Evaluation of adenosine triphosphate test for cleaning assessment of gastroscopes and the effect on workload in a busy endoscopy center.

OBJECTIVE: Using adenosine triphosphate (ATP) tests to assess manual cleaning of gastroscopes and to determine the associated workload in a busy endoscopy unit. METHODS: Patient-used gastroscopes were sampled before and after cleaning to assess ATP levels, bioburden, and protein. Samples were collected by flushing 20 mL of sterile water through the biopsy port to the distal end. Time spent for reprocessing and performing the ATP test was recorded. RESULTS: Twenty-four samples were collected from 10 gastroscopes. After manual cleaning, 14/24 (58.3%) samples had no microbial growth (mean, 21 colony-forming units/cm2), and in 22/24 (91.7%) samples the protein was undetectable (mean, 0.04 µg/cm2). ATP test was above the cutoff (200 relative light units [RLU]) in 17/24 (70.8%) samples (mean, 498 RLU). After the second cleaning, 11/17 (64.7%) gastroscopes still failed the ATP test (mean, 321.2 RLU). The mean time spent to perform manual cleaning and ATP tests was 16 and 8 minutes, respectively. Hence, each test increased the length of time for cleaning plus testing cleanliness by 50%. CONCLUSION: Further studies regarding the optimal cutoff for ATP tests are needed. ATP tests for cleaning monitoring are easy to perform and provide immediate feedback to the team. However, the increased workload needs to be considered.

Complicações em colonoscopia / Complications in colonoscopy

A colonoscopia é um exame com possibilidade terapêutica que vem sendo cada vez mais executado. Entretanto, como qualquer procedimento médico, esta modalidade diagnóstica não é isenta de complicações. Estas podem estar relacionadas ao preparo do cólon, à sedação, à analgesia e ao exame colonoscópico propriamente dito. As complicações referentes ao preparo envolvem o jejum e as soluções para limpeza do cólon, que são capazes de ocasionar alterações hidroeletrolíticas que serão mais graves nos pacientes com comorbidades. Durante o exame, alterações dos sinais vitais como hipóxia e hipotensão podem ser induzidas pelos sedativos. Em relação à colonoscopia per si, as complicações estão relacionadas à técnica de exame e aos procedimentos terapêuticos, sendo o sangramento e a perfuração suas principais consequências indesejadas. Neste texto, fazemos uma revisão dos diversos eventos adversos que podem ocorrer na preparação da colonoscopia e nos períodos peri e pós-exame.

The colonoscopy is an diagnostic procedure with the possibility of therapy that is being increasingly performed. However, this diagnostic modality is not free from complications. These may be related to bowel preparation, sedation and analgesia and the colonoscopy itself. Complications related to preparation involve fasting and solutions for cleaning the colon, which are capable to cause electrolytic changes, more severe in patients with co-morbidities. During the examination, changes in vital signs such as hypoxia and hypotension may be induced by sedatives. Regarding the colonoscopy itself, the complications are related to technical examination and therapeutic procedures, with bleeding and perforation its major unintended consequences. In this paper, we review the various adverse events that may occur in preparation for colonoscopy and in the peri-and post-test.

I Consenso Brasileiro de Ecoendoscopia / I Brazilian Consensus of Endoscopic Ultrasonography

RACIONAL: Ainda que se reconheça a eficiência da ecoendoscopia para o diagnóstico e até mesmo para o tratamento de várias doenças do aparelho digestivo, a sua inclusão nos algoritmos de decisão clínica em gastroenterologia tem sofrido restrições. Este fato é comprovado indiretamente através da existência de vários estudos que se preocuparam em demonstrar o impacto do exame ecoendoscópio na mudança de condutas e na redução de custos. Outra evidência, esta direta e identificável em nosso meio, é a disponibilidade bastante limitada da ecoendoscopia no Brasil. Neste sentido, quiseram-se identificar as situações clínicas em que o exame ecoendoscópico é eficiente, através de revisões sistemáticas, graduando-se o grau da evidência e a força da recomendação, realizadas pelo grupo envolvido com o método em nosso país, apresentadas e votadas na forma de consenso. MÉTODO: O grupo de médicos que realiza ecoendoscopia foi formado a partir de informações obtidas junto às sociedades de especialidades e aos fabricantes de equipamentos. A lista de tópicos e perguntas relevantes foi formulada por dois membros do consenso (FMF, CMD), discutida com e distribuída aos consensualistas 5 meses antes da reunião de consenso. Foi solicitado que se realizassem, na medida do possível, revisões sistemáticas e que as respostas fossem apresentadas para a votação com o grau de evidência e a força da recomendação. Nos 2 dias da reunião de consenso, as respostas foram apresentadas, debatidas e votadas. Quando, no mínimo, 70 por cento dos votantes concordaram com o texto da resposta, houve consenso. O relatório final foi submetido a apreciação e aprovado por todos os consensualistas. RESULTADOS: Setenta e nove questões foram debatidas na pré-reunião do consenso, resultando 85 questões que foram então distribuídas. Nos 2 dias da reunião do consenso, 22 participantes debateram e votaram as 85 respostas. O impacto causado pelo exame ecoendoscópico foi comprovado por evidências...

