Impact of radiotherapy on adverse events of self-expanding metallic stents in patients with esophageal cancer.

Self-expanding metallic stents (SEMS) are considered the treatment of choice for the palliation of dysphagia and fistulas in inoperable esophageal neoplasms. However, the safety of SEMSs in patients who received or who will be submitted to radiotherapy (RT) is uncertain. The study aimed to evaluate the impact of RT on adverse events (AEs) in patients with esophageal cancer with SEMSs. This is a retrospective study conducted at a tertiary cancer hospital from 2009 to 2018. We collected information regarding RT, the histological type of the tumor, the model of SEMSs and AEs after stent placement. Three hundred twenty-three patients with malignant stenosis or fistula were treated with SEMSs. The predominant histological type was squamous cell carcinoma (79.6%). A total of 282 partially covered and 41 fully covered SEMSs were inserted. Of the 323 patients, 182 did not received RT, 118 received RT before SEMS placement and 23 after. Comparing the group that received RT before stent insertion with the group that did not, the first one presented a higher frequency of severe pain (9/118 7.6% vs. 3/182 1.6%; P = 0.02). The group treated with RT after stent placement had a higher risk of global AEs (13/23 56.5% vs. 63/182 34.6%; P = 0.019), ingrowth/overgrowth (6/23 26.1% vs. 21/182 11.5%; P = 0.045) and gastroesophageal reflux (2/23 8.7% vs. 2/182 1.1%; P = 0.034). Treatment with RT before stent placement in patients with inoperable esophageal neoplasm prolongs survival and is associated with an increased risk of severe chest pain. Treatment with RT of patients with an esophageal stent increases the frequency of minor, not life-threatening AEs.

Results of endoscopic biliary drainage in patients with malignant hilar stricture.

In Malignant Hilar Biliary Stricture (MHBS) palliative biliary drainage is a frequent strategy, improving the quality of life, reducing pruritus, loss of appetite and relieving cholangitis. The endoscopic approach is an effective, although challenging procedure. This study aimed to evaluate technical and clinical success rates of biliary drainage by ERCP. This is a retrospective study including all patients with MHBS referred to Instituto do Cancer do Hospital de São Paulo (ICESP) submitted to biliary drainage by ERCP, between January 2010 and December 2017. Multivariable logistic regression was performed to evaluate predictors of clinical failure, as total bilirubin levels, Bismuth classification, number of hepatic sectors drained and presence of cholangitis. In total, 82 patients presenting unresectable MHBS were included in this study. 58.5% female and 41.5% male, with a mean age of 60±13 years. Bismuth classification grades II, IIIA, IIIB and IV were noted in 23.2%, 15.9%, 14.6% and 46.3%, respectively. Technical and clinical success was achieved in 92.7% and 53.7% respectively. At multivariable logistic-regression analyses, Bismuth IV strictures were related to higher clinical failure rates when compared to other strictures levels, with an Odds Ratio of 5.8 (95% CI 1.28‒20.88). In conclusion, endoscopic biliary drainage for malignant hilar biliary stricture had a high technical success but suboptimal clinical success rate. Proximal strictures (Bismuth IV) were associated with poor drainage outcomes.

Results of endoscopic biliary drainage in patients with malignant hilar stricture

Abstract In Malignant Hilar Biliary Stricture (MHBS) palliative biliary drainage is a frequent strategy, improving the quality of life, reducing pruritus, loss of appetite and relieving cholangitis. The endoscopic approach is an effective, although challenging procedure. This study aimed to evaluate technical and clinical success rates of biliary drainage by ERCP. This is a retrospective study including all patients with MHBS referred to Instituto do Cancer do Hospital de São Paulo (ICESP) submitted to biliary drainage by ERCP, between January 2010 and December 2017. Multivariable logistic regression was performed to evaluate predictors of clinical failure, as total bilirubin levels, Bismuth classification, number of hepatic sectors drained and presence of cholangitis. In total, 82 patients presenting unresectable MHBS were included in this study. 58.5% female and 41.5% male, with a mean age of 60±13 years. Bismuth classification grades II, IIIA, IIIB and IV were noted in 23.2%, 15.9%, 14.6% and 46.3%, respectively. Technical and clinical success was achieved in 92.7% and 53.7% respectively. At multivariable logistic-regression analyses, Bismuth IV strictures were related to higher clinical failure rates when compared to other strictures levels, with an Odds Ratio of 5.8 (95% CI 1.28‒20.88). In conclusion, endoscopic biliary drainage for malignant hilar biliary stricture had a high technical success but suboptimal clinical success rate. Proximal strictures (Bismuth IV) were associated with poor drainage outcomes.

Endoscopy infection control strategy during the COVID-19 pandemic: experience from a tertiary cancer center in Brazil.

