RESUMO CONTEXTO: O preparo intestinal com manitol é um método bem estabelecido no Brasil. No entanto, os fatores que interferem no tempo de esvaziamento gástrico ainda não são conhecidos. O conhecimento desses fatores pode favorecer a logística de agendamento do exame e a orientação individualizada para cada paciente. OBJETIVO: Estudar os fatores que podem contribuir para o tempo de esvaziamento gástrico após o preparo intestinal com manitol expresso. MÉTODOS: Trata-se de um estudo observacional prospectivo com o objetivo de conhecer os seguintes fatores que podem contribuir no tempo de esvaziamento gástrico: tipo de dieta predominante, comorbidades, uso de medicamentos, cirurgias anteriores, número de evacuações por semana, portador de obstipação intestinal, tipo fecal, tipo de dieta, número de evacuações após o uso domiciliar de bisacodil antes da ingestão de manitol e número de evacuações após a ingestão de manitol até atingir o preparo intestinal adequado. Antes de iniciar o preparo intestinal, os pacientes responderam a um questionário clínico. O endoscópio foi introduzido para aspirar o conteúdo gástrico, antes de iniciar a colonoscopia. RESULTADOS: A amostra foi composta por 103 pacientes, sendo 55 mulheres, com média de idade de 61 anos, peso médio de 75,3 kg, altura média de 1,7 m e IMC médio de 26,6 kg/m2. O volume residual gástrico médio medido foi 120,9 (0-900) mL. Volume residual gástrico inferior a 100 mL (VRG ≤100 mL) foi encontrado em 45 (43,6%) pacientes, sendo 24 (53,3%) mulheres, com média de idade de 61,0 anos e IMC médio de 26,7 kg/m2. Volume residual gástrico acima de 100 mL (VRG >100 mL) ocorreu em 58 (56,3%) pacientes, sendo 29 (50%) mulheres, com idade média de 61,0 anos e IMC médio de 26,2 kg/m2. Comparando os dois grupos, notou-se que o tempo médio de jejum após a ingestão de manitol foi significativamente maior no grupo com VRG ≤100 mL do que no grupo com VRG> 100 mL, 123,1 (60-246) vs 95,3 (55-195) minutos, respectivamente. Também houve significância estatística em relação ao uso de ezetimiba 6 (13,7%), sendo maior no grupo com VRG ≤100 mL. Além disso, houve significância estatística no grupo com VRG >100 mL quanto ao uso de paroxetina 3 (6,7%) e tadalafil 3 (6,7%) e história cirúrgica de prostatectomia 3 (6,7%) e retirada de bridas 3 (6,7%). CONCLUSÃO: Podemos concluir neste estudo que o uso de ezetimiba e o jejum acima de 2 horas após a ingestão de manitol diminuem significativamente a incidência de um VRG> 100 mL. O uso de paroxetina, tadalafil e história cirúrgica de prostatectomia ou retirada de bridas podem contribuir para o aumento da incidência de um VRG >100 mL.

ABSTRACT BACKGROUND: Bowel preparation with mannitol is a well-established method in Brazil. However, factors that interfere with the gastric emptying time period are yet to be known. Knowing these factors may favor the examination scheduling logistics and the individualized orientation for each patient. OBJECTIVE: Know the factors that can contribute to the gastric emptying time after intestinal preparation with express mannitol. METHODS: This is a prospective observational study to know factors that may contribute on the gastric emptying timing: predominant type of diet, comorbidities, medication usage, previous surgeries, number of evacuation per week, bearer of bowel obstipation, fecal type, diet type, number of evacuations after the home usage of bisacodyl before the ingestion of mannitol and number of evacuations after the ingestion of mannitol until reaching a proper bowel preparation. Before starting the colonoscopy exam, an upper digestive endoscopy exam was made to aspirate the gastric content. RESULTS: Sample was composed of 103 patients, 55 (53.4%) women, medium age 61 (±12.1) years, medium weight 75.3 (±14.1) kg, medium height 1.7 (±10) m and medium BMI of 26.6 (±3.9) kg/m2. Average gastric residual volume was 120.9 (0-900) mL. Gastric residual volume (GRV) below 100 mL (GRV ≤100 mL) occurred in 45 (43.6%) patients, 24 (53.3%) women, medium age of 61.0 years and medium BMI of 26.7 kg/m2. Gastric residual volume above 100 mL (GRV >100 mL) occurred on 58 (56.3%) patients, 29 (50%) women, medium age of 61.0 years and medium BMI of 26.2 kg/m2. Comparing both groups, average fasting time period after the ingestion of mannitol was significantly higher on the group with GRV ≤100 mL than group with GRV >100 mL, 123.1 (60-246) vs 95.3 (55-195) minutes, respectively. There was also statistical significance concerning the usage of ezetimibe 6 (13.7%) in the group with GRV ≤100 mL and statistical significance in the group with GRV >100 mL concerning the usage of paroxetine 3 (6.7%) and tadalafil 3 (6.7%) and surgical history of prostatectomy 3 (6.7%) and bridle withdrawal 3 (6.7%). CONCLUSION: We may conclude in this study that the usage of ezetimibe and fasting above 2 hours after the ingestion of mannitol decrease significantly the incidence of a GRV >100 mL. The usage of paroxetine, tadalafil and surgical history of prostatectomy or bridle withdrawal may contribute to increase de incidence of a GRV >100 mL.

