ABSTRACT Purpose: To conduct a systematic literature review with meta-analysis to identify whether antibiotic prophylaxis after removal of the indwelling urinary catheter reduces posterior infections. Methods: A systematic literature review was conducted in the databases PubMed, Embase, Cochrane, Google Scholar, and Latin American and Caribbean Health Sciences Literature, using the keywords “antibiotics” AND “prostatectomy” AND “urinary catheter.” Results: Three articles were identified having the scope of our review, with 1,040 patients, which were subjected to our meta-analysis revealing a marginally significant decrease in the risk of urinary infection after indwelling urinary catheter removal (odds ratio–OR = 0.51; 95% confidence interval–95%CI 0.27–0.98; p = 0.04; I2 = 0%). No difference was found regarding the presence of bacteriuria (OR = 0.39; 95%CI 0.12–1.24; p = 0.11; I2 = 73%). Conclusions: In our meta-analysis, there was a significant decrease in urinary tract infection with antibiotic prophylaxis after indwelling urinary catheter removal following radical prostatectomy. Purpose metaanalysis meta analysis infections Methods PubMed Embase Cochrane Scholar Literature antibiotics “antibiotics prostatectomy “prostatectomy catheter. Results 1040 1 040 1,04 patients odds ratioOR ratio OR 0.51 051 0 51 95 interval95CI intervalCI interval CI 0.27–0.98 027098 27 98 0.04 004 04 I 0%. 0% . 0%) 0.39 039 39 95CI 0.12–1.24 012124 12 24 0.11 011 11 73%. 73 73% 73%) Conclusions metaanalysis, analysis, 104 1,0 0.5 05 5 9 0.27–0.9 02709 2 0.0 00 0.3 03 3 0.12–1.2 01212 0.1 01 7 10 1, 0. 0.27–0. 0270 0.12–1. 0121 0.27–0 027 0.12–1 012 0.27– 02 0.12– 0.27 0.12 0.2

ABSTRACT Purpose: Medical expulsive therapy (MET) is recommended for distal ureteral stones from 5 to 10 mm. The best drug for MET is still uncertain. In this review, we aim to compare the effectiveness of tadalafil and tamsulosin for distal ureteral stones from 5 to 10 mm in terms of stone expulsion rate (SER), stone expulsion time (SET) and the side effect profile. Materials and methods: A comprehensive literature search was conducted on MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials, Scopus and Web of Science, from inception until April 2023. Only randomized controlled trials were included in the analysis. Results: Eleven publications with 1,330 patients were included. We observed that tadalafil has a higher SER (OR 0.55, CI 95% 0.38;0.80, p=0.02, I2=52%) and the same efficacy in SET (MD 1.07, CI 95% -0.25; 2.39, p=0.11, I2=84%). No differences were found when comparing side effects as headache, backache, dizziness, and orthostatic hypotension. Conclusion: Tadalafil has a higher stone expulsion rate than tamsulosin as a medical expulsive therapy for patients with distal stones from 5 to 10 mm without differences in side effects. Purpose (MET 1 uncertain review SER, , (SER) (SET profile methods MEDLINE EMBASE Trials Science 2023 analysis Results 1330 330 1,33 OR 055 0 55 0.55 95 0.380.80, 038080 0.38 0.80, 38 80 0.38;0.80 p002 p 02 p=0.02 I2=52% I252 I I2 52 MD 107 07 1.07 0.25 025 25 -0.25 239 2 39 2.39 p011 11 p=0.11 I2=84%. I284 I2=84% . 84 I2=84%) headache backache dizziness hypotension Conclusion (SER 202 133 33 1,3 05 0.5 9 380 0.380.80 03808 038 0.3 080 0.80 3 8 0.38;0.8 p00 p=0.0 I2=52 I25 1.0 0.2 -0.2 23 2.3 p01 p=0.1 I28 I2=84 20 13 1, 0. 0.380.8 0380 03 08 0.8 0.38;0. p0 p=0. I2=5 1. -0. 2. I2=8 0.380. 0.38;0 p=0 I2= -0 0.380 0.38; p= -

