Resección transmural endoscópica de adenoma colónico residual con fibrosis / Endoscopic full-thickness resection of residual colonic adenoma with fibrosis

Resumen La resección transmural endoscópica es una técnica que permite la resección en bloque de lesiones colónicas en pacientes en los cuales han fracasado los métodos endoscópicos convencionales como la resección mucosa endoscópica o la disección submucosa endoscópica. Presentamos el caso de un hombre de 75 años con antecedentes de adenoma de colon con fibrosis debido a dos intentos previos fallidos de resección endoscópica en otra institución. Realizamos con éxito el procedimiento de resección transmural endoscópica evitando así una cirugía.

Abstract Endoscopic full-thickness resection is a technique that allows in block resection of colonic lesions in patients in whom conventional endoscopic methods such as endoscopic mucosal resection or endoscopic submucosal dissection have failed. We present a case of a 75-year-old man with history of a difficult-to-resect colon adenoma. He had undergone two previous failed attempts of endoscopic mucosal resection due to non-lifting sign in another center. We successfully performed an endoscopic full-thickness resection procedure, avoiding unnecessary surgery.

[Endoscopic full-thickness resection of residual colonic adenoma with fibrosis]. / Resección transmural endoscópica de adenoma colónico residual con fibrosis.

Endoscopic fullthickness resection is a technique that allows in block resection of colonic lesions in patients in whom conventional endoscopic methods such as endoscopic mucosal resection or endoscopic submucosal dissection have failed. We present a case of a 75-year-old man with history of a difficult-to-resect colon adenoma. He had undergone two previous failed attempts of endoscopic mucosal resection due to non-lifting sign in another center. We successfully performed an endoscopic full-thickness resection procedure, avoiding unnecessary surgery.

La resección transmural endoscópica es una técnica que permite la resección en bloque de lesiones colónicas en pacientes en los cuales han fracasado los métodos endoscópicos convencionales como la resección mucosa endoscópica o la disección submucosa endoscópica. Presentamos el caso de un hombre de 75 años con antecedentes de adenoma de colon con fibrosis debido a dos intentos previos fallidos de resección endoscópica en otra institución. Realizamos con éxito el procedimiento de resección transmural endoscópica evitando así una cirugía.

The role of endoscopic ultrasound guidance for biliary and pancreatic duct access and drainage to overcome the limitations of ERCP: a retrospective evaluation.

BACKGROUND: Endoscopic ultrasound (EUS)-guided ductal access and drainage (EUS-DAD) of biliary/pancreatic ducts after failed endoscopic retrograde cholangiopancreatography (ERCP) is less invasive than percutaneous transhepatic biliary drainage (PTBD). The actual need for EUS-DAD remains unknown. We aimed to determine how often EUS-DAD is needed to overcome ERCP failure. METHODS: Consecutive duct access procedures (n = 2205; 95 % biliary) performed between June 2013 and November 2015 at a tertiary-care center were reviewed. ERCP was used first line, EUS-DAD as salvage after ERCP, and PTBD when both had failed. Procedures were defined as "index" in patients without prior endoscopic duct access and "combined" when EUS-DAD followed successful ERCP. The main outcomes were the EUS-DAD and PTBD rates. RESULTS: EUS-DAD was performed in 7.7 % (170/2205) of overall procedures: 9.1 % (116/1274) index and 5.8 % (54/931) follow-up. Most index EUS-DADs were performed following (46 %) or anticipating (39 %) ERCP failure, whereas 15 % followed successful ERCP (combined procedures). Among index procedures, the EUS-DAD rate was higher in surgically altered anatomy (58.2 % [39 /67)] vs. 6.4 % [77/1207]); PTBD was required in 0.2 % (3/1274). Among follow-up procedures, ERCP represented 85.7 %, cholangiopancreatography through mature transmural fistulas 8.5 %, and EUS-DAD 5.8 %; no patient required PTBD. The secondary PTBD rate was 0.1 % (3/2205). Six primary PTBDs were performed (overall PTBD rate 0.4 % [9/2205]). CONCLUSIONS: EUS-DAD was required in 7.7 % of ERCPs for benign and malignant biliary/pancreatic duct indications. Salvage PTBD was required in 0.1 %. This high EUS-DAD rate reflects disease complexity, a wide definition of ERCP failure, and restrictive PTBD use, not poor ERCP skills. EUS-DAD effectively overcomes the limitations of ERCP eliminating the need for primary and salvage PTBD in most cases.

Undifferentiated carcinoma with osteoclast-like giant cells of the pancreas diagnosed by endoscopic ultrasound guided biopsy.