RESUMO Desde a publicação em 2015 das recomendações da Sociedade Brasileira de Hepatologia sobre a prevenção e tratamento de doenças hepáticas autoimunes, novos dados baseados em evidências científicas foram publicados na literatura, mudando o diagnóstico e tratamento da hepatite autoimune (HAI), colangite biliar primária (CBP), colangite esclerosante primária (CEP), síndromes de sobreposição de HAI, CBP e CEP e o manejo de complicações específicas além de outros tópicos relativos à HAI e doenças hepáticas colestáticas. Este manuscrito atualiza as recomendações anteriores de acordo com as melhores evidências disponíveis na literatura até o momento. O mesmo painel de experts que participou da primeira diretriz revisou todas as recomendações de acordo com os dados publicados na literatura e elaborou um manuscrito submetido subsequentemente à apreciação e revisão de todos os membros da Sociedade Brasileira de Hepatologia via homepage da sociedade. As recomendações finais atualizadas foram condensadas no presente documento.

ABSTRACT New data concerning the management of autoimmune liver diseases have emerged since the last single-topic meeting sponsored by the Brazilian Society of Hepatology to draw recommendations about the diagnosis and treatment of autoimmune hepatitis (AIH), primary biliary cholangitis (PBC), primary sclerosing cholangitis (PSC), overlap syndromes of AIH, PBC and PSC and specific complications and topics concerning AIH and cholestatic liver diseases. This manuscript updates those previous recommendations according to the best evidence available in the literature up to now. The same panel of experts that took part in the first consensus document reviewed all recommendations, which were subsequently scrutinized by all members of the Brazilian Society of Hepatology using a web-based approach. The new recommendations are presented herein.

RESUMO CONTEXTO: Uma das complicações mais temidas com o uso de cianoacrilato para tratamento de varizes gástricas é a ocorrência de embolia sistêmica potencialmente fatal. Assim, os endoscopistas estão se aprimorando com novas técnicas, incluindo o uso de coils endoscópico, como uma opção de tratamento potencialmente mais segura e eficaz. No entanto, nenhum estudo foi realizado comparando as duas técnicas. OBJETIVO: Este estudo tem como objetivo comparar a segurança e eficácia da injeção de coil com cianoacrilato guiados por ultrassom endoscópico versus a técnica convencional de injeção de cianoacrilato. DESIGN: Um ensaio piloto controlado aleatoriamente. MÉTODOS: Os pacientes randomizados para o grupo I foram tratados com coil + cianoacrilato e os do grupo II apenas com cianoacrilato. O fluxo dentro da variz foi avaliado imediatamente após a sessão de tratamento e um mês após o tratamento inicial. Se a trombose foi confirmada, o acompanhamento adicional era realizado em 4 e 10 meses após o tratamento inicial. Todos os pacientes foram submetidos a uma tomografia computadorizada torácica após o procedimento. RESULTADOS: Um total de 32 pacientes, 16 em cada grupo, foram acompanhados por uma média de 9,9 meses (variação de 1-26 meses). Imediatamente após o procedimento, 6 (37,5%) pacientes do grupo I e 8 (50%) pacientes do grupo II apresentaram redução total do fluxo no vaso tratado (P=0,476). Após 30 dias, 11 (73,3%) pacientes do grupo I e 12 (75%) pacientes do grupo II apresentaram trombose da variz. Em ambos os grupos, a maioria dos pacientes necessitou de apenas uma única sessão para obliteração da variz (73,3% no grupo I versus 80% no grupo II). Embolia pulmonar assintomática ocorreu em 4 (25%) pacientes do grupo I e em 8 (50%) pacientes no grupo II (P=0,144). Nenhuma diferença significativa entre os grupos foi observada. CONCLUSÃO Apesar de não haver diferença estatística entre os dois grupos em relação à incidência de embolia neste estudo piloto, observou-se maior tendência de embolia no grupo tratado pela técnica convencional.

