RESUMO RACIONAL: Os tumores irressecáveis da cabeça do pâncreas desenvolvem icterícia por obstrução e colestase durante o acompanhamento. A colestase está associada a complicações e as opções de tratamento são colocação de prótese endoscópica (PE) e a cirurgia biliodigestiva (CB). OBJETIVOS: O objetivo do presente estudo é comparar a segurança e eficácia da cirurgia biliodigestiva (CB) com a prótese endoscópica (PE) para colestase em câncer de pâncreas avançado. MÉTODOS: Este é um estudo coorte retrospectivo de pacientes com colestase e câncer de pâncreas irressecável ou metastático, tratados com CB ou PE. Os resultados de curto e longo prazo foram avaliados. Consideramos a necessidade de readmissão hospitalar por complicações biliares falha no tratamento. RESULTADOS: Foram incluídos 93 pacientes (CB=43; PE=50). A CB foi associada a maior demanda por cuidados intensivos pós-operatórios (37 vs. 10%; p=0,002, p<0.05), maior tempo de permanência na UTI (1,44±2,47 vs. 0,66±2,24 dias; p=0,004, p<0.05) e maior tempo de internação hospitalar (7,95±2,99 vs. 4,29±5,5 dias. A CB apresentou maior risco de complicações relacionadas ao procedimento (23 vs. 8%; p=0,049, p<0.05). Não houve diferença na sobrevida global entre CB e PE (p=0,089). A PE foi independentemente associada a um maior risco de falha do tratamento do que a CCB na análise multivariada (HR=3,97; p=0,009). CONCLUSÕES: A CB está associada a uma eficácia mais prolongada do que a PE no tratamento da colestase no câncer pancreático avançado. Entretanto, a CB está associada a internações prolongadas em UTI e hospitalares e maior demanda por cuidados intensivos. RACIONAL acompanhamento (PE CB. . OBJETIVOS (CB avançado MÉTODOS metastático avaliados RESULTADOS 9 CB=43 CB43 43 (CB=43 PE=50. PE50 PE=50 50 PE=50) pósoperatórios pós operatórios 37 (3 vs 10% 10 p0002 p 0 002 p=0,002 p<0.05, p005 p<0.05 , 05 1,44±2,47 144247 1 44 2 47 (1,44±2,4 066224 66 24 0,66±2,2 dias p0004 004 p=0,004 7,95±2,99 795299 7 95 99 (7,95±2,9 42955 4 29 5 4,29±5, 23 (2 8% 8 p0049 049 p=0,049 p<0.05. p=0,089. p0089 p=0,089 089 (p=0,089) HR=3,97 HR397 HR 3 97 (HR=3,97 p=0,009. p0009 p=0,009 009 p=0,009) CONCLUSÕES Entretanto CB=4 CB4 (CB=4 PE5 PE=5 ( p000 00 p=0,00 p00 p<0.0 1,44±2,4 14424 (1,44±2, 06622 6 0,66±2, 7,95±2,9 79529 (7,95±2, 4295 4,29±5 p004 04 p=0,04 p008 p=0,08 08 (p=0,089 HR=3,9 HR39 (HR=3,9 CB= (CB= PE= p=0,0 p0 p<0. 1,44±2, 1442 (1,44±2 0662 0,66±2 7,95±2, 7952 (7,95±2 429 4,29± (p=0,08 HR=3, HR3 (HR=3, p=0, p<0 1,44±2 144 (1,44± 066 0,66± 7,95±2 795 (7,95± 42 4,29 (p=0,0 HR=3 (HR=3 p=0 p< 1,44± 14 (1,44 06 0,66 7,95± 79 (7,95 4,2 (p=0, HR= (HR= p= 1,44 (1,4 0,6 7,95 (7,9 4, (p=0 (HR 1,4 (1, 0, 7,9 (7, (p= 1, (1 7, (7 (p