Undifferentiated pancreatic carcinoma with osteoclast-like giant cells is a rare tumour that has been published under a wide variety of names, including pleomorphic carcinoma, giant cell carcinoma, sarcomatoid carcinoma and carcinosarcoma, among others. For these reasons and its low frequency, the reports of these tumours are scarce and frequently lead to confusion with other entities which present with giant cells. We present the case of a patient with obstructive jaundice and a mixed cystic and solid pancreatic mass, accompanied by multiple hepatic lesions. The histological study of the material obtained by endoscopic ultrasound guided biopsy demonstrated a proliferation of atypical epithelioid cells, accompanied by a spindle cell component with marked pleomorphism and numerous osteoclast-like giant cells. The epithelioid component showed positive immunostaining with cytokeratin cocktail and cytokeratin 7. The spindle cell component showed coexpression of cytokeratins and vimentin. The osteoclast-like giant cells were positive for CD68. Protein p53 was overexpressed in both epithelial and spindle cell neoplastic components, and was negative in the giant cells. These findings permitted the diagnosis of undifferentiated carcinoma of the pancreas with osteoclast-like giant cells. This case outlines the effectiveness of endoscopic ultrasound-guided biopsy and the importance of morphological and immunohistochemical examination in the diagnosis of different types of pancreatic tumours, especially when they are in advanced stages and are not suitable for surgical treatment.

[Endoscopic ultrasound-guided hepaticogastrostomy for treatment of malignant biliary obstruction in patient with Roux-en-Y gastrectomy]. / Hepático-gastrostomía guiada por eco endoscopia en obstrucción biliar maligna y gastrectomía subtotal con reconstrucción en Y de Roux.

Endoscopic retrograde cholangiography with biliary stenting is the generally recognized optimal treatment of malignant biliary obstruction. This procedure, though, is challenging in patients with surgically altered anatomy. Endoscopic ultrasound (EUS) enables tissue sampling by means of fine-needle aspiration and also represents an alternative recourse for biliary drainage in preference to a percutaneous approach. We aimed to report a case in which EUS enabled a definitive diagnosis of the recurrence of oncologic disease and the relief of biliary obstruction in a patient with a surgically altered anatomy.

Hepático-gastrostomía guiada por eco endoscopia en obstrucción biliar maligna y gastrectomía subtotal con reconstrucción en Y de Roux / Endoscopic ultrasound-guided hepaticogastrostomy for treatment of malignant biliary obstruction in patient with Roux-en-Y gastrectomy

RESUMEN La colangiopancreatografía retrógrada endoscópica (CPRE) representa el tratamiento de primera línea para el drenaje biliar en pacientes con obstrucción biliar maligna avanzada. Sin embargo, este procedimiento representa un desafío en pacientes con anatomía alterada quirúrgicamente. El ultrasonido endoscópico (USE) permite la toma de muestras de tejido mediante punción aspiración con aguja fina y también representa una alternativa de drenaje biliar al abordaje percutáneo o quirúrgico. Nuestro objetivo es comunicar un caso en el que la ecoendoscopia permitió el diagnóstico definitivo de la recurrencia de la enfermedad oncológica de base y el alivio de la obstrucción biliar en un paciente con anatomía alterada quirúrgicamente.

ABSTRACT Endoscopic retrograde cholangiography with biliary stenting is the generally recognized optimal treatment of malignant biliary obstruction. This procedure, though, is challenging in patients with surgically altered anatomy. Endoscopic ultrasound (EUS) enables tissue sampling by means of fine-needle aspiration and also represents an alternative recourse for biliary drainage in preference to a percutaneous approach. We aimed to report a case in which EUS enabled a definitive diagnosis of the recurrence of oncologic disease and the relief of biliary obstruction in a patient with a surgically altered anatomy.

INCREASED RISK OF SYNCHRONOUS COLORECTAL LESIONS IN PATIENTS REFERRED FOR ENDOSCOPIC MUCOSAL RESECTION OF LATERAL SPREADING TUMORS.

BACKGROUND: Endoscopic mucosal resection is one of the most frequent therapeutic alternatives for large colorectal lateral spreading tumors. There are few data on the prevalence of synchronous lesions on these patients. OBJECTIVE: To describe the prevalence of synchronous colorectal lesions in patients referred for endoscopic mucosal resection of lateral spreading tumors >20 mm. METHODS: We reviewed the endoscopic database of our Department and identified adult patients who were referred for the resection of a colorectal lateral spreading tumor >20 mm and had a diagnostic colonoscopy performed up to six months before. The proportion of patients with at least one synchronous lesion was estimated. The following features were compared between patients with and without synchronous lesions: age, gender, bowel preparation quality and cecal intubation on index colonoscopy and therapeutic colonoscopy, serrated adenoma as index lesion. RESULTS: From December 2016 to November 2017, we identified 70 patients who fulfilled inclusion criteria. Median size of lesions was 25 mm (20-45). Eighty percent were located in the right colon and 35.71% were serrated adenomas. Synchronous lesion rate was 38.57%. Bowel preparation quality was similar in both groups when comparing both index and therapeutic colonoscopies. Patients with synchronous lesions had a higher proportion of serrated adenoma as index lesion than patients without synchronous lesions [51.85% vs 25.58%, OR 3.13 (1.13-8.68), P=0.03]. CONCLUSION: We found a high prevalence of synchronous lesions among patients with a large colorectal lateral spreading tumor. This risk seems to be increased if index lesions are serrated adenomas.