ABSTRACT BACKGROUND: One of the most feared complications with the use of cyanoacrylate for treatment of gastric varices is the occurrence of potentially life-threatening systemic embolism. Thus, endoscopists are turning towards new techniques, including endoscopic coiling, as a potentially safer and more effective treatment option. However, no studies have been performed comparing the two techniques. OBJECTIVE: This study aims to compare the safety and efficacy of endoscopic ultrasound guided coil and cyanoacrylate injection versus the conventional technique of injection of cyanoacrylate alone. DESIGN: A pilot randomized controlled trial. METHODS: Patients randomized into group I were treated with coil and cyanoacrylate, and those in group II with cyanoacrylate alone. Flow within the varix was evaluated immediately after the treatment session and one month following initial treatment. If thrombosis was confirmed, additional follow-up was performed 4 and 10 months following initial treatment. All patients underwent a thoracic computerized tomography scan after the procedure. RESULTS: A total of 32 patients, 16 in each group, were followed for an average of 9.9 months (range 1-26 months). Immediately after the procedure, 6 (37.5%) group-I patients and 8 (50%) group-II patients presented total flow reduction in the treated vessel (P=0.476). After 30 days, 11 (73.3%) group-I patients and 12 (75%) group-II patients were found to have varix thrombosis. In both groups, the majority of patients required only one single session for varix obliteration (73.3% in group I versus 80% in group II). Asymptomatic pulmonary embolism occurred in 4 (25%) group-I patients and 8 (50%) group-II patients (P=0.144). No significant difference between the groups was observed. CONCLUSION: There is no statistical difference between endoscopic ultrasound guided coils plus cyanoacrylate versus conventional cyanoacrylate technique in relation to the incidence of embolism. However, a greater tendency towards embolism was observed in the group treated using the conventional technique. Both techniques have similar efficacy in the obliteration of varices. Given the small sample size of our pilot data, our results are insufficient to prove the clinical benefit of the combined technique, and do not yet justify its use, especially in light of higher cost. Further studies with larger sample size are warranted.

Our aim in this study was to compare the efficiency of 25G versus 22G needles in diagnosing solid pancreatic lesions by EUS-FNA. We performed a systematic review and meta-analysis. Studies were identified in five databases using an extensive search strategy. Only randomized trials comparing 22G and 25G needles were included. The results were analyzed by fixed and random effects. A total of 504 studies were found in the search, among which 4 randomized studies were selected for inclusion in the analysis. A total of 462 patients were evaluated (233: 25G needle/229: 22G needle). The diagnostic sensitivity was 93% for the 25G needle and 91% for the 22G needle. The specificity of the 25G needle was 87%, and that of the 22G needle was 83%. The positive likelihood ratio was 4.57 for the 25G needle and 4.26 for the 22G needle. The area under the sROC curve for the 25G needle was 0.9705, and it was 0.9795 for the 22G needle, with no statistically significant difference between them (p=0.497). Based on randomized studies, this meta-analysis did not demonstrate a significant difference between the 22G and 25G needles used during EUS-FNA in the diagnosis of solid pancreatic lesions.