ABSTRACT BACKGROUND: The unresectable pancreatic head tumors develop obstructive jaundice and cholestasis during follow-up. Cholestasis is associated with complications and treatment options are endoscopic stenting (ES) and biliary bypass surgery (BBS). AIMS: The aim of the current study was to compare the safety and efficacy of biliary bypass surgery (BBS) and endoscopic stenting (ES) for cholestasis in advanced pancreas cancer. METHODS: This is a retrospective cohort of patients with cholestasis and unresectable or metastatic pancreas cancer, treated with BBS or ES. Short and long-term outcomes were evaluated. We considered the need for hospital readmission due to biliary complications as treatment failure. RESULTS: A total of 93 patients (BBS=43; ES=50) were included in the study. BBS was associated with a higher demand for postoperative intensive care (37 vs.10%; p=0.002, p<0.050), longer intensive care unit stay (1.44 standard deviation±2.47 vs. 0.66±2.24 days; p=0.004, p<0.050), and longer length of hospital stay (7.95±2.99 vs. 4.29±5.50 days; p<0.001, p<0.050). BBS had a higher risk for procedure-related complications (23 vs. 8%; p=0.049, p<0.050). There was no difference in overall survival between BBS and ES (p=0.089, p>0.050). ES was independently associated with a higher risk for treatment failure than BBS on multivariate analysis (hazard ratio 3.97; p=0.009, p<0.050). CONCLUSIONS: BBS is associated with longer efficacy than ES for treating cholestasis in advanced pancreatic cancer. However, the BBS is associated with prolonged intensive care unit and hospital stays and higher demand for intensive care. BACKGROUND followup. followup follow up. up follow-up (ES BBS. . AIMS (BBS cancer METHODS longterm long term evaluated RESULTS 9 BBS=43 BBS43 43 (BBS=43 ES=50 ES50 50 37 (3 vs.10% vs10 vs 10 p0002 p 0 002 p=0.002 p<0.050, p0050 p<0.050 , 050 p<0.050) 1.44 144 1 44 (1.4 deviation247 deviation 2 47 deviation±2.4 066224 66 24 0.66±2.2 days p0004 004 p=0.004 7.95±2.99 795299 7 95 99 (7.95±2.9 429550 4 29 5 4.29±5.5 p0001 001 p<0.001 p<0.050. procedurerelated procedure related 23 (2 8% 8 p0049 049 p=0.049 p=0.089, p0089 089 (p=0.089 p>0.050. p>0.050 p>0.050) hazard 3.97 397 3 97 p0009 009 p=0.009 CONCLUSIONS However BBS=4 BBS4 (BBS=4 ES=5 ES5 ( vs.10 vs1 p000 00 p=0.00 p005 p<0.05 05 1.4 14 (1. deviation24 deviation±2. 06622 6 0.66±2. 7.95±2.9 79529 (7.95±2. 42955 4.29±5. p<0.00 p004 04 p=0.04 p=0.089 p008 08 (p=0.08 p>0.05 3.9 39 BBS= (BBS= ES= vs.1 p00 p=0.0 p<0.0 1. (1 deviation2 deviation±2 0662 0.66±2 7.95±2. 7952 (7.95±2 4295 4.29±5 p=0.08 (p=0.0 p>0.0 3. p0 p=0. p<0. deviation± 066 0.66± 7.95±2 795 (7.95± 429 4.29± (p=0. p>0. p=0 p<0 06 0.66 7.95± 79 (7.95 42 4.29 (p=0 p>0 p= p< 0.6 7.95 (7.9 4.2 (p= p> 0. 7.9 (7. 4. (p 7. (7