ABSTRACT Neoplasms of the biliopancreatic confluence may present with obstruction of the bile tract, leading to jaundice, pruritus and cholangitis. In these cases drainage of the bile tract is imperative. Endoscopic retrograde cholangiopancreatography (ERCP) with placement of a choledochal prosthesis is an effective treatment in about 90% of cases, even in experienced hands. In cases of ERCP failure, therapeutic options traditionally include surgical bypass by hepaticojejunostomy (HJ) or percutaneous transparietohepatic drainage (DPTH). In recent years, endoscopic ultrasound-guided biliary drainage techniques have gained space because they are less invasive, effective and have an acceptable incidence of complications. Endoscopic echo-guided drainage of the bile duct can be performed through the stomach (hepatogastrostomy), duodenum (choledochoduodenostomy) or by the anterograde drainage technique. Some services consider ultrasound-guided drainage of the bile duct the procedure of choice in the event of ERCP failure. The objective of this review is to present the main types of endoscopic ultrasound-guided biliary drainage and compare them with other techniques. jaundice cholangitis imperative (ERCP 90 hands failure HJ (HJ DPTH. DPTH . (DPTH) years ultrasoundguided ultrasound guided invasive complications echoguided echo hepatogastrostomy, hepatogastrostomy , (hepatogastrostomy) choledochoduodenostomy (choledochoduodenostomy technique 9 (DPTH (hepatogastrostomy

RESUMO Neoplasias da confluência biliopancreática podem cursar com obstrução da via biliar, levando a icterícia, prurido e colangite. Nesses casos a drenagem da via biliar é imperativa. A colangiopancreatografia endoscópica retrógrada (CPER) com colocação de prótese coledociana constitui tratamento eficaz em cerca de 90% dos casos mesmo em mãos experientes. Nos casos de insucesso da CPER, tradicionalmente as opções terapêuticas incluem a derivação cirúrgica por hepaticojejunostomia (HJ) ou drenagem percutânea transparietohepática (DPTH). Nos últimos anos as técnicas endoscópicas ecoguiadas de drenagem biliar ganharam espaço por serem menos invasivas, eficazes e apresentarem incidência aceitável de complicações. A drenagem endoscópica ecoguiada da via biliar pode ser realizada pelo estômago (hepatogastrostomia), duodeno (coledocoduodenostomia) ou pela técnica de drenagem anterógrada. Alguns serviços consideram a drenagem ecoguiada da via biliar o procedimento de escolha no caso de insucesso da CPER. O objetivo desta revisão é apresentar os principais tipos de drenagem biliar endoscópica ecoguiada e confrontá-los com outras técnicas. icterícia colangite imperativa CPER (CPER 90 experientes HJ (HJ DPTH. DPTH . (DPTH) invasivas complicações hepatogastrostomia, hepatogastrostomia , (hepatogastrostomia) coledocoduodenostomia (coledocoduodenostomia anterógrada confrontálos confrontá los 9 (DPTH (hepatogastrostomia

ABSTRACT Introduction: flexible ureteroscopy is a minimally invasive surgical technique used for the treatment of renal lithiasis. Postoperative urosepsis is a rare but potentially fatal complication. Traditional models used to predict the risk of this condition have limited accuracy, while models based on artificial intelligence are more promising. The objective of this study is to carry out a systematic review regarding the use of artificial intelligence to detect the risk of sepsis in patients with renal lithiasis undergoing flexible ureteroscopy. Methods: the literature review is in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA). The keyword search was performed in MEDLINE, Embase, Web of Science and Scopus and resulted in a total of 2,496 articles, of which 2 met the inclusion criteria. Results: both studies used artificial intelligence models to predict the risk of sepsis after flexible uteroscopy. The first had a sample of 114 patients and was based on clinical and laboratory parameters. The second had an initial sample of 132 patients and was based on preoperative computed tomography images. Both obtained good measurements of Area Under the Curve (AUC), sensitivity and specificity, demonstrating good performance. Conclusion: artificial intelligence provides multiple effective strategies for sepsis risk stratification in patients undergoing urological procedures for renal lithiasis, although further studies are needed. Introduction complication accuracy promising Methods MetaAnalysis Meta Analysis PRISMA. PRISMA . (PRISMA) MEDLINE Embase 2496 496 2,49 articles criteria Results uteroscopy 11 parameters 13 images AUC, AUC , (AUC) specificity performance Conclusion needed (PRISMA 249 49 2,4 1 (AUC 24 4 2,