OBJECTIVES: Serrated polyps, which are considered to be precursors of colorectal carcinoma, include hyperplastic polyps, sessile serrated adenomas and traditional serrated adenomas. With the exception of hyperplastic polyps, all of these lesions must be removed. This study sought to examine whether underwater endoscopic mucosal resection is a safe and effective technique for treating serrated polyps. METHODS: Cases in which patients were submitted for underwater endoscopic mucosal resection and histologically diagnosed with sessile serrated adenoma were prospectively registered. RESULTS: The median patient age was 54.5 years (range, 48 to 72 years), and the patients included 4 men (28.5%) and 10 women (71.5%). One lesion (6.2%), 10 lesions (62.5%), 1 lesion (6.2%), 3 lesions (18.8%) and 1 lesion (6.2%) were found in the cecum, the ascending colon, the hepatic flexure, the transverse colon and the descending colon, respectively. The median lesion size was 20 mm (range, 10 to 35 mm). Eight lesions (50%) were removed en bloc, and the remaining eight lesions (50%) were removed using a piecemeal technique. None of the cases were complicated by perforation or delayed bleeding. CONCLUSION: Underwater resection could be a feasible, safe and effective alternative for the resection of sessile serrated adenomas.

The aim of this study is to address the outcomes of endoscopic resection compared with surgery in the treatment of ampullary adenomas. A systematic review and meta-analysis were performed according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) recommendations. For this purpose, the Medline, Embase, Cochrane, Literatura Latino-Americana e do Caribe em Ciências da Saúde (LILACS), Scopus and Cumulative Index to Nursing and Allied Health Literature (CINAHL) databases were scanned. Studies included patients with ampullary adenomas and data considering endoscopic treatment compared with surgery. The entire analysis was based on a fixed-effects model. Five retrospective cohort studies were selected (466 patients). All five studies (466 patients) had complete primary resection data available and showed a difference that favored surgical treatment (risk difference [RD] = -0.24, 95% confidence interval [CI] = -0.44 to -0.04). Primary success data were identified in all five studies as well. Analysis showed that the surgical approach outperformed endoscopic treatment for this outcome (RD = -0.37, 95% CI = -0.50 to -0.24). Recurrence data were found in all studies (466 patients), with a benefit indicated for surgical treatment (RD = 0.10, 95% CI = -0.01 to 0.19). Three studies (252 patients) presented complication data, but analysis showed no difference between the approaches for this parameter (RD = -0.15, 95% CI = -0.53 to 0.23). Considering complete primary resection, primary success and recurrence outcomes, the surgical approach achieves significantly better results. Regarding complication data, this systematic review concludes that rates are not significantly different.

RESUMO Para definir as recomendações baseadas em evidências científicas sobre o diagnóstico e tratamento das doenças autoimnus do fígado, a Sociedade Brasileira de Hepatologia organizou em Outubro de 2014, encontro monotemático em São Paulo. Um Comitê organizador de sete investigadores foi selecionado pela Diretoria da Sociedade para organizar a agenda científica, assim como para selecionar vinte debatedores para fazer uma revisão sistemática e apresentar tópicos relacionados à hepatite autoimune, colangite esclerosante primária, cirrose biliar primária e suas síndromes de superposição (overlap). O texto inicial do submetidoo a apreciação e aprovação da Sociedade Brasileira de Hepatologia através de consulta a todos associados através da home page da Sociedade, O trabalho apresentado representa a versão final do trabalho original, devidamente revisado e organizado em tópicos, segundo as recomendações da Sociedade Brasileira de Hepatologia.

ABSTRACT In order to draw evidence-based recommendations concerning the management of autoimmune diseases of the liver, the Brazilian Society of Hepatology has sponsored a single-topic meeting in October 18th, 2014 at São Paulo. An organizing committee comprised of seven investigators was previously elected by the Governing Board to organize the scientific agenda as well as to select twenty panelists to make a systematic review of the literature and to present topics related to the diagnosis and treatment of autoimmune hepatitis, primary sclerosing cholangitis, primary biliary cirrhosis and their overlap syndromes. After the meeting, all panelists gathered together for the discussion of the topics and the elaboration of those recommendations. The text was subsequently submitted for suggestions and approval of all members of the Brazilian Society of Hepatology through its homepage. The present paper is the final version of the reviewed manuscript organized in topics, followed by the recommendations of the Brazilian Society of Hepatology.