RESUMO Contexto: Nas últimas décadas, a ecoendoscopia evoluiu de uma ferramenta diagnóstica para uma plataforma para diversas intervenções terapêuticas. Vários avanços tecnológicos surgiram desde o último Consenso Brasileiro, demandando uma revisão e atualização das recomendações baseadas nas melhores evidências científicas. Métodos: Um grupo de 32 ecoendoscopistas renomados selecionou oito tópicos relevantes para serem discutidos a fim de gerar questões clínicas. Em seguida, foi realizada uma revisão da literatura para responder a essas perguntas com base nas evidências mais atualizadas. Resultados: Trinta e três tópicos foram formulados e votados pelos especialistas para alcançar um consenso. O Sistema de Oxford foi utilizado para classificar o nível de evidência. Conclusão: Há evidências moderadas para sustentar que a forma da agulha, calibre ou técnica de aspiração não influenciam no rendimento da amostragem tecidual guiada por ultrassom endoscópico (USE) de lesões sólidas pancreáticas. Há evidências moderadas para sustentar o uso da biópsia transcutânea guiada por USE da parede cística para diferenciar entre neoplasias císticas mucinosas e não mucinosas. Existem poucas evidências para apoiar o tratamento guiado por USE de varizes gástricas. Há um alto nível de evidência para sustentar que a drenagem biliar guiada por USE e a CPRE apresentam resultados semelhantes em pacientes com obstrução biliar maligna distal. Há um alto nível de evidência para o uso da USE no diagnóstico de cistos pancreáticos neoplásicos e na detecção de necrose antes de indicar a drenagem. Há evidências moderadas para sustentar a preferência pela gastroenterostomia guiada por USE em relação ao stent duodenal para obstrução maligna da saída gástrica em pacientes com expectativa de vida superior a 2 meses. Há um alto nível de evidência para sustentar o uso da ablação por radiofrequência no tratamento de ambos os tipos, funcionantes e não funcionantes, de tumores neuroendócrinos. Contexto décadas terapêuticas Brasileiro científicas Métodos 3 clínicas seguida atualizadas Resultados consenso Conclusão agulha (USE pancreáticas gástricas distal meses tipos neuroendócrinos

ABSTRACT Background: In the past decades, endoscopic ultrasound has developed from a diagnostic tool to a platform for many therapeutic interventions. Various technological advancements have emerged since the last Brazilian Consensus, demanding a review and update of the recommendations based on the best scientific evidence. Methods: A group of 32 renowned echoendoscopists selected eight relevant topics to be discussed to generate clinical questions. After that, a literature review was conducted to answer these questions based on the most updated evidence. Results: Thirty-three statements were formulated and voted on by the experts to reach a consensus. The Oxford System was used to grade the level of evidence. Conclusion: There is moderate evidence to support that the needle shape, gauge, or aspiration technique does not influence the yield of endoscopic ultrasound (EUS)-guided tissue sampling of pancreatic solid lesions. There is moderate evidence to support using EUS-TTNB of the cyst wall to differentiate between mucinous and non-mucinous cystic neoplasms. There is little evidence to support the EUS-guided treatment of gastric varices. There is a high level of evidence to support that EUS-guided biliary drainage and ERCP present similar outcomes in patients with distal malignant biliary obstruction. There is a high level of evidence for using EUS to diagnose neoplastic pancreatic cysts and detect necrosis before indicating drainage. There is moderate evidence to support EUS-GE over duodenal stent for malignant gastric outlet obstruction in patients with a life expectancy higher than 2 months. There is a high level of evidence to support the use of RFA in treating both functioning and non-functioning types of NET. Background decades interventions Consensus Methods 3 Results Thirtythree Thirty three consensus Conclusion shape gauge EUSguided guided lesions EUSTTNB TTNB nonmucinous non neoplasms varices EUSGE GE months nonfunctioning NET

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. (MHBS strategy life pruritus cholangitis effective procedure ERCP ICESP (ICESP 201 2017 levels 8 585 58 5 58.5 415 41 41.5 male 6013 60 13 60±1 years II IIIA 232 23 2 23.2% 159 15 9 15.9% 146 14 6 14.6 463 46 3 46.3% respectively 927 92 7 92.7 537 53 53.7 logisticregression analyses 5. 95% 95 (95 1.28‒20.88. 1282088 1.28‒20.88 . 1 28 20 88 1.28‒20.88) conclusion rate outcomes 58. 4 41. 601 60± 23.2 15.9 14. 46.3 92. 53. (9 128208 1.28‒20.8 23. 15. 46. ( 12820 1.28‒20. 1282 1.28‒20 128 1.28‒2 12 1.28‒ 1.28 1.2 1.