BACKGROUND: In the last 20 years, several papers have focused on demonstrating the impact of endoscopic ultrasonography findings on the management of different clinical scenarios in digestive disease. This fact is an indirect evidence of the difficulty of popularization of the method. On other hand, the limited availability of endoscopic ultrasonography in Brazil is a direct evidence of this limitation. This was the rationale for the organization of a consensus meeting on endoscopic ultrasonography. It was aimed to identify the best evidence that support the use of endoscopic ultrasonography in gastroenterology. METHODS: A panel of experts on endoscopic ultrasonography was selected based on the files of the Gastroenterology and Endoscopy Societies and on the registries of endoscope manufacturers. Two members of the meeting selected the relevant topics that were transformed into questions. The topics and the questions were debated among the experts five months before the consensus meeting. The experts were asked to perform systematic reviews in order to answer the questions so it could be possible to grade the answers based on the strength of the evidence. During the two days of the meeting the answers were presented, debated and voted. Consensus was reached when a minimum of 70 percent of the voters were in agreement. The final consensus report was submitted to the experts' evaluation and approval. RESULTS: Seventy nine questions were debated by the experts at the pre-Consensus meeting. As the result of this debate 85 questions came out and were assigned to the members of the panel. During the Consensus meeting 22 experts debated and voted 85 answers. Consensus was reached for several clinical scenarios for which the impact of endoscopic ultrasonography findings were supported by level 1 evidences: differential diagnosis of subepithelial lesions and thickening of gastric folds, staging and diagnosis of unresectable esophageal cancer...

[I Brazilian consensus of endoscopic ultrasonography]. / I Consenso Brasileiro de Ecoendoscopia.

BACKGROUND: In the last 20 years, several papers have focused on demonstrating the impact of endoscopic ultrasonography findings on the management of different clinical scenarios in digestive disease. This fact is an indirect evidence of the difficulty of popularization of the method. On other hand, the limited availability of endoscopic ultrasonography in Brazil is a direct evidence of this limitation. This was the rationale for the organization of a consensus meeting on endoscopic ultrasonography. It was aimed to identify the best evidence that support the use of endoscopic ultrasonography in gastroenterology. METHODS: A panel of experts on endoscopic ultrasonography was selected based on the files of the Gastroenterology and Endoscopy Societies and on the registries of endoscope manufacturers. Two members of the meeting selected the relevant topics that were transformed into questions. The topics and the questions were debated among the experts five months before the consensus meeting. The experts were asked to perform systematic reviews in order to answer the questions so it could be possible to grade the answers based on the strength of the evidence. During the two days of the meeting the answers were presented, debated and voted. Consensus was reached when a minimum of 70% of the voters were in agreement. The final consensus report was submitted to the experts' evaluation and approval. RESULTS: Seventy nine questions were debated by the experts at the pre-Consensus meeting. As the result of this debate 85 questions came out and were assigned to the members of the panel. During the Consensus meeting 22 experts debated and voted 85 answers. Consensus was reached for several clinical scenarios for which the impact of endoscopic ultrasonography findings were supported by level 1 evidences: differential diagnosis of subepithelial lesions and thickening of gastric folds, staging and diagnosis of unresectable esophageal cancer, indirect signs of peritoneal involvement of gastric cancer, MALT gastric lymphoma and rectal cancer staging, diagnosis of common bile duct and gallbladder stones, diagnosis of chronic pancreatitis and differential diagnosis of a solid mass in chronic pancreatitis, differential diagnosis of the pancreatic cyst, prediction of the results of the endoscopic treatment of esophageal varices and diagnosis and staging of non-small cell lung cancer. CONCLUSIONS: There are the highest levels of evidences that support the indication of endoscopic ultrasonography for several digestive diseases and even for non-small cell lung cancer.

Aplicaçäo do ultra-som endoscópico na avaliaçäo dos tumores vilosos do reto / The endoscopic ultrasound application at the avaliation of the rectal villous tumor

Um dos mais importantes e decisivos aspectos no tratamento dos tumores vilosos do reto (TVR) é a presença de adenocarcinoma invasivo, o quel necessita de uma abordagem mais agressiva. O ultra-som endoscópico (USE) permite um estadiamento local apropriado, diminuindo os índices de sub ou superestadiamento, evitando uma abordagem terapêutica inicial inadequada.Entre junho de 1997 a outubro de 2000, doze pacientes com diagnóstico de TVR foram submetidos ao USE, a fim de se estabelecer a profundidade de invasäo da lesäo na parede retal. Houve concordância diagnóstica em 11 de 12 casos: 10, onde o USE mostrou lesões restritas à mucosa e 1 com invasäo da gordura peri-retal. No caso discordante, com suspeita de invasäo da submucosa, houve um superestadiamento, quando na realidade o tumor se restringia à mucosa. Essa experiência inicial permite concluir que o USE tem grande sensibilidade e pode ser importante na definiçäo do estadiamento dos TVR