Applying basic principles of surgery may pave the way for more effective endoscopic bariatric techniques.

Background and study aims In the last decade, gastroenterologists have been attempting to use endoscopy to reproduce the great success of traditional surgical suture techniques. Despite recent advances, we still lack a reliable method that results in a permanent suture with minimal incidence of suture failure. This was an experimental study in pigs with an innovative technique that applied basic surgical concepts to endoscopy to evaluate the effectiveness of a novel suture technique. Methods The procedures were performed on six live pigs under general anesthesia. Endoscopic mucosal resection (EMR) first was performed in the stomach, exposing the submucosal or muscularis propria layers. A novel device, a transparent chamber cap (DASE), was developed to aspirate the gastric wall, allowing the sutures to reach deep layers. The aspiration was performed with a standard gastroscope to which the novel cap was distally attached. Three sutures aligned were defined as a plication. Each pig received two or three plications and was placed on a liquid diet for 14 days after the procedure. The pigs were sacrificed at 4 and 8 weeks and the sutures were reviewed. Results The technique was feasible in all animals. Of 16 plications, only one failed. One perforation occurred after EMR. There were no other complications or adverse events. Permanent fusion of the gastric wall was confirmed by histology in all cases. Conclusions This study showed that basic principles of surgery can be applied endoscopically to ensure a permanent suture with reduced chances of failure. These findings can help to pave the way for more effective bariatric endoscopic techniques.

Initial experience of endoscopic submucosal dissection in Brazil to treat early gastric and esophagheal cancer: a multi-institutional analysis.

OBJECTIVE: This study aimed to evaluate the feasibility and clinicopathological characteristics of early gastric and esophageal cancers treated with endoscopic submucosal dissection (ESD) at five centers in Brazil. METHODS: Five centers in Brazil reported their initial experience with ESD. The cases reported had already been collected by each center before pooled analysis. RESULTS: Were resected 62 gastric lesions; 52(83,8%) of the gastric lesions were well-differentiated adenocarcinoma, 31(50%) from the antrum, 24 (38.7%) type IIa. 51 (82.2%) lesions had en-block resection with three showing lateral margin compromise. Concerning invasion, 25 (40.3%) tumors were M1. Mean tumor diameter was 18.9 mm (range, 0.6-5.0 cm) and mean procedure duration was 119.45 minutes. Gastric perforation occurred in three (4.8%) patients. Mean follow-up duration was 11.3 months, with two local recurrences and one death from pneumonia Seven months after treatment. Of the 16 esophageal lesions resected, 14 (87.4%) were squamous cell carcinoma, 10 (62.5%) were located proximally and 8 (50.0%) type IIa. Mean tumor diameter was 23.8 mm (range, 6-60 mm). Thirteen (81.2%) lesions had en-block resection with five cases of lateral margin compromise. Eight (50.0%) lesions were M1. Mean procedure duration was 78 minutes (range, 20-150 min). Complications included pneumomediastinum in two (12.5%) patients and stenosis in one (6.2%). Mean duration of follow-up was 8.6 months, with no local recurrence despite the presence of lateral margin compromise. CONCLUSION: Different centers in Brazil feasibly perform ESD with a high success rate.

INITIAL EXPERIENCE OF ENDOSCOPIC SUBMUCOSAL DISSECTION IN BRAZIL TO TREAT EARLY GASTRIC AND ESOPHAGHEAL CANCER: a multi-institutional analysis

Objective This study aimed to evaluate the feasibility and clinicopathological characteristics of early gastric and esophageal cancers treated with endoscopic submucosal dissection (ESD) at five centers in Brazil. Methods Five centers in Brazil reported their initial experience with ESD. The cases reported had already been collected by each center before pooled analysis. Results Were resected 62 gastric lesions; 52(83,8%) of the gastric lesions were well-differentiated adenocarcinoma, 31(50%) from the antrum, 24 (38.7%) type IIa. 51 (82.2%) lesions had en-block resection with three showing lateral margin compromise. Concerning invasion, 25 (40.3%) tumors were M1. Mean tumor diameter was 18.9 mm (range, 0.6-5.0 cm) and mean procedure duration was 119.45 minutes. Gastric perforation occurred in three (4.8%) patients. Mean follow-up duration was 11.3 months, with two local recurrences and one death from pneumonia Seven months after treatment. Of the 16 esophageal lesions resected, 14 (87.4%) were squamous cell carcinoma, 10 (62.5%) were located proximally and 8 (50.0%) type IIa. Mean tumor diameter was 23.8 mm (range, 6-60 mm). Thirteen (81.2%) lesions had en-block resection with five cases of lateral margin compromise. Eight (50.0%) lesions were M1. Mean procedure duration was 78 minutes (range, 20-150 min). Complications included pneumomediastinum in two (12.5%) patients and stenosis in one (6.2%). Mean duration of follow-up was 8.6 months, with no local recurrence despite the presence of lateral margin compromise. Conclusion Different centers in Brazil feasibly perform ESD with a high success rate. .