RESUMO Introdução: a ureteroscopia flexível é uma técnica cirúrgica minimamente invasiva utilizada para o tratamento de litíase renal. A urosepse pós-operatória é uma complicação rara, mas potencialmente fatal. Os modelos tradicionais utilizados para prever o risco dessa condição apresentam precisão limitada, enquanto modelos baseados em inteligência artificial são mais promissores. O objetivo desse estudo é realizar uma revisão sistemática a respeito do uso de inteligência artificial para detecção do risco de sepse em pacientes com litíase renal submetidos à ureteroscopia flexível. Métodos: a revisão de literatura está de acordo com o Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA). A busca com palavras-chave foi realizada no MEDLINE, Embase, Web of Science e Scopus e resultou no total de 2.496 artigos, dos quais 2 se enquadraram nos critérios de inclusão. Resultados: os dois estudos utilizaram modelos de inteligência artificial para predizer o risco de sepse após utereroscopia flexível. O primeiro teve uma amostra de 114 pacientes e foi baseado em parâmetros clínicos e laboratoriais. O segundo teve uma amostra inicial de 132 pacientes e foi baseado em imagens de tomografia computadorizada no pré-operatório. Ambos obtiveram boas medidas de Area Under the Curve (AUC), sensibilidade e especificidade, demonstrando boa performance. Conclusão: a inteligência artificial fornece múltiplas estratégias eficazes para estratificação do risco de sepse em pacientes submetidos a procedimentos urológicos para litíase renal, ainda que mais estudos sejam necessários. Introdução pósoperatória pós operatória rara fatal limitada promissores Métodos MetaAnalysis Meta Analysis PRISMA. PRISMA . (PRISMA) palavraschave palavras chave MEDLINE Embase 2496 496 2.49 artigos inclusão Resultados 11 laboratoriais 13 préoperatório. préoperatório pré operatório. operatório pré-operatório AUC, AUC , (AUC) especificidade performance Conclusão necessários (PRISMA 249 49 2.4 1 (AUC 24 4 2.

ABSTRACT Purpose: In Brazil, healthcare services traditionally follow a fee-for-service (FFS) payment system, in which each medical procedure incurs a separate charge. An alternative reimbursement with the aim of reducing costs is diagnosis related group (DRG) remuneration, in which all patient care is covered by a fixed amount. This work aimed to perform a systematic review followed by meta-analysis to assess the effectiveness of the Budled Payment for Care Improvement (BPCI) versus FFS. Methods: Our work was performed following the items of the PRISMA report. We included only observational trials, and the primary outcome assessed was the effectiveness of FFS and DRG in appendectomy considering complications. We also assessed the costs and length of hospital stay. Meta-analysis was performed with Rev Man version 5.4. Results: Out of 735 initially identified articles, six met the eligibility criteria. We demonstrated a shorter hospital stay associated with the DRG model (mean difference = 0.39; 95% confidence interval – 95%CI – 0.38–0.40; p < 0.00001; I2 = 0%), however the hospital readmission rate was higher in this model (odds ratio = 1.57; 95%CI 1.02–2.44, p = 0.04; I2 = 90%). Conclusions: This study reveals a potential decrease in the length of stay for appendectomy patients using the DRG approach. However, no significant differences were observed in other outcomes analysis between the two approaches. Purpose Brazil feeforservice fee service (FFS system charge (DRG remuneration amount metaanalysis meta BPCI (BPCI Methods report trials complications Metaanalysis Meta 54 5 4 5.4 Results 73 articles criteria mean 0.39 039 0 39 95 95CI CI 0.38–0.40 038040 38 40 0.00001 000001 00001 I 0%, 0% , 0%) odds 1.57 157 1 57 102244 02 2 44 1.02–2.44 0.04 004 04 90%. 90 90% . 90%) Conclusions approach However approaches 5. 7 0.3 03 3 9 0.38–0.4 03804 0.0000 00000 0000 1.5 15 10224 1.02–2.4 0.0 00 0. 0.38–0. 0380 0.000 000 1. 1022 1.02–2. 0.38–0 038 0.00 102 1.02–2 0.38– 10 1.02– 0.38 1.02 1.0