ABSTRACT Introduction: Portal hypertension still represents an important health problem worldwide. In the search for knowledge regarding this syndrome, experimental studies with animal models have proven to be useful to point the direction to be taken in future randomized clinical trials. Purpose: To validate the experimental model of portal hypertension and esophagogastric varices in a medium-sized animal. Methods: This study included five minipigs br1. Midline laparotomy with dissection of the portal vein and production of a calibrated stenosis of this vein was performed. Measurement of pressure in the portal venous and digestive endoscopic were performed before and five weeks after the production of a stenosis. Results: All animals were 8 months old, average weight of 17 ± 2.5 kg. The mean pressure of the portal vein immediately before the partial ligation of the portal vein was 8.9 + 1.6 mm Hg, with 26.6 + 5.4 mm Hg in the second measurement five weeks later (p < 0.05). No gastroesophageal varices or hypertensive portal gastropathy were seen at endoscopy procedures in our sample at any time in the study. Conclusion: Portal vein ligation in minipigs has been validated in the production of portal hypertension, but not in the formation of esophageal varices.

RESUMO CONTEXTO: O câncer colorretal é uma das principais causas de morte relacionada ao câncer em todo o mundo. A colonoscopia é o padrão ouro para diagnosticar e tratar lesões precoces, levando à diminuição da incidência e mortalidade do câncer colorretal. Entretanto, é importante o reconhecimento de que alguns adenomas podem não ser detectados (adenomas perdidos) durante o exame, e todos os esforços vêm sendo destinado a reduzir esta taxa. O aprimoramento das tecnologias de imagem, incluindo cromoendoscopia eletrônica e ampliação, tem sido cada vez mais adotado para melhorar a taxa de detecção de adenomas colorretais. Como exemplo, as imagens obtidas com o I-scan® (Pentax, Tóquio, Japão), que fornecem cromoendoscopia virtual em tempo real durante o exame para visão do padrão de superfície, destacando a microvasculatura da lesão detectada. As evidências sobre o impacto do uso do I-scan® na taxa de detecção de adenoma colorretal são escassas. OBJETIVO: Avaliar se o uso de imagens I-scan® (Pentax, Tóquio, Japão) tem impacto na taxa de perda de adenoma nas colonoscopias de triagem. MÉTODOS: Estudo observacional prospectivo de colonoscopias comparando cromoscopia com o aprimoramento de superfície e luz-branca. Pacientes acima de 50 anos submetidos à colonoscopia foram alocados aleatoriamente em dois grupos usando randomização eletrônica - Grupo 1: primeira inspeção com luz branca de alta definição seguida por uma segunda inspeção com o aprimoramento de superfície pelo I-scan 1®; Grupo 2: primeira inspeção com o aprimoramento de superfície I-scan 1® seguida de uma segunda inspeção com luz branca de alta definição. O desfecho primário foi a taxa de perda de adenomas do primeiro exame, calculado com o número de adenomas detectados na segunda inspeção do exame dividido pelo número total de adenomas detectados em ambas inspeções. RESULTADOS: Participaram do estudo 85 pacientes, sendo excluídos 14, com amostra final de 71 pacientes. 34 foram alocados para o Grupo 1 e 37 no Grupo 2. Um total de 58 adenomas foram detectados, 40 na primeira inspeção (20 em cada grupo) e 18 na segunda inspeção, somente no Grupo 1. A taxa de perda de adenoma foi maior para o Grupo 1 do que para o Grupo 2 (47,4% vs 0% P=0,0002). CONCLUSÃO: A utilização de aprimoramento de superfície I-scan 1 reduz a taxa de perda de adenomas em exames colonoscópios.

ABSTRACT BACKGROUND: Colonoscopy is the gold standard for the diagnosis and treatment of adenomas. It is related with decreased colorectal cancer incidence and mortality. However, an important problem is missed colorectal adenoma. All efforts should be undertaken to reduce this rate. Enhancing imaging technologies including electronic chromoendoscopy and magnification has been increasingly adopted for improving the colorectal neoplasia detection rate and the detailed study of its surface, as well. I-scan images (Pentax, Tokyo, Japan) provides virtual chromoendoscopy in real-time during the examination to view the surface pattern, highlighting the microvasculature of the neoplastic lesion. The evidence on the impact of the use of I-scan on the colorectal adenoma detection rate is scarce. OBJECTIVE: To evaluate whether the use of I-scan has impact on the adenoma miss rate (AMR) of screening colonoscopy exams. METHODS: Observational and prospective study conducted by monitoring patients over 50 years undergoing colonoscopy. There were two groups: Group 1 - first inspection with standard high-definition white-light (HDWL) followed by a second inspection with I-scan 1; Group 2 - first inspection with I-scan 1 followed by a second inspection with standard HDWL. The primary outcome was the AMR from the first exam, calculated with the number of adenomas detected in the second exam, divided by the total number of adenomas detected in both exams. RESULTS: A total of 85 patients participated in the study. 14 were excluded, with a final sample of 71 patients, in the Group 1, 34 patients, and the Group 2, 37. A total of 58 adenomas were detected, 40 in the first inspection (20 in each group) and 18 in the second inspection in group 1. The overall AMR was higher for the Group 1 than the Group 2 (47.4% vs 0% P=0.0002). CONCLUSION: The use of I-scan 1 during colonoscopy exam reduces the AMR.

