Endoscopic transmural resection as an alternative to colorectal surgery after high-risk (non-curative) endoscopic resection.

Endoscopic full-thickness resection (eFTR) is an emerging technique that enables effective and safe management of complex colorectal lesions. The full-thickness resection device (FTRD®, Ovesco, Germany) has primarily been used for non-exposed transmural resection of challenging subepithelial or epithelial lesions, where conventional methods may be limited. This technique represents an alternative to surgery in selected patients, and its applications are rapidly expanding. In recent years, eFTR has been described as an alternative to surgery for scars aiming to exclude residual tumors after non-curative endoscopic resection. We present a case of a 41-year-old woman with Lynch syndrome (dMLH1) with rectal adenocarcinoma at the age of 20 underwent anterior resection of the rectum and adjuvant chemoradiotherapy. At the age of 39, during endoscopic surveillance, she presented with a suspicious lesion (Paris 0-Is+IIa, NICE2, JNET2B) measuring 16mm in the hepatic angle, and underwent en bloc endoscopic mucosal resection (EMR). Histopathological analysis revealed a low-grade invasive adenocarcinoma with lymphoid stroma with deep invasion of the submucosa and resection margin involvement (vertical R1). After a multidisciplinary team discussion, complementary surgery was proposed but the patient refused, opting for close endoscopic and imaging surveillance. Two subsequent colonoscopies plus computed tomography (CT) scans showed no signs of macro or microscopic residual or recurrent tumor, even after extensive biopsies of the colonic scar. However, a CT scan 20months post-resection showed a de novo 2cm thickening of the parietal wall in the hepatic angle, consistent with the location of the previous endoscopic resection. Suspecting deep parietal tumor recurrence without superficial endoscopic findings, a transmural endoscopic resection using FTRD® of the EMR scar was performed, whose histology revealed no transparietal tumor recurrence.

Case of autoimmune haemolytic anaemia, possibly secondary to vedolizumab in ulcerative colitis, successfully treated with rituximab.

Autoimmune haemolytic anaemia (AIHA), autoimmune destruction of erythrocytes is most commonly secondary to immunomodulated conditions. The association between AIHA and inflammatory bowel disease (IBD) has been poorly investigated. We aim to report a case of AIHA in a patient with ulcerative colitis (UC) treated with vedolizumab.A case of a woman in her 30s with UC that after the initiation of vedolizumab developed severe anaemia. Due to the absence of visible blood losses and a positive Coombs direct test, the diagnosis of AIHA was established. The patient initially initiated prednisolone with no response. Rituximab had to be introduced. After a few days with this therapy, there was a clinical and analytical improvement.AIHA must be taken into account as a possible cause of anaemia in patients with IBD. The differential diagnosis between IBD or drug-related (namely vedolizumab) as the cause of the AIHA is complex and almost impossible to establish.

Protein-losing enteropathy: is it Crohn's disease?

Case of a 24-year-old woman presenting due to edema in lower extremities. The patient had had infectious mononucleosis three weeks prior and had medical history of suspicion of Crohn's disease (CD) (due to a non-specific ileocolitis in a colonoscopy/EnteroRM). No ongoing medication. Laboratory evaluation unveiled hypoproteinemia with severe hypoalbuminemia, no renal abnormalities. A PLE was assumed, with post-infectious or CD being the most likely culprits. Alternative causes were extensively excluded. A videocapsule revealed white-tipped or granular villi, some white nodular villi and diffuse edema of the mucosa, and multiple extensive erosions and superficial ulcers in the jejunum and proximal ileum, not suggestive of CD. A push enteroscopy revealed unspecific histopathology. After incomplete response to enteral nutrition, corticotherapy was initiated resulting in sustained improvement. A follow-up Ileocolonoscopy and double balloon enteroscopy revealed no abnormalities. Six months post-treatment, the patient remains asymptomatic, with unremarkable laboratory results and no need for medication.

Is hybrid therapy more efficient in the eradication of Helicobacter pylori infection? A systematic review and meta-analysis.

INTRODUCTION: Hybrid therapy (HT) is a non-bismuth quadruple therapy created to surpass Helicobacter pylori's (H. pylori) resistance rates to antibiotics. HT has excellent eradication rates, as well as a very good compliance and safety profile. We aim to compare HT with sequential therapy (ST) and concomitant therapy (CT) for the eradication of H. pylori. METHODS: This systematic review was conducted following the principles of the PRISMA guidelines. Literature was electronically searched on the CENTRAL library, PubMed, Embase, Scopus, LILACS, and ClinicalTrials.gov. Only randomized controlled trials were included. The primary outcome evaluated was eradication rate of H. pylori. The secondary outcomes evaluated were adverse events and compliance rates. Meta-analyses were performed with Cochrane Review Manager 5.4. The Mantel-Haenszel method was used to estimate the pooled relative risk and 95% confidence interval of the eradication rates between HT and other regimens, as well as the secondary outcomes. RESULTS: 10 studies were included, comprising 2993 patients. The mean eradication rates achieved by HT with intention-to-treat (ITT) and per-protocol (PP) analyses were, respectively, 86% (range: 79.2-90.8%) and 91.7% (range: 82.6-96.1%). No statistically significant difference was found in ITT eradication rate between HT and CT (relative risk: 1; 95% CI: 0.96- 1.03) and between HT and ST (relative risk: 1.02; 95% CI: 0.92-1.14). PP analysis revealed similar results. HT was associated with higher compliance rates than CT and slightly lower than ST. As far as adverse events are concerned, this meta-analysis demonstrated a higher occurrence of adverse events on the group of patients treated with CT when compared with HT. HT and ST showed similar results. CONCLUSION: HT has similar eradication, compliance and adverse event rates when compared to ST, but a better safety profile than the CT.