Background: Abdominal pain is present in the vast majority of patients with chronic pancreatitis, being frequently debilitating. Celiac plexus block (CPB) is an interventional technique that can be considered to provide a temporary pain relief. Objective: To estimate the effectiveness and safeness of endoscopic-ultrasound (EUS) comparing with percutaneous-guided CBP in patients with pancreatic pain. Methods: A systematic review of English and non-English articles using MEDLINE, EMBASE, LILACS and COCHRANE (via BVS). Study selection and data extraction: Only randomized control trials (RCT) comparing the beneficial and harmful effects of EUS and percutaneous-guided celiac plexus block for managing pancreatic pain were included. Data was extracted and analyzed on variables including pain relief and related procedure complications. Results: Two RCT met the inclusion criteria. Both studies assessed the primary outcome (reduction on pain score) and evaluated adverse effects. The drugs injected were the same; nevertheless percutaneous technique was guided by fluoroscopy in one study and by computer tomography (CT) in other. The results showed that the EUS-CPB group was more effective to reduce pain score after 4 weeks after the procedure, with risk of bias to do this affirmation. No statistical difference in pain relief at 1, 8 and 12 weeks and in complications rates. Conclusions: Based on this systematic review and meta-analysis, no statistically significant difference was noted in pain relief and complications for EUS and percutaneous - CPB.

Antecedentes: El dolor abdominal es presente en la gran mayoría de pacientes con pancreatitis crónica, siendo con frecuencia debilitante. El bloqueo del plexo celíaco (BPC) es una técnica de intervención que puede ser considerado para proporcionar un alivio temporal del dolor. Objetivo: Estimar la eficacia y seguridad de la ecografía endoscópica-(EE) comparando con percutánea en pacientes con dolor de páncreas. Fuentes de datos: una revisión sistemática de los artículos utilizando MEDLINE, EMBASE, LILACS y COCHRANE (a través de la BVS). Selección de los estudios y la extracción de datos: se incluyeron solo ensayos controlados aleatorios que compararon los efectos beneficiosos y perjudiciales de la USE y bloqueo del plexo celiaco percutánea para el manejo del dolor de pancreas. Los datos fueron extraídos y analizados en variables incluyendo el alivio del dolor y las complicaciones de procedimientos relacionados. Resultados: Dos ensayos controlados cumplieron los criterios de inclusión. Ambos estudios evaluaron el resultado primario (reducción en la puntuación de dolor) y los efectos adversos. Las drogas inyectadas fueron las mismas; sin embargo, la técnica percutánea fue guiado por fluoroscopia en un estudio y por tomografía computarizada (TC) en el otro. Los resultados mostraron que el grupo de la EE fue más eficaz para reducir la escala de dolor después de 4 semanas del procedimiento, con el riesgo de sesgo de hacer esta afirmación. No hay diferencia estadística en el alivio del dolor en el 1, 8 y 12 semanas y en las tasas de complicaciones. Conclusiones: En base a esta revisión sistemática y meta-análisis, no se observaron diferencias estadísticamente significativas en el alivio del dolor y las complicaciones de la BCP por EE y percutánea.

ContextoA ecoendoscopia é considerada o melhor método de imagem para diagnosticar e avaliar as lesões subepiteliais do trato digestivo.ObjetivoO presente estudo tem como objetivo fazer uma análise dos casos submetidos a ecoendoscopia para avaliação de lesões subepiteliais do trato digestivo alto.MétodosForam analisados de forma retrospectiva 342 pacientes submetidos a ecoendoscopia para avaliação de lesões subepiteliais.ResultadosLesões da quarta camada foram mais comuns no estômago (63,72%) do que no esôfago (44,68%) e no duodeno (29,03%). No estômago, 81,1% das lesões >2 cm, e 96,5% >3 cm, eram da quarta camada. Sinais endossonográficos que poderiam ser relacionados com o comportamento maligno, como bordas irregulares, focos ecogênicos, espaços císticos e/ou tamanho maior que 3 cm foram identificados em 34 lesões (15,81%) na primeira avaliação com ecoendoscopia. Aspiração por agulha fina guiada por ultrassom endoscópico fez o diagnóstico em 21 (61,76%) dos pacientes que foram submetidos a punção ecoguiada. Três (12,0%) lesões das 25, que foram submetidas a vigilância pela ecoendoscopia, aumentaram de tamanho.ConclusãoO estômago é o órgão mais afetado pelas lesões subepitelias do trato gastrointestinal alto, sendo a camada muscular própria a camada de origem mais comum. Mais de 80% das lesões gástricas subepiteliais da quarta camada são >2 cm. A avaliação ecoendoscópica das lesões subepiteliais tem sido muito importante para a estratificação em grupos de risco e para determinar a melhor conduta.