RESUMO CONTEXTO: Um local comum de tumores neuroendócrinos (TNEs) é o reto. A técnica mais utilizada é a ressecção endoscópica da mucosa com injeção de solução salina. No entanto, as margens profundas costumam ser difíceis de ressecar porque a invasão da submucosa é comum. A ressecção endoscópica sob imersão d’água (RESI) é uma técnica em que o lúmen intestinal é preenchido com água em vez de ar, evitando a necessidade de elevação submucosa. OBJETIVO: Este estudo teve como objetivo avaliar a eficácia e segurança da RESI para a remoção de pequenos TNEs retais (rTNEs). MÉTODOS: Estudo retrospectivo com pacientes que realizaram RESI em dois centros. RESI foi realizada usando um colonoscópio padrão. Nenhuma injeção submucosa foi realizada. Patologistas certificados conduziram avaliação histopatológica. RESULTADOS: RESI foi realizada para pequenos rTNEs em 11 pacientes (nove mulheres) com média de idade de 55,8 anos e 11 lesões (tamanho médio de 7 mm, variando de 3-12 mm). Havia 9 (81%) pacientes com G1 rTNEs e dois pacientes com G2, sendo que todos os tumores invadiam a submucosa sendo apenas um restrito a mucosa. Nenhum caso mostrou invasão vascular ou perineural. Todas as lesões foram removidas em bloco. Nove (81%) ressecções tiveram margens livres. Dois pacientes tiveram envolvimento de margens profundas; um teve biópsias negativas por meio de vigilância endoscópica e o outro perdeu o acompanhamento. Não ocorreram perfurações ou sangramento tardios. CONCLUSÃO: A RESI parece ser uma alternativa eficaz e segura para o tratamento de pequenos rTNEs sem eventos adversos e com altas taxas de ressecção em bloco e R0. Mais estudos prospectivos são necessários para comparar as intervenções endoscópicas disponíveis e para elucidar a técnica endoscópica mais adequada para ressecção de rTNEs.

ABSTRACT BACKGROUND: A common site of neuroendocrine tumors (NETs) is the rectum. The technique most often used is endoscopic mucosal resection with saline injection. However, deep margins are often difficult to obtain because submucosal invasion is common. Underwater endoscopic mucosal resection (UEMR) is a technique in which the bowel lumen is filled with water rather than air, precluding the need for submucosal lifting. OBJECTIVE: This study aimed to evaluate the efficacy and safety of UEMR for removing small rectal neuroendocrine tumors (rNETs). METHODS: Retrospective study with patients who underwent UEMR in two centers. UEMR was performed using a standard colonoscope. No submucosal injection was performed. Board-certified pathologists conducted histopathologic assessment. RESULTS: UEMR for small rNET was performed on 11 patients (nine female) with a mean age of 55.8 years and 11 lesions (mean size 7 mm, range 3-12 mm). There were 9 (81%) patients with G1 rNET and two patients with G2, and all tumors invaded the submucosa with only one restricted to the mucosa. None case showed vascular or perineural invasion. All lesions were removed en bloc. Nine (81%) resections had free margins. Two patients had deep margin involvement; one had negative biopsies via endoscopic surveillance, and the other was lost to follow-up. No perforations or delayed bleeding occurred. CONCLUSION: UEMR appeared to be an effective and safe alternative for treatment of small rNETs without adverse events and with high en bloc and R0 resection rates. Further prospective studies are needed to compare available endoscopic interventions and to elucidate the most appropriate endoscopic technique for resection of rNETs.

