[Endoscopic ultrasound-guided choledochoduodenostomy for relieving malignant distal biliary obstruction]. / Coledocoduodenostomía guiada por Ultrasonido Endoscópico para la paliación de la obstrucción biliar distal maligna.

Ultrasound-guided biliary drainage is a new and effective method for relieving obstructive lesions of the biliary tract. In the hands of experienced operators, ultrasound-guided diversion of the mid portion of the common bile duct and the duodenal bulb is a feasible strategy for the relief of jaundice secondary to distal obstruction (distal bile duct tumors, pancreatic head cancer, or major duodenal papillary tumor), with low morbidity and mortality rates. The technical aspects of the procedure and its indications are reviewed herein, emphasizing its performance in institutions equipped with experienced personnel adhering to strict study protocols.

Evaluation of rats´ soleus muscle submitted to remobilization protocol with therapeutic ultrasound associated with static stretching

Despite the deleterious effects, immobilization, is still often used in the treatment of musculoskeletal disorders, even with the occurrence of muscular atrophy, its reversal is a major challenge to rehabilitation. The aim of this study was evaluate the tropism of rats soleus muscle submitted to remobilization with static stretching, preceded by ultrasound, thermal and non thermal. We used 28 rats divided into four groups: G1‑immobilized and remobilized with static stretching, G2-remobilized with stretching preceded by ultrasound 1.0 W.cm–²; G3 – ultrasound at 0.5 W.cm–² , G4 – ultrasound with 0.2 W.cm–². All animals were immobilized in plantarflexion, producing shortening of the right soleus muscle for 15 days. For the groups subjected to remobilization with ultrasound doses were used according to the group, for 3 minutes, for 10 days with an interval of 2 days after the 5th treatment. After treatment with ultrasound (or not for the G1), the animals were subjected to 3 sets of 30 seconds, with 30 seconds interval between them, of static stretching of the soleus. The soleus were dissected, weighed and processed for preparation of histological slides in cross section, and evaluated the smallest diameter of 100 fibers per muscle. There was significant reduction in weight between left and right muscles in all groups, for diameters G3 showed no difference. Conclusion: stretching with or without ultrasound, was unable to reverse the deleterious effects of immobilization on muscle weight, but in the mean dose there was protective effect on the diameter of the fibers.

Successful endoscopic ultrasound-guided overstenting biliary drainage through a pre-existing proximal migrated metal biliary stent.

Biliary endoscopic drainage using metallic self-expanded stents has become a well-established method for palliative treatment of malignant biliary obstruction. However, its occlusion, mainly by tumor overgrowth, is still the main complication without a standard treatment. We here describe a new method of treatment for biliary metallic stent occlusion, through the echo guided biliary drainage. We present a 68-year-old patient with metastatic pancreatic cancer previously treated for jaundice with ERCP and self-expandable metallic stent insertion. Four weeks later, the patient developed jaundice and symptoms of gastric outlet obstruction. A new ERCP confirmed obstruction of the second portion of the duodenum, due to diffuse tumor growth. EUS was performed, and the previous metal biliary stent was seen occluded at the distal portion in the common bile duct. A EUS-guided choledocododenostomy was performed and then, an overlapping self-expanding metal enteral stent was placed through the malignant obstruction. There were no early complications and the procedure was also clinically effective in relieving jaundice and gastric outlet obstruction symptoms. If ERCP fails in the management of occluded biliary metallic stents, EUS biliary drain can provide effective biliary decompression and should be considered an alternative to other endoscopic techniques.

[Epidermolysis bullosa acquisita complicated by esophageal stenosis. Endoscopic treatment with thermoplastic dilators and intralesional steroid injection]. / Epidermólisis bullosa adquirida complicada por estenosis de esófago. Tratamiento endoscópico con sondas termoplásticas e inyección intralesional de corticoesteroide.

Epidermolysis bullosa acquisita (EBA) is a rare auto-immune dermatologic disease, produced by auto-antibodies against colagen VII. We report a 44 years old male patient with EBA diagnosed 15 years before, who presented with progressive disphagia, being diagnosed an esophageal involvement of EBA. The patient was submitted to endoscopic treatment with thermoplastic bougie dilation and intralesional corticosteroid injection. The patient improved clinically with recovery of nutritional status. Esophageal involvement in EBA is very rare and its reason is still unknown. Endoscopic approach must be cautiously performed with the use of small diameter endoscopes, small caliber dilators, intralesional injection of corticosteroid and enteral tube in order to minimize the risks of complications, as well as esophageal rest from food trauma and better reparatory molding of the epithelium.

