of absolute alcohol injection compared with band ligation in the eradication of esophageal varices. Arq Gastroenterol 2005; 42:72-6. [PMID: 16127560 DOI: 10.1590/s0004-28032005000200002] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
BACKGROUND Endoscopic sclerotherapy is an absolute indication for treating esophageal varices. Re-bleeding is common during the treatment period, before all varices become eradicated. AIM To compare two techniques of endoscopic esophageal varices eradication: sclerotherapy with absolute alcohol and banding ligation. PATIENTS AND METHOD Forty-six patients with liver cirrhosis and esophageal varices were prospectively randomized into two treatment groups: endoscopic sclerotherapy with absolute alcohol and banding ligation. Patients were included if they had large varices with signs of high bleeding risk. Informed writing consent was obtained from every patient and the Ethics Committee of Federal University of São Paulo, SP, Brazil, approved the study. After eradication, all patients were followed up to 1 year to look for re-bleeding episodes and variceal recurrence. RESULTS Both groups were similar except that male gender was more common in the sclerotherapy group. There was no statistical difference regarding variceal eradication (78.3% in sclerotherapy group vs 73.9% in the ligation group), recurrence (26.7% vs 42.9%, respectively) and death related to any cause (21.7% vs 13.9%). In the sclerotherapy group more sessions were need to obtain complete variceal eradication. In this group we did observe a high re-bleeding rate (34.8%) and more ulcers associated with retrosternal pain right after the procedure. There was no difference regarding overall morbidity and mortality. CONCLUSIONS Banding ligation requires fewer sessions than sclerotherapy with absolute alcohol to eradicate esophageal varices. Both methods are equally efficient regarding variceal eradication and recurrence during a short follow-up period.
Collapse
Affiliation(s)
- Angelo Paulo Ferrari
- Division of Gastroenterology, Federal University of São Paulo, São Paulo, SP, Brazil.
| | | | | | | | | |
Collapse
|
15
|
Ornellas LC, Santos GDC, Libera ED, Cury MDS, Ferrari AP. [Survival of patients with malignant biliary stricture based on endoscopic brushing and on bilirubinemia]. Arq Gastroenterol 2005; 41:167-72. [PMID: 15678201 DOI: 10.1590/s0004-28032004000300006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
BACKGROUND Pancreatic cancer and cholangiocarcinoma are the main causes of malignant biliary stricture. Both types of cancers have dismal survival rates, and treatment has little or no effect on prolonging the patients lives. Prognostic definition at initial endoscopic retrograde cholangiopancreatography is important to choose the most suitable management. AIM To analyse endoscopic brushing and bilirubinemia importance in determination of the survival of patients with malignant biliary stricture. METHODS Patients with biliary strictures diagnosed during endoscopic retrograde cholangiopancreatography were submitted to double brushing cytology. Serum samples were taken from all patients for bilirubinemia assay. Patients were followed to determine the final diagnosis and survival rates. RESULTS A total of 50 patients with biliary stricture underwent endoscopic retrograde cholangiopancreatography (40 ultimately found to have a final diagnosis of malignant disease). Hyperbilirubinemia or cytology brushing positive for malignancy was related to a shorter survival rate. CONCLUSION This research data demonstrate the possibility of determining the prognosis of patients with malignant biliary stricture using endoscopic brushing results and bilirubinemia levels.
Collapse
Affiliation(s)
- Laura Cotta Ornellas
- Departamento de Medicina, Universidade Federal de São Paulo (UNESP), São Paulo, SP.
| | | | | | | | | |
Collapse
|
16
|
Di Sena V, Thuler FPBM, Macedo EP, Paulo GAD, Della Libera E, Ferrari AP. Obstructive jaundice secondary to bile duct involvement with Hodgkin's disease: a case report. SAO PAULO MED J 2005; 123:30-2. [PMID: 15821813 DOI: 10.1590/s1516-31802005000100007] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
CONTEXT Obstructive jaundice due to lymphoma is very rare. It may be difficult to distinguish between this condition and a large number of causes of extrahepatic bile duct obstruction, even by endoscopic retrograde cholangiography. Its prognosis is poor. Combined chemotherapy and/or radiotherapy with bile duct drainage is a therapeutic option. CASE REPORT We describe a case of obstructive jaundice as the initial presentation of Hodgkin's disease. After chemotherapy and endoscopic bile duct stenting, it was noted that the enlarged lymph nodes, jaundice and bile duct dilation disappeared.