ABSTRACT Purpose: Kidney stones are one of the most common urological diseases worldwide. The size and location of the stone are the most important factors in determining the most suitable treatment options. The aim of this review was to evaluate the displacement of lower pole stones. Methods: Three studies assessing the efficacy of translocating kidney stones from the lower pole of the kidney to other locations during retrograde intrarenal surgery published in the last 20 years were included. A systematic search was conducted in the PubMed, Embase, Latin American and Caribbean Health Sciences Literature (LILACS), and Web of Science databases using the following search terms: “Lower pole,” “Lithotripsy.” Meta-analysis was performed using Review Manager version 5.4. Results: Stone-free rates were improved through displacement (odds ratio – OR = -0.15; 95% confidence interval–95%CI -0.24–-0.05; p = 0.002; I2 = 21%), but at the cost of increased surgical duration (mean difference = -12.50; 95%CI -24.06–-0.95; p = 0.03; I2 = 94%). Although this represents a potentially negative outcome, the improvement in clearance rates justifies the additional investment of time and effort. Conclusions: Displacement of lower pole kidney stones for subsequent lithotripsy brings significant benefits in terms of stone-free rate, with no difference in laser energy usage. However, it results in increased surgical time. Despite these factors, the benefits to patients undergoing the procedure are substantial. Purpose worldwide options Methods 2 included PubMed Embase LILACS, LILACS , (LILACS) Lower pole, Lithotripsy. Lithotripsy “Lithotripsy. Metaanalysis Meta analysis 54 5 4 5.4 Results Stonefree Stone free odds 0.15 015 0 15 -0.15 95 interval95CI intervalCI interval CI 0.24–0.05 024005 0.24– 0.05 24 05 -0.24–-0.05 0.002 0002 002 I 21%, 21 21% 21%) mean 12.50 1250 12 50 -12.50 95CI 24.06–0.95 2406095 24.06– 0.95 06 -24.06–-0.95 0.03 003 03 94%. 94 94% . 94%) outcome effort Conclusions stonefree rate usage However substantial (LILACS “Lithotripsy 5. 0.1 01 1 -0.1 9 0.24–0.0 02400 024 0.24 005 0.0 -0.24–-0.0 0.00 000 00 12.5 125 -12.5 24.06–0.9 240609 2406 24.06 095 0.9 -24.06–-0.9 0. -0. 0.24–0. 0240 02 0.2 -0.24–-0. 12. -12. 24.06–0. 24060 240 24.0 09 -24.06–-0. -0 0.24–0 -0.24–-0 -12 24.06–0 24. -24.06–-0 - -0.24–- -1 -24.06–- -0.24– -24.06– -0.24 -24.06 -0.2 -24.0 -24. -24 -2

ABSTRACT Purpose: Vasoplegia, or vasoplegic shock, is a syndrome whose main characteristic is reducing blood pressure in the presence of a standard or high cardiac output. For the treatment, vasopressors are recommended, and the most used is norepinephrine. However, new drugs have been evaluated, and conflicting results exist in the literature. Methods: This is a systematic review of the literature with meta-analysis, written according to the recommendations of the PRISMA report. The SCOPUS, PubMed, and ScienceDirect databases were used to select the scientific articles included in the study. Searches were conducted in December 2022 using the terms “vasopressin,” “norepinephrine,” “vasoplegic shock,” “postoperative,” and “surgery.” Meta-analysis was performed using Review Manager (RevMan) 5.4. The endpoint associated with the study was efficiency in treating vasoplegic shock and reduced risk of death. Results: In total, 2,090 articles were retrieved; after applying the inclusion and exclusion criteria, ten studies were selected to compose the present review. We found no significant difference when assessing the outcome mortality comparing vasopressin versus norepinephrine (odds ratio = 1.60; confidence interval 0.47–5.50), nor when comparing studies on vasopressin versus placebo. When we analyzed the length of hospital stay compared to the use of vasopressin and norepinephrine, we identified a shorter length of hospital stay in cases that used vasopressin; however, the meta-analysis did not demonstrate statistical significance. Conclusions: Considering the outcomes included in our study, it is worth noting that most studies showed that using vasopressin was safe and can be considered in managing postoperative vasoplegic shock. Purpose Vasoplegia output treatment recommended However evaluated Methods metaanalysis, metaanalysis meta analysis, analysis report SCOPUS PubMed 202 vasopressin, “vasopressin, “norepinephrine, postoperative, “postoperative, surgery. surgery “surgery. Metaanalysis Meta RevMan (RevMan 54 5 4 5.4 death Results total 2090 2 090 2,09 retrieved criteria odds 1.60 160 1 60 0.47–5.50, 047550 0.47–5.50 , 0 47 50 0.47–5.50) placebo however significance Conclusions 20 “vasopressin “norepinephrine “postoperative “surgery 5. 209 09 2,0 1.6 16 6 04755 0.47–5.5 2, 1. 0475 0.47–5. 047 0.47–5 04 0.47– 0.47 0.4 0.