BackgroundEndoscopic ultrasound is considered the best imaging test for the diagnosis and evaluation of subepithelial lesions of the gastrointestinal tract.ObjectiveThe present study aims to describe the endosonographic characteristics of upper gastric subepithelial lesions and our experience using endoscopic ultrasound for evaluation of such lesions.MethodsRetrospective data study of 342 patients who underwent endoscopic ultrasound evaluation of subepithelial lesions.ResultsLesions of the fourth layer were more common in the stomach (63.72%) than in the esophagus (44.68%) and duodenum (29.03%). In stomach, 81.1% of the lesions ≥2 cm, and 96.5% ≥3 cm, were from the fourth layer. Endosonographic signs that could be related to malignant behavior, such as irregular borders, echogenic foci, cystic spaces and/or size greater than 3 cm were identified in 34 (15.81%) lesions at the first endoscopic ultrasound evaluation. Endoscopic ultrasound-fine needle aspiration did the diagnosis in 21 (61.76%) patients who were submitted a puncture. Three (12.0%) lesions of 25 who were submitted to regular endoscopic ultrasound surveillance increased the size.ConclusionStomach is the organ most affected with subepithelial lesions of the gastrointestinal tract and the fourth layer was the most common layer of origin. More than 80% of gastric subepithelial lesions from the fourth layer are ≥2 cm. Endoscopic ultrasound evaluation of subepithelial lesions has been very important for stratification into risk groups and to determine the best management.

Objectivo Este estudo tem como objetivo avaliar a viabilidade da técnica de dissecção endoscópica da submucosa (DES) no tratamento do câncer precoce do estômago e do esôfago, assim como as características clinicopatológicas dos pacientes tratados em diferentes centros no Brasil. Métodos Cinco centros no Brasil relataram sua experiência inicial com a técnica de DES. Os casos relatados vinham sendo coletados em cada serviço antes da análise agrupada dos dados. Resultados Foram ressecadas 62 lesões gástricas, sedo 52 (83,8%) adenocarcinoma bem diferenciado, 31 (50%) localizadas no antro e 24 (38.7%) do tipo macroscópico IIa. Foram ressecadas em monobloco 51 (82.2%) lesões, com 3 apresentando margem lateral comprometida. Quanto ao grau de invasão, 25 (40.3%) eram restritas ao epitélio da mucosa (M1). O diâmetro médio das lesões foi de 18.9 (6-50) mm, o tempo médio dos procedimentos foi de 119.45 minutos. A incidência de perfuração gástrica foi de 4,8% (três casos). O tempo médio de seguimento foi de 11.3 meses, com duas recorrências locais e uma morte por pneumonia 7 meses após o tratamento. Das 16 lesões esofágicas ressecadas, 14 (87.4%) eram carcinoma epidermóide, 10 (62.5%) localizados na porção proximal, 8 (50.0%) do tipo macroscópico IIa. O diâmetro médio das lesões foi de 23.8 (6-60) mm. Foram ressecadas em monobloco 13 (81.2%) lesões, sendo que 5 apresentaram margem lateral comprometida e 8 (50.0%) com invasão restrita a camada epitelial (M1). A duração média dos procedimentos foi de 78 (20-150) minutos. Dois (12.5%) pacientes tiveram pequeno pneumomediastino e um (6.2%) evoluiu com estenose esofágica. O tempo médio de seguimento foi de 8.6 meses, sem recorrência local mesmo nos casos que apresentaram margem lateral comprometida pela histopatologia. Conclusão A técnica de DES tem sido factível em diferentes centros do Brasil com alto índice de sucesso.