OBJECTIVES: Strategic planning for coronavirus disease (COVID-19) care has dominated the agenda of medical services, which have been further restricted by the need for minimizing viral transmission. Risk is particularly relevant in relation to endoscopy procedures. This study aimed to describe a contingency plan for a tertiary academic cancer center, define a strategy to prioritize and postpone examinations, and evaluate the infection rate among healthcare workers (HCWs) in the endoscopy unit of the Cancer Institute of the State of São Paulo (ICESP). METHODS: We created a strategy to balance the risk of acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection and to mitigate the effects of postponing endoscopic procedures in oncological patients. A retrospective analysis of prospectively collected data on all endoscopies between March and June 2020 compared with those during the same period in 2019 was carried out. All HCWs were interviewed to obtain clinical data and SARS-CoV-2 test results. RESULTS: During the COVID-19 outbreak, there was a reduction of 55% in endoscopy cases in total. Colonoscopy was the most affected modality. The total infection rate among all HCWs was 38%. None of the senior digestive endoscopists had COVID-19. However, all bronchoscopists had been infected. One of three fellows had a serological diagnosis of COVID-19. Two-thirds of all nurses were infected, whereas half of all technicians were infected. CONCLUSIONS: In this pandemic scenario, all endoscopy services must prioritize the procedures that will be performed. It was possible to maintain some endoscopic procedures, including those meant to provide nutritional access, tissue diagnosis, and endoscopic resection. Personal protective equipment (PPE) seems effective in preventing transmission of COVID-19 from patients to digestive endoscopists. These measures can be useful in planning, even for pandemics in the future.

Endoscopy infection control strategy during the COVID-19 pandemic: experience from a tertiary cancer center in Brazil

OBJECTIVES: Strategic planning for coronavirus disease (COVID-19) care has dominated the agenda of medical services, which have been further restricted by the need for minimizing viral transmission. Risk is particularly relevant in relation to endoscopy procedures. This study aimed to describe a contingency plan for a tertiary academic cancer center, define a strategy to prioritize and postpone examinations, and evaluate the infection rate among healthcare workers (HCWs) in the endoscopy unit of the Cancer Institute of the State of São Paulo (ICESP). METHODS: We created a strategy to balance the risk of acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection and to mitigate the effects of postponing endoscopic procedures in oncological patients. A retrospective analysis of prospectively collected data on all endoscopies between March and June 2020 compared with those during the same period in 2019 was carried out. All HCWs were interviewed to obtain clinical data and SARS-CoV-2 test results. RESULTS: During the COVID-19 outbreak, there was a reduction of 55% in endoscopy cases in total. Colonoscopy was the most affected modality. The total infection rate among all HCWs was 38%. None of the senior digestive endoscopists had COVID-19. However, all bronchoscopists had been infected. One of three fellows had a serological diagnosis of COVID-19. Two-thirds of all nurses were infected, whereas half of all technicians were infected. CONCLUSIONS: In this pandemic scenario, all endoscopy services must prioritize the procedures that will be performed. It was possible to maintain some endoscopic procedures, including those meant to provide nutritional access, tissue diagnosis, and endoscopic resection. Personal protective equipment (PPE) seems effective in preventing transmission of COVID-19 from patients to digestive endoscopists. These measures can be useful in planning, even for pandemics in the future.

EUS-guided Choledochoduodenostomy Versus Hepaticogastrostomy: A Systematic Review and Meta-analysis.

BACKGROUND AND AIMS: Endoscopic ultrasound-guided biliary drainage (EUS-BD) has emerged as an alternative in cases of endoscopic retrograde cholangiopancreatography (ERCP) failure. Two types of EUS-BD methods for achieving biliary drainage when ERCP fails are choledochoduodenostomy (CDS) or hepaticogastrostomy (HGS). However, there is no consensus if one approach is better than the other. Therefore, we conducted a systematic review and meta-analysis to evaluate these 2 main EUS-BD methods. METHODS: We searched MEDLINE, Embase, Scopus, Cochrane database, LILACS from inception through April 8, 2017, using the following search terms in various combinations: biliary drainage, biliary stent, transluminal biliary drainage, choledochoduodenostomy, hepaticogastrostomy, endoscopic ultrasound-guided biliary drainage. We selected studies comparing CDS and HGS in patients with malignant biliary obstruction with ERCP failure. Pooled odds ratio (OR) were calculated for technical success, clinical success, and adverse events and difference of means calculated for duration of procedure and survival after procedure. RESULTS: A total of 10 studies with 434 patients were included in the meta-analysis: 208 underwent biliary drainage via HGS and the remaining 226 via CDS. The technical success for CDS and HGS was 94.1% and 93.7%, respectively, pooled OR=0.96 [95% confidence interval (CI)=0.39-2.33, I=0%]. Clinical success was 88.5% in CDS and 84.5% in HGS, pooled OR=0.76 (95% CI=0.42-1.35, I=17%). There was no difference for adverse events OR=0.97 (95% CI=0.60-1.56), I=37%. CDS was about 2 minutes faster with a pooled difference in means of was -2.69 (95% CI=-4.44 to -0.95). CONCLUSION: EUS-CDS and EUS-HGS have equal efficacy and safety, and are both associated with a very high technical and clinical success. The choice of approach may be selected based on patient anatomy.

Comparison of the pull and introducer percutaneous endoscopic gastrostomy techniques in patients with head and neck cancer.