Collapse
Affiliation(s)
- Veruska Di Sena
- Universidade Federal de São Paulo, Escola Paulista de Medicina, São Paulo, Brazil
| | | | | | | | | | | |
Collapse
|
17
|
Thuler FPBM, Di Sena VO, Hervoso CM, Della Libera E, Ferrari AP. Quantos exames são necessários para adquirir aptidão em colonoscopia? Arq Gastroenterol 2004; 41:211-4. [PMID: 15806262 DOI: 10.1590/s0004-28032004000400002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
RACIONAL: Capacitação para realização de colonoscopia implica em competência técnica e cognitiva. A Sociedade Americana de Endoscopia sugere que 100 colonoscopias supervisionadas sejam necessárias para tal. Não há recomendações específicas no Brasil. OBJETIVO: Avaliar o desempenho e progresso técnico de médicos durante programa de treinamento em colonoscopia. MATERIAIS E MÉTODO: Dois residentes em gastroenterologia da Universidade Federal de São Paulo, SP, foram acompanhados prospectivamente no seu primeiro ano de treinamento em colonoscopia. Os parâmetros avaliados foram: capacidade de atingir o ceco, tempo de chegada ao ceco, duração total do exame, identificação das lesões e desconforto do paciente. RESULTADOS: Foram realizadas 271 colonoscopias pelos dois residentes (186 pelo residente A e 85 pelo B). Foram excluídos 27 casos por lesões obstrutivas ou antecedente de cirurgia do cólon, restando 171 e 72 exames, respectivamente, para avaliação dos parâmetros propostos. A taxa de sucesso em alcançar o ceco sem ajuda foi 82,5% e 56,9%, respectivamente, para A e B. Nos primeiros 72 exames foi: 72,2% (A) e 56,9% (B), diferença estatisticamente significativa. O residente A atingiu o ceco em 76% dos primeiros 100 exames e após o 101º, a taxa aumentou para 91,5%. O tempo médio de chegada ao ceco foi 17,7 e 23,5 minutos para os residentes A e B. Para o examinador A o tempo foi de 19,8 e 14,7 minutos antes e depois do 100º exame. DISCUSSÃO: Observou-se que o sucesso em atingir o ceco e o tempo necessário para alcançá-lo melhoraram proporcionalmente ao número de exames realizados, com significância estatística. Contudo, diferenças individuais sugerem que, talvez, 100 colonoscopias seja número insuficiente para aquisição da competência técnica. CONCLUSÃO: Apesar de avaliar a curva de aprendizado de apenas dois residentes, observou-se melhora estatisticamente significativa na taxa e tempo de chegada ao ceco com o número de exames realizados. Dependendo, porém, de aptidões individuais, talvez mais de 100 exames sejam necessários no treinamento.
Collapse
|
18
|
Di Sena V, de Paulo GA, Macedo EP, Triviño T, Della Libera E, Ferrari AP. Choledochal cyst mimicking a pancreatic pseudocyst: case report and review. Gastrointest Endosc 2003; 58:620-4. [PMID: 14520307] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Affiliation(s)
- Veruska Di Sena
- Surgical Unit, Endoscopy Unit, Universidade Federal de São Paulo (UNIFESP), São Paulo - SP - Brazil
| | | | | | | | | | | |
Collapse
|
19
|
Siqueira ES, Rohr MR, Libera ED, Castro RR, Ferrari AP. Band ligation or sclerotherapy as endoscopic treatment for oesophageal varices in schistosomotic patients: results of a randomized study. HPB Surg 1998; 11:27-32. [PMID: 9830578 PMCID: PMC2423920 DOI: 10.1155/1998/68394] [Citation(s) in RCA: 22] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Endoscopic sclerotherapy and banding ligation are the two preferred methods to treat oesophageal variceal bleeding. There are many reports dealing with such treatment in cirrhotic patients but we do not know how good they are to treat varices secondary to other forms of portal hypertension. Schistosomiasis mansoni is the main cause of portal hypertension and oesophageal varices in Brazil. We performed a prospective randomised study to compare: 1) the efficacy of both treatments in eradicating oesophageal varices, and 2) complications secondary to both treatments. Forty patients were divided in two groups. Both sclerotherapy and banding ligation were performed until variceal eradication. There were no severe complications. Variceal eradication was faster obtained with banding ligation than sclerotherapy although there was no statistical difference (mean number of sessions 3.05 vs 3.72, p = 0.053). Benign complications were equally frequent in both groups, although additional sedation was more common in the sclerotherapy group. We concluded that both treatments are equally effective in the eradication of oesophageal varices, although banding ligation is better tolerated by the patient and probably faster.
Collapse
Affiliation(s)
- E S Siqueira
- Division of Gastroenterology, Universidade Federal de São Paulo, Escola Paulista de Medicina
| | | | | | | | | |
Collapse
|
20
|
da Silveira Rohr MR, Siqueira ES, Brant CQ, Morais M, Libera ED, Castro RR, Ferrari AP. Prospective study of bacteremia rate after elastic band ligation and sclerotherapy of esophageal varices in patients with hepatosplenic schistosomiasis. Gastrointest Endosc 1997; 46:321-3. [PMID: 9351034 DOI: 10.1016/s0016-5107(97)70118-4] [Citation(s) in RCA: 23] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
BACKGROUND Esophageal band ligation is considered to be as efficient as endoscopic sclerotherapy, with a lower complication rate, including bacteremia. There are few studies comparing the two methods. The aim of this study was to compare the incidence of bacteremia after both treatments in patients with portal hypertension secondary to schistosomiasis. METHODS Endoscopic sclerotherapy and band ligation were performed using standard techniques. Blood samples were obtained 5 and 30 minutes after endoscopic band ligation or sclerotherapy and cultured for aerobic and anaerobic organisms. RESULTS In the sclerotherapy group 2 of 43 (4.6%) blood cultures were positive (Peptostreptococcus sp and Streptococcus mitis). A similar result was obtained in the band ligation group: 2 of 35 (5.7%) had positive cultures, both with Staphylococcus aureus. CONCLUSIONS There is no difference in the frequency of bacteremia after treatment of esophageal varices with endoscopic sclerotherapy or endoscopic band ligation in patients with portal hypertension secondary to schistosomiasis.
Collapse
|