Objective This study aimed to evaluate the feasibility and clinicopathological characteristics of early gastric and esophageal cancers treated with endoscopic submucosal dissection (ESD) at five centers in Brazil. Methods Five centers in Brazil reported their initial experience with ESD. The cases reported had already been collected by each center before pooled analysis. Results Were resected 62 gastric lesions; 52(83,8%) of the gastric lesions were well-differentiated adenocarcinoma, 31(50%) from the antrum, 24 (38.7%) type IIa. 51 (82.2%) lesions had en-block resection with three showing lateral margin compromise. Concerning invasion, 25 (40.3%) tumors were M1. Mean tumor diameter was 18.9 mm (range, 0.6-5.0 cm) and mean procedure duration was 119.45 minutes. Gastric perforation occurred in three (4.8%) patients. Mean follow-up duration was 11.3 months, with two local recurrences and one death from pneumonia Seven months after treatment. Of the 16 esophageal lesions resected, 14 (87.4%) were squamous cell carcinoma, 10 (62.5%) were located proximally and 8 (50.0%) type IIa. Mean tumor diameter was 23.8 mm (range, 6-60 mm). Thirteen (81.2%) lesions had en-block resection with five cases of lateral margin compromise. Eight (50.0%) lesions were M1. Mean procedure duration was 78 minutes (range, 20-150 min). Complications included pneumomediastinum in two (12.5%) patients and stenosis in one (6.2%). Mean duration of follow-up was 8.6 months, with no local recurrence despite the presence of lateral margin compromise. Conclusion Different centers in Brazil feasibly perform ESD with a high success rate.

BACKGROUND: Endoscopic submucosal dissection is a new Japanese technique characterized by en-bloc resection of the entire lesion irrespective of size, with lower local recurrence when compared to endoscopic mucosal resection. OBJECTIVE: To evaluate the feasibility, early results and complications of the endoscopic submucosal dissection technique for treating early gastric and esophageal cancer at the Endoscopic Unit of Clinics Hospital and Cancer Institute of the São Paulo University. MATERIALS AND METHODS: Twenty patients underwent endoscopic resection using the endoscopic submucosal dissection technique for early gastric or esophageal cancer. The patients were evaluated prospectively as to the executability of the technique, the short-term results of the procedure and complications. RESULTS: Sixteen gastric adenocarcinoma lesions and six esophageal squamous carcinoma lesions were resected. In the stomach, the mean diameter of the lesions was 16.2 mm (0.6-3.5 mm). Eight lesions were type IIa + IIc, four were type IIa and four IIc, with thirteen being well differentiated and three undifferentiated. Regarding the degree of invasion, five were M2, seven were M3, two were Sm1 and one was Sm2. The mean duration of the procedures was 85 min (20-160 min). In the esophagus, all of the lesions were type IIb, with a mean diameter of 17.8 mm (6-30 mm). Regarding the degree of invasion, three were M1, one was M2, one was M3 and one was Sm1. All had free lateral and deep margins. The mean time of the procedure was 78 min (20-150 min). CONCLUSION: The endoscopic submucosal dissection technique was feasible in our service with a high success rate.

RACIONAL: Ecoendoscopia é técnica mista que adiciona as vantagens da endoscopia àquelas da ecografia, somente que o procedimento ecográfico é realizado do interior dos órgãos para fora deles, no sentido centrífugo. OBJETIVO: Verificar a positividade da ecoendoscopia na punção com agulhas (EEPTN) ou (EE-PAF) em tumores sólidos pancreáticos baseados na técnica utilizada pelo Serviço de Endoscopia Digestiva do Hospital de Clínicas da Universidade de São Paulo. MÉTODOS: Cohorte retrospectiva de 138 pacientes que realizaram ecoendoscopia com punção aspirativa por agulha fina (EE-PAAF) no período de maio de 2004 a junho de 2007. Os dados foram coletados por meio de consulta aos prontuários, constantes do arquivo médico. O critério de inclusão foi a presença de massa pancreática sólida à tomografia computadorizada e o critério de exclusão a presença de tumor pancreático não sólido. Foram utilizadas as seguintes variáveis: característica da massa (tamanho, localização, presença de linfonodo peripancreático, presença de linfonodo em tronco celíaco); número de punções para obtenção de microfragmento; citologia e experiência do profissional executante. O aparelho utilizado foi um ecoendoscópio da marca Olympus, modelo OLYMPUS EUS (EYS) EXERA EU-C60, com transdutor setorial eletrônico e agulhas de 22 gauges da marca Boston Scientific. RESULTADOS: Setenta e seis (55,4 %) deles eram do sexo masculino e 61 (44,5 %) do feminino. A idade variou de 16 a 87 anos, com média de 59,9 anos. As lesões foram cefálicas em 94 (68,1 %) dos casos. Massas maiores que 4 cm tiveram percentual de positividade maior, chegando a 40%, mas as lesões menores que 2 cm obtiveram percentual de 43 % de inconclusivo. A obtenção de microfragmentos foi conseguida em 100% dos casos positivos e apenas 73,1 %, quando negativo (P=0,004). Não houve diferença estatística em relação à experiência do endoscopista. Apenas 80 pacientes tiveram anotado o número de punções e notou-se que existe melhor desempenho quanto maior for o número delas. O diagnóstico anatomopatológico definitivo de neoplasia pancreática ocorreu em apenas 41 (29,7 %) indivíduos. CONCLUSÕES: Em relação às características da massa, quanto maior ela era maior a positividade do método; a localização não correlacionou com maior positividade; há tendência de positividade quando presentes os linfonodos peripancreáticos; em relação ao número de punções, quanto maior o número delas, maior a positividade do método; em relação à experiência do profissional, não houve diferença no índice de positividade da punção da massa pancreática sólida.