Transvenous Obliteration Procedure in the Management of Parastomal Variceal Bleeding: A Case Report.

Introduction: Parastomal variceal bleeding (PVB) is a recognized complication of ostomized patients in the presence of portal hypertension. However, since there are few reported cases, a therapeutic algorithm has not yet been established. Case Presentation: A 63-year-old man, who had undergone a definitive colostomy, recurrently presented to the emergency department hemorrhage of bright red blood from his colostomy bag, initially assumed to be caused by stoma trauma. Accordingly, temporary success on local approaches such as direct compression, silver nitrate application and suture ligation was achieved. However, bleeding recurred, requiring transfusion of red blood cell concentrate and hospitalization. The patient's evaluation showed chronic liver disease with massive collateral circulation, particularly at the colostomy site. After a PVB with associated hypovolemic shock, the patient was submitted to a balloon-occluded retrograde transvenous obliteration (BRTO) procedure which stopped the bleeding successfully. The patient was subsequently proposed for a transjugular intrahepatic portosystemic shunt (TIPS) conjugated with percutaneous transhepatic obliteration (PTO). After an initial refusal by the patient, a new episode of self-limited PVB resulted in execution of the procedure. Four months later, in a routine consultation, the patient presented with grade II hepatic encephalopathy, successfully treated with medical therapy. After a 9-month follow-up, he remained clinically well and without further episodes of PVB or other adverse effects. Discussion: This report highlights the importance of a high index of suspicion when dealing with significant stomal hemorrhage. Portal hypertension as an etiology of this entity may compel to a specific approach to prevent recurrence of bleeding, including conjugation of endovascular procedures. The authors pre-sent a case of PVB, initially submitted to a variety of treatment options including BRTO, which was successfully addressed with conjugated treatment of TIPS and PTO.

Introdução: A hemorragia de varizes periestomais é uma complicação conhecida de doentes ostomizados com hipertensão portal. Contudo, devido ao pequeno número de casos descritos, ainda não foi estabelecido um algoritmo terapêutico. Apresentação do caso: Homem, 63 anos, com antecedentes de colostomia definitiva, recorre ao Serviço de Urgência recorrentemente por sangue vivo no saco de colostomia. Inicialmente, presumindo-se trauma do estoma, foi submetido a tratamentos locais, como compressão, aplicação de nitrato de prata e sutura, com sucesso temporário. Contudo, houve recorrência da hemorragia, com necessidade de suporte transfusional e hospitalização. A avaliação do doente evidenciou doença hepática crónica com circulação colateral exuberante, predominantemente junto da colostomia. Devido a hemorragia com choque hipovolémico, foi submetido a obliteração transvenosa retrógrada ocluída por balão (BRTO). Posteriormente, foi proposto para shunt portossistémico transjugular intra-hepático (TIPS) conjugado com obliteração transhepática percutânea (PTO). Após recusa inicial do doente, ocorreu novo episódio de hemorragia autolimitado, tendo o doente concordado em realizar o procedimento. Quatro meses depois, em consulta, apresentava sinais de encefalopatia hepática grau II, tendo sido controlada eficazmente com tratamento médico. Após nove meses de seguimento, mantém-se sem novos episódios de hemorragia ou efeitos adversos dos procedimentos. Discussão: É necessário um alto índice de suspeição clínica ao abordar a hemorragia significativa do estoma. A hipertensão portal como etiologia exige uma abordagem específica para prevenir a recorrência da hemorragia, incluindo a conjugação de procedimentos endovasculares. Os autores apresentam o caso de um doente com hemorragia de varizes periestomais submetido inicialmente a vários tratamentos, incluindo BRTO e que foi tratado com sucesso com TIPS e PTO.

Prognostic Factors After Hepatectomy for Gastric Adenocarcinoma Liver Metastases: Desmoplastic Growth Pattern as the Key to Improved Overall Survival.

PURPOSE: Hepatectomy (Hp) is an alternative approach for the treatment of gastric carcinoma liver metastases (GCLM). However, prognostic factors that may assist patient selection are still controversial. Several pathologic features, such as the growth pattern (GP), associated with prognosis in colorectal cancer liver metastases, were never investigated in GCLM. Our principal aim was to assess if the GP has prognostic impact on GCLM. PATIENTS AND METHODS: Review of the clinical and pathological characteristics of 19 consecutive patients submitted to surgical resection of GCLM with curative intent at our department. Major potential prognostic factors considered were patients' gender, age, timing and extent of Hp, postoperative course, as well as histopathological characteristics of primary and secondary tumors. RESULTS: Major morbidity occurred in four patients, mortality in one. Median and 5-year overall survival were 17 months and 26.7%, respectively. Ten patients developed recurrent disease and two patients survived more than 10 years. Factors independently associated with overall survival were the absence of major morbidity, distal location of the primary tumor, and desmoplastic GP (p<0.05). CONCLUSION: The selection of patients is crucial for the improvement of survival rates of GCLM. Consequently, we demonstrate for the first time that the desmoplastic GP of GCLM is associated with improved outcomes, prompting further research on tumor-host interactions.