ABSTRACT Purpose: Colorectal cancer is responsible for 9.4% of cancer deaths, and low polyp detection rate and cecal intubation rate increase the risks of interval colorectal cancer. Despite several population studies that address colonoscopy quality measures, there is still a shortage of these studies in Latin America. The aim of this study was to assess quality indicators in colonoscopy, enabling future strategies to improve colorectal cancer prevention. Methods: An observational retrospective study, in which all colonoscopies performed in 11 hospitals were evaluated through a review of medical records. Information such as procedure indication, colorectal polyp detection rate, cecal intubation rate, quality of colonic preparation, and immediate adverse events were collected and analyzed. Results: In 17,448 colonoscopies performed by 86 endoscopists, 57.9% were in patients aged 50 to 74 years old. Colon preparation was adequate in 94.4% procedures, with rates of cecal intubation and polyp detection of 94 and 36.6%, respectively. Acute adverse events occurred in 0.2%. In 53.9%, high-definition imaging equipment was used. The procedure location, colon preparation and high-definition equipment influenced polyp detection rates (p < 0.001). Conclusions: The extraction and analysis of electronic medical records showed that there are opportunities for improvement in colonoscopy quality indicators in the participating hospitals. Purpose 9 4 9.4 deaths measures America prevention Methods 1 indication analyzed Results 17448 17 448 17,44 8 endoscopists 579 57 57.9 5 7 old 944 94.4 procedures 366 36 6 36.6% respectively 02 0 2 0.2% 539 53 53.9% highdefinition high definition used location p 0.001. 0001 0.001 . 001 0.001) Conclusions 9. 1744 44 17,4 57. 94. 3 36.6 0.2 53.9 000 0.00 00 174 17, 36. 0. 53. 0.0

RESUMO CONTEXTO: A canulação biliar de sucesso é pré-requisito para a realização da colangiopancreatografia retrógrada endoscópica (CPRE). Quando a canulação biliar não é possível, a fistulotomia com auxílio do cateter Needle-Knife (NKF) pode ser realizada. Entretanto, quando o acesso biliar não é atingido mesmo após a realização de um NKF, é possível optar-se pela interrupção do procedimento, e pela repetição da CPRE após curto intervalo de 48 horas. OBJETIVO: O objetivo desse estudo é analisar se a repetição da CPRE após um curto intervalo de 48 horas é efetivo em atingir o acesso biliar, quando um NKF foi realizado inicialmente sem sucesso. MÉTODOS: Um total de 1024 pacientes com papila virgem de tratamento, submetidos à CPRE entre os anos de 2009-2019, foram retrospectivamente analisados. Canulação biliar difícil foi identificada em 238 deles, e NKF foi então realizado. Foram avaliadas as taxas de sucesso durante a canulação biliar, assim como durante a realização de NKF na primeira e segunda CPREs. A associação entre o tipo de papila, dilatação biliar e o sucesso final na realização do NFK também foi avaliada, assim como a presença de eventos adversos associados à realização do NKF. RESULTADOS: Dentre todos os NKF realizados, acesso biliar foi inicialmente atingido em 183 (76,8%) casos. Os 55 (23,1%) casos restantes, foram submetidos a uma segunda CPRE após 48 horas e o acesso biliar foi atingido em 46 (83,6%) deles, resultando em uma taxa final de sucesso, após a primeira e segunda CPREs, de 96,2%. Papila localizada fora da sua posição habitual foi relacionada a menor chance de sucesso durante a realização de NKF (P<0,05). CONCLUSÃO: Concluiu-se que quando o acesso biliar não pode ser atingido após a realização de um NKF, uma segunda CPRE é segura, efetiva e deve ser realizada.