BACKGROUND: Echoendoscopy is a mixed technique which adds the advantages of endoscopy to those of transabdominal ultrasonography through an endoscope with transductor in its distal extremity, allowing for the evaluation of the abdominal organs reached by the endoscope and in contact with the intestinal wall. AIM: To verify the positivity rate of the echoendoscopy with puncture with thin needle (EEPTN) or (EE-PAF) in solid pancreatic mass based on the technique used in the Gastrointestinal Endoscopy Unit of Hospital das Clínicas, University of São Paulo. METHODS: Retrospective evaluation - cohort study - of 138 patients who were submitted to echoendoscopy through aspiration puncture between May 2004 and June 2007. The data were collected through the medical charts present in the medical files of Hospital das Clínicas (Clinical Hospital) of the University of São Paulo, having as inclusion criterion the presence of solid pancreatic mass in computerized tomography and as exclusion criterion the presence of non solid pancreatic tumor. The routine technique was the one used in the Gastrointestinal Endoscopy Unit focusing the following variables: mass characteristics (size, location, presence of peripancreatic lymph node, presence of lymph node in celiac trunk); number of punctures to obtain microfragment for cytology, and experience of the professional in charge. The equipment used was an echoendoscopy device model Olympus EUS (EYES) Exera EU - C60, with electronic sectorial transductor and 22 gauges Wilson-Cook needles. RESULTS: Seventy six (55,4 %) male patients and 61 (44.5 %) female were enrolled. Age ranged from 16 to 87 years and means 59,9 years. The lesions were cephalic in 94 (68,1 %). Mass larger than 4 cm had a higher percentage of positivity reaching 40%, but lesions smaller than 2 cm had a percentage of 43% of inconclusive. Microfragments were obtained in 100% of the positive cases and only 73,1 % when negative (P=0,004). There was no statistic difference regarding the experience of the endoscopy professional. Only 80 patients had the number of punctures written down and it was noticed that there is better performance as the number of punctures was increased. The definitive histopathologycal diagnosis of pancreatic neoplasia occurred in only 41(29,7 %) patients. CONCLUSIONS: Regarding mass characteristics, when larger is the mass, larger is the positivity of the method; the location didn't correlate with higher positivity; when the lymph nodes were present, there was a tendency to positivity; concerning the number of punctures, the higher number, higher positivity; in relationship to the professional experience in endoscopy, there was no difference in the rate of positivity of the puncture of the solid pancreatic mass.

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% 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 do nível 1, gerando recomendações grau A e consenso entre os participantes nas seguintes situações: diagnóstico diferencial da lesão subepitelial do tubo digestivo e do espessamento de pregas gástricas, estádio e identificação de lesão irressecável no câncer do esôfago, sinais indiretos de carcinomatose peritonial no câncer gástrico avançado, estádio de linfoma gástrico tipo Malt e estádio do câncer de reto, diagnóstico da litíase da vesícula biliar e do colédoco, diagnóstico da pancreatite crônica, diagnóstico diferencial do nódulo sólido da pancreatite crônica, diagnóstico diferencial do cisto pancreático, resultados do tratamento endoscópico das varizes esofágicas, diagnóstico e estádio do câncer de pulmão não-pequenas células. CONCLUSÃO: Já há evidências do melhor nível na literatura médica justificando a utilização do exame ecoendoscópico em várias doenças do sistema digestório e, até mesmo, no câncer do pulmão.

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.