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.

RESUMO CONTEXTO: A dissecção endoscópica da submucosa (ESD) é uma técnica popular no Japão e em outros países asiáticos e, supostamente, ainda está limitada a centros terciários no Ocidente. OBJETIVO: Este estudo teve como objetivo investigar a prática clínica da ESD no Brasil por meio de um questionário eletrônico elaborado pela Sociedade Brasileira de Endoscopia Digestiva (SOBED). MÉTODOS: Em outubro de 2019, 3512 endoscopistas membros da SOBED foram convidados a responder a uma pesquisa eletrônica contendo 40 questões divididas em quatro tópicos: perfil do operador; experiência clínica com ESD; eventos adversos e treinamento. O consentimento informado foi solicitado a todos os participantes. Os investigadores analisaram todas as respostas e consideraram válidas se mais de 50% das perguntas fossem respondidas e informações adicionais, quando solicitadas, fossem fornecidas. RESULTADOS: Um total de 155 (4,4%) respostas qualificadas foram incluídas no estudo. A ESD foi executada em 22 dos 26 estados da Federação e a maioria dos entrevistados (32,2%) possuía de 10 a 20 anos de prática endoscópica. A ESD foi realizada com maior frequência em hospitais privados (101 indivíduos; 66,9%) e clínicas ambulatoriais privadas (41 indivíduos; 27,1%). A ESD foi realizada principalmente no estômago (72%), seguido pelo reto (57%) e 80% dos indivíduos relataram menos de 25 operações. Vinte e quatro (15,4%) indivíduos relataram algum caso de perfuração no procedimento e 4 (2,5%) deles relataram óbito pós-operatório. Aproximadamente um quarto dos respondentes negou treinamento prático em modelos ou visita a centros de treinamento. CONCLUSÃO: A ESD parece ser praticada em todo o país, não apenas em instituições terciárias ou acadêmicas e principalmente na prática privada. A maioria dos respondedores recebeu treinamento limitado e ainda está no início da curva de aprendizado. Os eventos adversos relatados e as taxas de mortalidade parecem ser maiores do que os relatos orientais.

ABSTRACT BACKGROUND: Endoscopic submucosal dissection (ESD) enables en bloc excision of superficial neoplasms. Although ESD is widely practiced in Eastern countries like Japan, South Korea and China, its use in the West is supposed to be still limited to few tertiary centers. OBJECTIVE: This study aimed to investigate the clinical practice of ESD in Brazil by means of an electronic questionnaire elaborated by the Brazilian Society of Digestive Endoscopy (SOBED). METHODS: In October 2019, 3512 endoscopist members of SOBED were invited to respond to an electronic survey containing 40 questions divided into four topics: operator profile; clinical experience with ESD; adverse events and training. Informed consent was requested to all participants. The investigators reviewed all responses and considered valid if more than 50% of the questions were answered and additional information, when requested, was provided. RESULTS: A total of 155 (4.4%) qualified responses entered the study. ESD has been practiced in 22 of 26 Federation States and majority of respondents (32.2%) have 10 to 20 years of practice. ESD has been performed more frequently in private hospitals (101 individuals, 66.9%) and private ambulatory centers (41 individuals, 27.1%). ESD was performed mainly in the stomach (72%), followed by the rectum (57%) and 80% of the individuals reported less than 25 operations. Twenty-four (15.4 %) individuals reported perforation and 4 (2.5%) of them reported postoperative deaths. Approximately a quarter of responders denied hands-on training in models or visit to training centers. CONCLUSION: ESD appears to be practiced throughout the country, not only in tertiary or academic institutions and mainly in private practice. Most operators received limited training and still are at the beginning of their learning curve. The reported adverse events and mortality rates appear to be higher than Eastern reports.