ABSTRACT BACKGROUND: A successful bile duct cannulation is a prerequisite for the realization of endoscopic retrograde cholangiopancreatography (ERCP). When biliary cannulation is not possible, needle-knife fistulotomy (NKF) can be performed. However, when biliary access is not successfully achieved even after performing NKF, it is possible to interrupt the procedure, and repeat the ERCP after a short interval. OBJECTIVE: The aim of this study is to analyze if repeating an ERCP after a short interval of 48 hours is effective in achieving biliary access after an initial NKF was unsuccessfully performed. METHODS: A total of 1024 patients with a naive papilla, that underwent ERCP between the years of 2009-2019, were retrospectively reviewed. Difficult biliary cannulation was identified in 238 of these cases and NKF was performed. Success of biliary cannulation, NKF success at the first and second ERCPs, the associations between the type of the papilla, biliary dilatation, and overall success of NKF and adverse events rates were evaluated. RESULTS: Biliary access was initially achieved in 183 (76.8%) cases. Of the 55 (23.1%) remaining cases a second attempt was performed after 48 hours, and biliary access was successfully achieved in 46 (83.6%) of them. The overall success of NKF after the first and second ERCP, the success rate was 96.2%. Papilla located out of its normal position was related to a minor chance of success at NKF (P<0.05). CONCLUSION: We conclude that when biliary access is not achieved after the performance of a NKF, a second attempt is safe and effective and should be attempted.

Abstract Purpose To present new endoscopic robotic devices in the context of minimally invasive procedures with high precision and automation. Methods Review of the literature by December 2018 on robotic endoscopy. Results We present the studies and investments for robotic implementation and flexible endoscopy evolution. We divided them into forceps manipulation platforms, active endoscopy and endoscopic capsule. They try to improve forceps handling and stability and to promote active movement. Conclusion The implementation and propagation of robotic models depend on doing what the endoscopist is unable to. The new devices are moving forward in this direction.

RESUMO Racional: O diagnóstico tecidual é mandatório nas lesões subepiteliais gástricas da camada muscular própria para o diagnóstico diferencial das neoplasias do estroma gastrointestinal (GISTs). Contudo, ainda não há consenso quanto a melhor agulha para a punção ecoguiada destas lesões. Objetivo: Avaliar o valor da punção aspirativa ecoguiada com agulhas calibrosas de 19 gauge para o diagnóstico diferencial das lesões subepiteliais gástricas da camada muscular própria. Métodos: Foram revisados retrospectivamente os registros de pacientes consecutivos submetidos à punção aspirativa ecoguiada com agulhas de 19 e 22 gauge de lesões subepiteliais gástricas da quarta camada ecográfica em um centro de referência. A punção aspirativa foi realizada sempre pelo mesmo endoscopista, com o emprego da técnica de fanning, sem presença de citopatologista em sala. O material aspirado foi avaliado apenas pela técnica de cell block pelo mesmo patologista. Os resultados foram considerados diagnósticos, na presença de material adequado para coloração pela H&E e imunoistoquímica, ou não-diagnósticos. Resultados: Oitenta e nove pacientes (idade média: 59 anos, 77% do sexo feminino) foram submetidos a 92 punções aspirativas ecoguiadas com agulhas de 19 (75) ou 22 (17) gauges. O tamanho médio das lesões foi de 22,6 mm. O ganho diagnóstico geral foi de 88%. O ganho diagnóstico para as agulhas de 19 gauge foi superior ao das agulhas de 22 gauge (92%x70,6%; p=0,0410), e similar para lesões >2 cm e <2 cm (93,7%x90,7%; p=0,9563). Os melhores resultados com a agulha de 19 gauge foram obtidos com a realização de até três punções. A taxa de complicações foi de 2,8%. Conclusão: O ganho diagnóstico da punção aspirativa ecoguiada de lesões subepiteliais gástricas da camada muscular própria com agulhas de 19 gauge é de 92%. A punção com a agulha mais calibrosa para lesões de qualquer tamanho é procedimento seguro e de grande valor no diagnóstico diferencial dos GISTs e leiomiomas.