Aumento do risco de lesões colorretais síncronas em pacientes encaminhados para ressecção endoscópica da mucosa de tumores de propagação lateral / Increased risk of synchronous colorectal lesions in patients referred for endoscopic mucosal resection of lateral spreading tumors

ABSTRACT BACKGROUND: Endoscopic mucosal resection is one of the most frequent therapeutic alternatives for large colorectal lateral spreading tumors. There are few data on the prevalence of synchronous lesions on these patients. OBJECTIVE: To describe the prevalence of synchronous colorectal lesions in patients referred for endoscopic mucosal resection of lateral spreading tumors >20 mm. METHODS: We reviewed the endoscopic database of our Department and identified adult patients who were referred for the resection of a colorectal lateral spreading tumor >20 mm and had a diagnostic colonoscopy performed up to six months before. The proportion of patients with at least one synchronous lesion was estimated. The following features were compared between patients with and without synchronous lesions: age, gender, bowel preparation quality and cecal intubation on index colonoscopy and therapeutic colonoscopy, serrated adenoma as index lesion. RESULTS: From December 2016 to November 2017, we identified 70 patients who fulfilled inclusion criteria. Median size of lesions was 25 mm (20-45). Eighty percent were located in the right colon and 35.71% were serrated adenomas. Synchronous lesion rate was 38.57%. Bowel preparation quality was similar in both groups when comparing both index and therapeutic colonoscopies. Patients with synchronous lesions had a higher proportion of serrated adenoma as index lesion than patients without synchronous lesions [51.85% vs 25.58%, OR 3.13 (1.13-8.68), P=0.03]. CONCLUSION: We found a high prevalence of synchronous lesions among patients with a large colorectal lateral spreading tumor. This risk seems to be increased if index lesions are serrated adenomas.

DESCRITORES CONTEXTO: A ressecção endoscópica de mucosa é uma das alternativas terapêuticas frequentes para grandes tumores colorretais de propagação lateral. Há poucos dados sobre a prevalência de lesões síncronas nesses pacientes. OBJETIVO: Descrever a prevalência de lesões colorretais síncronas em pacientes encaminhados para ressecção endoscópica da mucosa de tumores de disseminação lateral >20 mm. MÉTODOS: Realizou-se a revisão de banco de dados endoscópicos de nosso departamento e foram identificados pacientes adultos encaminhados para a ressecção de um tumor colorretal com propagação lateral >20 mm e que tiveram colonoscopia diagnóstica realizada até seis meses antes. Estimou-se a proporção de pacientes com pelo menos uma lesão síncrona. As seguintes características foram comparadas entre pacientes com e sem lesões síncronas: idade, sexo, qualidade da preparação intestinal e intubação cecal pelo índice de colonoscopia e adenoma serrilhado como lesão índice. RESULTADOS: De dezembro de 2016 a novembro de 2017, identificamos 70 pacientes que preencheram os critérios de inclusão. O tamanho mediano das lesões foi de 25 mm (20-45). Foram 80% situados no cólon direito e 35,71% eram adenomas serrilhados. A taxa de lesão síncrona foi de 38,57%. A qualidade da preparação intestinal foi semelhante em ambos os grupos comparando-se os índices e colonoscopia terapêutica. Pacientes com lesões síncronas apresentaram maior proporção de adenoma serrilhado como lesão índice do que pacientes sem lesões síncronas [51,85% vs 25,58%, or 3,13 (1,13-8,68), P=0,03]. CONCLUSÃO: Encontramos alta prevalência de lesões síncronas entre pacientes com grande tumor de propagação lateral colorretal. Este risco parece ser aumentado se as lesões índice forem adenomas serrilhados.

Los adenomas metacrónicos de colon presentan un patrón de desarrollo diferente en pacientes obesos.

INTRODUCTION: XSome authors have assessed the link between obesity and colon adenoma risk. Moreover, it has been reported that obesity could increase the risk of proximal adenoma development. Accordingly, obese patients may have a distinctive pattern of adenoma recurrence. AIM: To determine whether metachronous adenoma features differ between obese and non-obese subjects submitted to colonoscopy surveillance. MATERIALS AND METHODS: We prospectively evaluated all patients over 18 years old that underwent surveillance colonoscopy at our institution between June 2013 and June 2014. Date of prior colonoscopy was registered. A body mass index ≥ 30 was used to define obesity. Analysis looking for variables significantly associated with metachronous adenoma was performed. Metachronous adenoma rate was compared between obese and non-obese subjects, as well as size, location, morphological and histopathological characteristics. RESULTS: Overall, 825 subjects were enrolled. Median time of surveillance colonoscopy was 38.9 months. Obesity was statistically more frequent in those subjects with metachronous adenomas (40% vs 25.71%, p < 0.001). On multivariate analysis, obesity [OR 1.7 (1.01-2.9)] and age [OR 1.02 (1-1.05)] were independently associated with metachronous adenoma presence. Obesity was also significantly associated with a higher risk of right colon adenomas [OR 2.4 (1.76-3.26)] and advanced adenoma [OR 1.99 (1.29-3.06)]. The risk is significantly higher in men and in those with a family history of colorectal cancer/adenoma. CONCLUSION: Obesity was associated with a higher risk of metachronous adenomas on surveillance colonoscopy. A higher risk of right-sided lesions and advanced adenomas was also found in this population.