RESUMO INTRODUÇÃO: A gastroenterostomia ecoguiada é um novo procedimento para paliação da obstrução maligna gastroduodenal. Nosso objetivo foi avaliar os resultados dessa técnica em nossa experiência inicial. MÉTODOS: Foram incluídos pacientes com obstrução maligna gastroduodenal de nossa instituição. O sucesso técnico foi definido como a realização adequada de uma gastroenterostomia. O sucesso clínico foi definido como boa aceitação de dieta pastosa durante a internação. Os eventos adversos e a aceitação alimentar foram avaliados um mês após o procedimento. RESULTADOS: Três pacientes foram incluídos. Os sucessos técnico e clínico foram alcançados em todos os casos. Não houve eventos adversos e a aceitação alimentar permaneceu adequada um mês após o procedimento nos pacientes incluídos. CONCLUSÃO: O EUS-GE é um tratamento promissor para pacientes com obstrução maligna gastroduodenal.

SUMMARY INTRODUCTION: EUS-guided gastroenterostomy (EUS-GE) is a novel procedure for palliation of malignant gastric outlet obstruction (GOO). Our aim was to evaluate the outcomes of this technique in our initial experience. METHODS: Patients with GOO from our institute were included. Technical success was defined as the successful creation of a gastroenterostomy. Clinical success was defined as the ability to tolerate a soft diet after the procedure. We assessed adverse events and diet tolerance 1 month after the procedure. RESULTS: Three patients were included. Technical and clinical success was achieved in all cases. There were no adverse events and good diet tolerance was observed 1 month after the procedure in the included patients. CONCLUSION: EUS-GE is a promising treatment for patients with GOO.

RESUMO CONTEXTO: A ressecção endoscópica da mucosa sob imersão d’água (REMS) surgiu como um método revolucionário que permite a ressecção de lesões colorretais sem injeção submucosa. A literatura brasileira sobre essa técnica é escassa. OBJETIVO: A finalidade deste estudo foi avaliar a eficácia e segurança da técnica REMS na remoção de lesões colorretais não pediculadas em dois centros terciários brasileiros. MÉTODOS: Este estudo prospectivo foi realizado entre junho de 2016 e maio de 2017. As lesões sem tentativa de ressecção prévia, não pediculadas e sem sinais de invasão submucosa foram ressecadas pela técnica REMS. RESULTADOS: Um total de 55 pacientes com 65 lesões foram incluídos. Todas as lesões, exceto uma, foram removidas com sucesso e completamente por REMS (taxa de sucesso de 98,5%). Durante a REMS, foram observados dois casos de sangramento (3,0%). Uma paciente apresentou dor abdominal no dia seguinte à ressecção sem pneumoperitônio. Não houve perfuração ou sangramento tardio. CONCLUSÃO: Este estudo apoia os dados existentes, indicando taxas aceitáveis de sucesso técnico e baixa incidência de eventos adversos com a REMS. Os resultados deste estudo brasileiro foram consistentes com estudos internacionais prévios.

ABSTRACT BACKGROUND: Underwater endoscopic mucosal resection (UEMR) has emerged as a revolutionary method allowing resection of colorectal lesions without submucosal injection. Brazilian literature about this technique is sparse. OBJECTIVE: The aim of this study was evaluate the efficacy and safety of UEMR technique for removing non-pedunculated colorectal lesions in two Brazilian tertiary centers. METHODS: This prospective study was conducted between June 2016 and May 2017. Naïve and non-pedunculated lesions without signs of submucosal invasion were resected using UEMR technique. RESULTS: A total of 55 patients with 65 lesions were included. All lesions, except one, were successfully and completely removed by UEMR (success rate 98.5%). During UEMR, two cases of bleeding were observed (3.0%). One patient had abdominal pain on the day after resection without pneumoperitoneum. There was no perforation or delayed bleeding. CONCLUSION: This study supports the existing data indicating acceptable rates of technical success, and low incidence of adverse events with UEMR. The results of this Brazilian study were consistent with previous abroad studies.