Objectivo Este estudo tem como objetivo avaliar a viabilidade da técnica de dissecção endoscópica da submucosa (DES) no tratamento do câncer precoce do estômago e do esôfago, assim como as características clinicopatológicas dos pacientes tratados em diferentes centros no Brasil. Métodos Cinco centros no Brasil relataram sua experiência inicial com a técnica de DES. Os casos relatados vinham sendo coletados em cada serviço antes da análise agrupada dos dados. Resultados Foram ressecadas 62 lesões gástricas, sedo 52 (83,8%) adenocarcinoma bem diferenciado, 31 (50%) localizadas no antro e 24 (38.7%) do tipo macroscópico IIa. Foram ressecadas em monobloco 51 (82.2%) lesões, com 3 apresentando margem lateral comprometida. Quanto ao grau de invasão, 25 (40.3%) eram restritas ao epitélio da mucosa (M1). O diâmetro médio das lesões foi de 18.9 (6-50) mm, o tempo médio dos procedimentos foi de 119.45 minutos. A incidência de perfuração gástrica foi de 4,8% (três casos). O tempo médio de seguimento foi de 11.3 meses, com duas recorrências locais e uma morte por pneumonia 7 meses após o tratamento. Das 16 lesões esofágicas ressecadas, 14 (87.4%) eram carcinoma epidermóide, 10 (62.5%) localizados na porção proximal, 8 (50.0%) do tipo macroscópico IIa. O diâmetro médio das lesões foi de 23.8 (6-60) mm. Foram ressecadas em monobloco 13 (81.2%) lesões, sendo que 5 apresentaram margem lateral comprometida e 8 (50.0%) com invasão restrita a camada epitelial (M1). A duração média dos procedimentos foi de 78 (20-150) minutos. Dois (12.5%) pacientes tiveram pequeno pneumomediastino e um (6.2%) evoluiu com estenose esofágica. O tempo médio de seguimento foi de 8.6 meses, ...

Fístula duodenal traumática tratada por duodenostomia endoscópica percutânea ecoguiada / Traumatic duodenal distula treated by percutaneous endoscopic duodenostomy ecoguiada

A conduta frente a uma fístula duodenal recidivada de alto débito é de difícil manejo. Uma nova cirurgia poderia aumentar as já elevadas taxas de morbimortalidade inerentes a esta situação. Para evitar isto, procedimentos alternativos, minimamente invasivos, têm sido relatados com sucesso para o tratamento das fístulas enterocutâneas. Apresentaremos um caso de fístula duodenal traumática recidivada após diverticulização duodenal em Y de Roux, que permaneceu com débito inalterado após 40 dias de tratamento conservador. A realização de uma duodenostomia endoscópica percutânea ecoguiada propiciou o fechamento da fístula. Nenhum relato de fístula duodenal tratada por esta técnica foi encontrado. Apesar deste procedimento ter se mostrado factível e seguro, mais fístulas deverão ser fechadas usando esta técnica para demonstrar que este será um instrumento seguro para se lidar com este problema.

Management of high output duodenal fistula is a difficult problem; another surgery would be associated with higher rates of morbidity and mortality. To avoid this, several minimal invasive alternative methods have been reported for the treatment of enterocutaneous fistulae. A case of a duodenal fistula following a blunt abdominal trauma, treated unsuccessful duodenal suture, followed by another surgery - duodenal exclusion using Roux - en - Y is reported. The fistula persisted for 40 days of conservative management. Echo guided percutaneous endoscopic duodenostomy was successfully performed leading to the obliteration of the fistula. No previous report of the closure of a duodenal fistula by this technique was found. This procedure showed simple and safe. Further experience may be necessary to demonstrate that it is an effective tool in dealing with this complex problem.

Fístula duodenal traumática tratada por duodenostomia endoscópica percutânea ecoguiada: relato de caso / Traumatic duodenal fistula treated by echo-guided percutaneous endoscopic duodenostomy

A conduta frente a uma fístula duodenal recidivada de alto débito é de difícil manejo; uma nova cirurgia poderia aumentar as já elevadas taxas de morbimortalidade inerentes a essa situação. Para evitar isto, procedimentos alternativos, minimamente invasivos, têm sido relatados com sucesso para o tratamento das fístulas enterocutâneas. Os autores apresentam caso de fístula duodenal traumática recidivada após diverticulização duodenal em Y de Roux que permaneceu com débito inalterado após 40 dias de tratamento conservador. A realização de uma duodenostomia endoscópica percutânea ecoguiada propiciou o fechamento da fístula. Nenhum relato de fístula duodenal tratada por esta técnica foi encontrado. Apesar de este procedimento ter-se mostrado factível e seguro, mais fístulas deverão ser fechadas usando esta técnica para demonstrar que este será um instrumento seguro para se lidar com este problema.