Low-level laser therapy, at 830 nm, for pain reduction in experimental model of rats with sciatica / Laser de baixa potência, 830 nm, na redução da dor em ratos submetidos à modelo experimental de ciatalgia

Chronic pain, resulting from nerve compression, is a common clinical presentation. One means of conservative treatment is low-level laser therapy, although controversial. The aim of this study was to evaluate the effects of two doses of low-level laser, at 830 nm, on pain reduction in animals subjected to sciatica. Eighteen rats were used, divided into three groups: GS (n=6), sciatica and simulated treatment; G4J (n=6), sciatica and treatment with 4 J/cm²; and G8J (n=6), sciatica and irradiation with 8 J/cm². The right sciatic nerve was exposed and compressed using catgut thread. Five days of treatment were started on the third postoperative day. Pain was assessed by means of the paw elevation time during gait: before sciatica, before and after the first and second therapies, and the end of the fifth therapy. Low-level laser was effective in reducing the painful condition.

A dor crônica, resultante de compressão nervosa, é uma apresentação clínica frequente. Um dos meios de tratamento conservador, é o laser de baixa potência, apesar de controvérsias. O objetivo do estudo foi avaliar os efeitos de duas doses de laser de baixa potência, 830 nm, na redução da dor em animais submetidos à ciatalgia. Foram utilizados 18 ratos, divididos em 3 grupos: GS (n=6) ciatalgia e simulado o tratamento; G4J (n=6) ciatalgia e tratado com 4 J/cm², G8J (n=6) ciatalgia e irradiado com 8 J/cm². O nervo isquiático direito foi exposto e realizada a compressão com fio catgut. No 3º dia pós-operatório, iniciou-se o tratamento, durante 5 dias. Verificou-se a dor, por meio do tempo de elevação da pata, na marcha: anterior à ciatalgia, pré e pós 1ª e 2ª terapias, e ao final da 5ª terapia. O laser de baixa potência foi eficaz na redução do quadro álgico.

Diagnosis of pancreatic plasmacytoma by endoscopic ultrasound-fine needle aspiration.

Plasmacytoma presents more frequently in middle age men with aerodigestive tract involvement, especially in the head and the neck. Gastrointestinal tract involvement is uncommon, but the organ most commonly involved is the stomach. We report the first case in the literature in which final diagnosis was made by fine- needle aspiration biopsy guided by endoscopic ultrasound with adequate sample for pathologic analysis. The treatment of this entity is systemic chemotherapy but its effectiveness is limited. Plasmacytoma should be taken into account in differential diagnosis of pancreatic masses.

Endoscopic recanalization following accidental ligation of the common hepatic duct. A new technique.

Bile duct injury is a known complication of cholecystectomy. While minor injuries can be treated endoscopically, successful endoscopic management of complete ligation of the common hepatic duct (CHD) has not been described. Our aim was to report a novel technique for endoscopic recanalization of accidently ligated CHD. We demonstrated a 75 year old woman presented with a small bile leak and complete ligation of the CHD after open cholecystectomy subjected to successful biliary endoscopic recanalization. Cholangiogram demonstrated resolution of the bile leak and minimal residual narrowing of the CHD. Endoscopic intervention following biliary needle puncture access may avoid surgery in patients with CHD ligation or complex stenosis.

Endoscopic ampullectomy in a patient with a duodenal diverticulum. A challenging procedure.

A 65 year-old male was admitted to the University hospital with obstructive jaundice. Endoscopic examination revealed a grossly abnormal major ampulla, situated at the edge of a large duodenal diverticulum. Biopsy of the ampulla was positive for villous adenoma. We describe the technique utilized to successfully perform an end-bloc endoscopic resection of a major ampulla on a diverticulum.

Treatment of achalasia: lessons learned with Chagas' disease.

Chagas' disease (CD) is highly prevalent in South America. Brazilian surgeons and gastroenterologists gained valuable experience in the treatment of CD esophagopathy (chagasic achalasia) due to the high number of cases treated. The authors reviewed the lessons learned with the treatment of achalasia by different centers experienced in the treatment of Chagas' disease. Preoperative evaluation, endoscopic treatment (forceful dilatation and botulinum toxin injection), Heller's myotomy, esophagectomy, conservative techniques other than myotomy, and reoperations are discussed in the light of personal experiences and review of International and Brazilian literature. Aspects not frequently adopted by North American and European surgeons are emphasized. The review shows that nonadvanced achalasia is frequently treated by Heller's myotomy. Endoscopic treatment is reserved to limited cases. Treatment for end-stage achalasia is not unanimous. Esophagectomy was a popular treatment in advanced disease; however, the morbidity/mortality associated to the procedure made some authors seek different alternatives, such as Heller's myotomy and cardioplasties. Minimally invasive approach to esophageal resection may change this concept, although few centers perform the procedure routinely.