The use of colorectal self-expanding metal stents (SEMS) as bridge therapy for malignant colorectal obstruction was first reported more than 20 years ago. However, its use remains controversial. Objective: In this study, we aimed to compare the long-term survival of patients with potentially resectable malignant colorectal obstruction who had undergone colorectal SEMS placement and emergency surgery. Methods: This study was a retrospective analyses. Patients who received treatment between 2009 and 2017 were included. According to the eligibility criteria, 21 patients were included in the SEMS group and 67 patients were included in the surgical group.. Results: The majority of the patients in the SEMS group were female (57.1%), whereas the majority of those in the surgical group were male (53.7%). The median follow-up time was 60 months for both groups with the same interquartile range of 60 months. There was no difference in the overall survival rate (log rank p=0.873) and disease-free survival rate (log rank p=0.2821) in the five-year analysis. There was no difference in local recurrence rates (38.1% vs. 22.4%, p=0.14) or distant recurrence rates (33.3% vs. 50.7%, p=0.16) in the SEMS and the surgical groups. Technical and clinical success rates of endoscopic stenting were 95.3% and 85.7%, respectively. There were no immediate adverse events (AEs). Severe AEs included perforation (14.3%), silent perforation (4.7%), reobstruction (14.3%), and bleeding (14.3%). Mild AEs included pain (42.8%), tenesmus (9.5%), and incontinence (4.76%). The limitations of this study was retrospective and was conducted at a single center. Conclusions: No differences in disease-free and overall survival rates were observed in the five-year analysis of patients with resectable colorectal cancer who had undergone SEMS placement or colostomy for the treatment of malignant colorectal obstruction. Patients in the SEMS group had a higher rate of primary anastomosis and a lower rate of temporary colostomy than did those in the surgery group.

OBJECTIVES: We aimed to evaluate the incidence of pancreatic alterations in Crohn's disease using endoscopic ultrasound (EUS) and to correlate the number of alterations with current clinical data. METHODS: Patients diagnosed with Crohn's disease (n=51) were examined using EUS, and 11 variables were analyzed. A control group consisted of patients with no history of pancreatic disease or Crohn's disease. Patients presenting with three or more alterations underwent magnetic resonance imaging (MRI). Pancreatic function was determined using a fecal elastase assay. RESULTS: Two of the 51 patients (3.9%) presented with four EUS alterations, 3 (5.9%) presented with three, 11 (21.5%) presented with two, and 13 (25.5%) presented with one; in the control group, only 16% presented with one EUS alteration (p<0.001). Parenchymal abnormalities accounted for 39 of the EUS findings, and ductal abnormalities accounted for 11. Pancreatic lesions were not detected by MRI. Low fecal elastase levels were observed in 4 patients, none of whom presented with significant pancreatic alterations after undergoing EUS. Ileal involvement was predictive of the number of EUS alterations. CONCLUSION: A higher incidence of pancreatic abnormalities was found in patients with Crohn's disease than in individuals in the control group. The majority of these abnormalities are related to parenchymal alterations. In this group of patients, future studies should be conducted to determine whether such morphological abnormalities could evolve to induce exocrine or endocrine pancreatic insufficiency and, if so, identify the risk factors and determine which patients should undergo EUS.

OBJECTIVE: Our aim was to evaluate the Japan Gastroenterological Endoscopy Society criteria for endoscopic submucosal resection of early gastric cancer (EGC) based on the experience in a Brazilian cancer center. METHODS: We included all patients who underwent endoscopic submucosal resection for gastric lesions between February 2009 and October 2016. Demographic data and information regarding the endoscopic resection, pathological report and follow-up were obtained. Statistical calculations were performed with Fisher’s exact test and chi-square tests, with 95% confidence intervals. RESULTS: In total, 76% of the 51 lesions were adenocarcinomas, 16% were adenomas, and 8% had other diagnoses. The average size was 19.9 mm (±11.7). The average procedure length was 113.9 minutes (±71.4). The complication rate was 21.3%, with only one patient who needed surgical treatment (transmural perforation). Among the adenocarcinomas, 39.5% met the classic criteria for curability, 31.6% met the expanded criteria and 28.9% met the criteria for noncurative resection. Analysis of the indication criteria and curability revealed differences among cases with “only-by-size” expanded criteria (64.28%), other expanded criteria (40%) and classic criteria (89.47%), with a p-value of 0.049. During follow-up (15.8 months; ±14.3), 86.1% of the EGC patients had no recurrence. When well-differentiated and poorly differentiated lesions or lesions included in the classic and expanded criteria were compared, there were no differences in recurrence. The noncurative group presented a higher recurrence rate than the classic group (p=0.014). CONCLUSION: These results suggest that the Japanese endoscopic submucosal resection criteria might be useful for endoscopic treatment of EGC in Western countries.