ABSTRACT Background: Tissue diagnosis is required for gastric subepithelial lesions for differential diagnosis of GISTs. However, there has not been consensus about the best needle for EUS-guided sampling of these lesions. Aim: To evaluate the diagnostic yield of EUS-FNA for gastric subepithelial lesions of the proper muscle layer with large-bore 19 gauge needles. Methods: A prospectively maintained database was retrospectively reviewed to identify consecutive patients who underwent EUS-FNA with 19 and 22 gauge needles for gastric subepithelial lesions of the fourth endosonographic layer in a tertiary care referral center. EUS-FNA was performed by the same endosonographer, using the fanning technique, without on-site cytopathologist. Specimens were analysed through cell blocks by the same pathologist. Procedure results were categorized into diagnostic, defined as enough material for histopathology and immunohistochemistry, or nondiagnostic. Results: Eighty-nine patients (mean age: 59 years, 77% women) underwent 92 EUS-FNA with 19 (75) or 22 (17) gauge needles. Mean lesion size was 22.6 mm. Overall diagnostic yield was 88%. The diagnostic yield of 19 gauge was higher than that of 22 gauge needle (92%x70.6%; p=0.0410), and similar for lesions >2 cm and <2 cm (93.7%x90.7%; p=0.9563). The best performance for 19 gauge needles was obtained performing <3 needle passes. Complication rate was 2.8%. Conclusions: Diagnostic yield of EUS-FNA with 19 gauge needles is 92% for gastric subepithelial lesions of the proper muscle layer. It is safe and highly valuable for differentiation between GIST and leiomyoma, no matter the size of the lesion.

RESUMO Racional: A propofolemia está diretamente relacionada com os efeitos clínicos desse anestésico e é foco de diversos estudos comparando os usos clínicos do propofol e os diferentes métodos de administração, como realizado amplamente nos centros de endoscopia. Objetivo: Avaliar os efeitos de três diferentes regimes de infusão de propofol intravenoso em colonoscopias. Métodos: Ao todo 50 pacientes que foram submetidos à colonoscopia foram consecutivamente divididos em três grupos: 1) infusão em bolus intermitente; 2) perfusão contínua controlada manualmente; 3) infusão automática contínua. Os pacientes foram monitorados com Bispectral IndexTM (BIS) e os níveis séricos de propofol foram coletados em três momentos diferentes. Foi necessário a preparação de uma diluição específica de propofol e o desenvolvimento de um cateter de capnografia original manufaturado para a realização do estudo. Resultados: Em relação aos desfechos clínicos, houve diferença estatística na agitação (maior no grupo 1, p=0,001) e pressão arterial inicial (p=0,008). Com relação aos níveis séricos de propofol, os resultados foram semelhantes no consumo por minuto (p=0,748) e ao longo do tempo (p=0,830). Em termos de análise de custo, no grupo 1 o custo foi de R$ 7,00 (aproximadamente US$ 2,25); grupo 2, R$ 17,50 (aproximadamente US$ 5,64); e grupo 3, R$ 112,70 (cerca de US$ 36,35, p<0,001). A capnografia foi capaz de diagnosticar 100% das dessaturações de oxigênio (abaixo de 90%). Conclusão: O uso de propofol em bolus para colonoscopias, por meio de infusão contínua controlada manualmente ou infusão automática são semelhantes quanto à propofolemia e os resultados clínicos avaliados. Além disso, o uso de um cateter de capnografia inovador é solução de baixo custo para a detecção precoce da obstrução da via aérea.

ABSTRACT Background: The propofolemia becomes directly linked to the clinical effects of this anesthetic and is the focus for studies comparing propofol clinical use, in different administration methods routinely used in endoscopy units where sedation is widely administered to patients. Aim: To evaluate the effects of three different regimens of intravenous propofol infusion in colonoscopies. Methods: A total of 50 patients that underwent colonoscopies were consecutively assigned to three groups: 1) intermittent bolus infusion; 2) continuous manually controlled infusion; 3) continuous automatic infusion. Patients were monitored with Bispectral IndexTM (BIS) and propofol serum levels were collected at three different timepoints. The development of an original dilution of propofol and an inventive capnography catheter were necessary. Results: Regarding clinical outcomes, statistical differences in agitation (higher in group 1, p=0.001) and initial blood pressure (p=0.008) were found. As for propofol serum levels, findings were similar in consumption per minute (p=0.748) and over time (p=0.830). In terms of cost analysis, group 1 cost was R$7.00 (approximately US$2,25); group2, R$17.50 (approximately US$5,64); and group 3, R$112.70 (approximately US$36,35, p<0.001). Capnography was able to predict 100% of the oxygen saturation drop (below 90%). Conclusion: The use of propofol bolus administration for colonoscopies, through continuous manually controlled infusion or automatic infusion are similar regarding propofolemia and the clinical outcomes evaluated. The use of an innovative capnography catheter is liable and low-cost solution for the early detection of airway obstruction.

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.