An evaluation of gastric scintigraphy pre- and postpyloroduodenal peptic stenosis dilation.

BACKGROUND: The usual treatment of pyloroduodenal peptic stenosis has been mainly surgical, through pyloroplasty or gastric resection, with or without vagotomy. Since the first description of treatment for this peptic complication by endoscopic balloon dilation perfomed by Benjamin in 1982 [2], this procedure has become a therapeutic option in association with the medical treatment of peptic disease. The aim of this study is to evaluate the results involving clinical, endoscopic, and gastric emptying scintigraphy parameters. METHODS: Between August 1998 and February 2000, 20 patients with pyloroduodenal stenosis refractory to conservative treatment were treated at the Gastrointestinal Endoscopy Unit of the University of São Paulo Medical School. All patients who presented clinical manifestations of pyloroduodenal stenosis underwent upper gastrointestinal endoscopy to confirm peptic stenosis. Biopsy of the narrowing for the confirmation of a benign disease and gastric biopsy for Helicobacter pylori detection were performed. The treatment consisted of dilation of the stenosis with type TTS (Through The Scope) hydrostatic balloon under endoscopic control, treatment of Helicobacter pylori infection, and gastric acid suppression with oral administration of proton pump inhibitor. All patients, except one who was excluded from this study, were submitted to a clinical endoscopic assessment and gastric emptying evaluation by ingestion of (99m)Tc before and after the treatment. Endoscopic evaluation considered the diameter of the stenotic area before and after treatment. A scintigraphic study compared the time of gastric emptying before and after balloon dilation. RESULTS: Nineteen patients completed treatment by hydrostatic balloon dilation. Clinical symptoms such as bloating (p < 0.0001), epigastric pain (p = 0.0159), gastric stasis (p < 0.0001), and weight gain (p = 0.036) showed significant improvement. The diameter of the stenotic area increased significantly (p < 0.01) after the dilation treatment as well as a better gastric emptying of (99m)Tc (p < 0.0001). CONCLUSION: The dilation of the peptic pyloroduodenal stenosis using a hydrostatic balloon is a safe and effective procedure. The evaluation with gastric scintigraphy by ingestion of (99m)Tc is an effective method of assessment for the improvement of gastric function, because its results corresponded to the clinical improvement after endoscopic treatment.

Fístulo-papilotomia endoscópica: uma alternativa à papila de difícil cateterizaçäo / Is the endoscopic fistulo-papilotomy an alternative to the difficult papilary cannulation?

A fistulizaçäo cirúrgico-endoscópica no contorno papilar superior é um procedimento destinado a facilitar a cateterizaçäo da porçäo terminal do ducto colédoco, pela impossibilidade do acesso habitual pelo óstio, tendo em vista a fibrose, tumores ou cálculo impacatado. Esse procedimento foi denominado por Schapira (19982) como fístulo-esfincterotomia endoscópica, embora tenha recebido outras denominações inapropriadas, como fistulotomia suprapapilar ou infundibulotomia. Tal intervençäo endoscópica viabiliza a catererizaçäo emcasos difíceis, ampliando o acesso ao colédoco terminal ao nível da ampola hepatopancreática. E difere do procedimento denominado pré-corte, porquanto o óstio da papila é poupado com o intuito de prevenir a pancreatite aguda. Essa intervençäo cirúrgico-endoscópica, com base anatômica, é denominada fístulo-papilotomia no Serviço de Endoscopia Digestiva do HC-FMUSP. No período de outubro de 1999 a dezembro de 2000, foram realizadas 451 papilotomias, sendo indicadas 65 (14,5por cento) fístulo-papilotomias, cuja indicaçäo miais frequente foi a coledocolitíase. Ocorreram nove (13,8por cento) complicações: pancreatite aguda em cinco (7,6por cento) casos, hemoragia em um (1,5por cento), colangite em dois (3por cento) e perfuraçäo retroduodenal em um (1.5por cento). Em todos esses casos houve resoluçäo espontânea através do tratamento conservador. Considerando-se o insucesso da cateterizaçäo do óstio da papila de forma convencional, a fístulo-papilotomia for a opçäo que demonstrou ser um procedimento viável e seguro