BACKGROUND AND STUDY AIMS: Percutaneous endoscopic gastrostomy (PEG) in head and neck cancer (HNC) patients is associated with higher complication and mortality rates when compared to a general patient population. The pull technique is still the preferred technique worldwide but it has some limitations. The aim of this study is to compare the pull and introducer PEG techniques in patients with HNC. PATIENTS AND METHODS: This study is based on a retrospective analysis of a prospectively collected database of 309 patients with HNC who underwent PEG in the Cancer Institute of São Paulo. RESULTS: The procedure was performed with the standard endoscope in 205 patients and the introducer technique was used in 137 patients. There was one procedure-related mortality. Age, sex and albumin level were similar in both groups. However in the introducer technique group, patients had a higher tumor stage, a lower Karnofsky status, and presented more frequently with tracheostomy and trismus. Overall, major, minor, immediate and late complications and 30-day mortality rates were similar but the introducer technique group presented more minor bleeding and tube dysfunctions. CONCLUSION: The push and introducer PEG techniques seem to be both safe and effective but present different complication profiles. The choice of PEG technique in patients with HNC should be made individually.

Biliary transpapillary endoscopic balloon dilation for treating choledocholithiasis.

OBJECTIVE: To evaluate the efficacy and safety of transpapillary papilloplasty in patients with choledocholithiasis. MATERIALS AND METHODS: All endoscopic retrograde cholangiopancreatography (ERCP) procedures performed at Hospital Ana Costa, in the city of Santos, Brazil, over the last five years were retrospectively evaluated using the hospital's information database. The success of the procedure and complications due to residual calculi, pancreatitis, bleeding and perforation were evaluated. RESULTS: From January 2010 to May 2014, 1860 ERCP procedures were performed. Fifty-five patients were evaluated here. Their ages ranged from 12 to 98 years (mean, 66.3; standard deviation, 19.34; median, 71). Thirty-two patients (58.2%) were women. Sixteen (29.1%) presented giant choledocholithiasis, with calculi larger than 12 mm. Twenty-seven (49.1%) had mul-tiple choledocholithiasis. CONCLUSION: In view of the therapeutic efficacy and low complication rate among our patients, we can conclude that endoscopic papilloplasty is a safe and effective method for endoscopic treatment of choledocolithiasis in selected cases.

Dilatación endoscópica biliar transpapilar con balón para el tratamiento de la colédoco litiasis / Biliary transpapillary endoscopic balloon dilation for treating choledocholithiasis

To evaluate the efficacy and safety of transpapillary papilloplasty in patients with choledocholithiasis. Materials and methods: All endoscopic retrograde cholangiopancreatography (ERCP) procedures performed at Hospital Ana Costa, in the city of Santos, Brazil, over the last five years were retrospectively evaluated using the hospitalÆs information database. The success of the procedure and complications due to residual calculi, pancreatitis, bleeding and perforation were evaluated. Results: From January 2010 to May 2014, 1860 ERCP procedures were performed. Fifty-five patients were evaluated here. Their ages ranged from 12 to 98 years (mean, 66.3; standard deviation, 19.34; median, 71). Thirty-two patients (58.2%) were women. Sixteen (29.1%) presented giant choledocholithiasis, with calculi larger than 12 mm. Twenty-seven (49.1%) had multiple choledocholithiasis. Conclusion: In view of the therapeutic efficacy and low complication rate among our patients, we can conclude that endoscopic papilloplasty is a safe and effective method for endoscopic treatment of choledocolithiasis in selected cases...

Evaluar la eficacia y seguridad de la papiloplastía trnaspapilar en la colédoco litiasis. Material y métodos: Todas las colangoipancreatografías retrogradas endoscópicas (CPRE) realizadas en el Hospital Ana Costa en la ciudad de Santos Brasil, en los últimos cinco años fueron evaluadas retrospectivamente usando la base de datos del hospital. El éxito y las complicaciones del procedimiento debido a cálculos residuales, pancreatitis, sangrados y perforación fueron estudiados. Resultados: De enero del 2010 a mayo del 2014, se realizaron 1860 CPREs. Se estudiaron 55 pacientes, cuyas edades fluctuaron entre 12 a 98 años con una media de 66,3 y desviación estándar de 19,34. Treinta dos pacientes fueron mujeres (58,2%). 16 (29,1%) tuvieron litiasis coledociana gigante con cálculos mayores de 12 mm y veintisiete (49,1%) tuvieron litiasis múltiple. Conclusión: En vista de la eficacia y la poca frecuencia de complicaciones entre nuestros pacientes podemos concluir que la papilotomía endoscópica es un método seguro y efectivo para el tratamiento de la coledocolitiasis en casos seleccionados...

Linfoma primário de cólon / Prymary limphoma of large bowell

O linfoma colorretal primário é uma doença rara (0,2 a 0,6% de todas as neoplasias colônicas), apresentando pior prognóstico quando comparado com o linfoma gástrico primário ou com o adenocarcinoma do cólon. É uma doença com sintomatologia inespecífica, o que dificulta o diagnóstico precoce. A importância deste caso é mostrar as variadas formas de apresentação macroscópica do linfoma de células do manto (MCL), uma variante do linfoma não-Hodgkin de células B, de ocorrência rara no cólon.