RESUMEN
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 por cento 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...
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 percent 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...
Asunto(s)
Humanos , Endosonografía , Medicina Basada en la Evidencia , Enfermedades Gastrointestinales , BrasilRESUMEN
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.
Asunto(s)
Endosonografía , Medicina Basada en la Evidencia , Enfermedades Gastrointestinales/diagnóstico por imagen , Brasil , HumanosRESUMEN
RACIONAL: A colangiografia retrógrada endoscópica é método acurado porém invasivo para o diagnóstico da coledocolitíase. A ecoendoscopia também é método bastante eficaz para a detecção de cálculo coledociano e apresenta riscos semelhantes àqueles de uma endoscopia digestiva convencional.OBJETIVOS: Comparar a acurácia da ecoendoscopia e da colangiografia endoscópica para o diagnóstico do cálculo da via biliar principal antes da colecistectomia laparoscópica e analisar a influência do tamanho do cálculo e do calibre da via biliar principal na eficácia diagnóstica da ecoendoscopia. PACIENTES E MÉTODOS: Duzentos e quinze pacientes com colecistolitíase sintomática foram admitidos para colecistectomia laparoscópica. Destes, 68 (31,7%) apresentaram dilatação da via biliar extra-hepática à ecografia convencional e/ou alteração de enzimas hepáticas e canaliculares. Foram, então, submetidos a ecoendoscopia e colangiografia endoscópica, seguida de papilotomia, se qualquer um dos métodos sugerisse a presença de coledocolitíase. Após a papilotomia, o maior cálculo foi recuperado e medido. A exploração endoscópica ou cirúrgica da via biliar foi considerada o padrão-ouro para o diagnóstico de coledocolitíase. RESULTADOS: Todos os 68 pacientes foram submetidos a colecistectomia laparoscópica com colangiografia intra-operatória, comprovando-se colecistolitíase neste grupo. A ecoendoscopia foi mais sensível do que a colangiografia endoscópica para a detecção de cálculos coledocianos (97% vs. 67%). Para os cálculos maiores de 4,0 mm, os métodos apresentaram sensibilidades semelhantes (96% vs. 90%). Os resultados da ecoendoscopia não foram influenciados pelo tamanho do cálculo ou pelo calibre do colédoco. CONCLUSÕES: Para pacientes com risco intermediário para coledocolitíase, a ecoendoscopia é método mais sensível do que a colangiografia endoscópica, especialmente para cálculos pequenos.
Asunto(s)
Adolescente , Adulto , Anciano , Anciano de 80 o más Años , Femenino , Humanos , Masculino , Persona de Mediana Edad , Colangiopancreatografia Retrógrada Endoscópica , Coledocolitiasis/diagnóstico , Endosonografía , Colecistectomía Laparoscópica , Coledocolitiasis/patología , Coledocolitiasis/cirugía , Conducto Colédoco/anatomía & histología , Conducto Colédoco , Intervalos de Confianza , Tamaño de la Partícula , Estudios Prospectivos , Sensibilidad y EspecificidadRESUMEN
BACKGROUND: Endoscopic retrograde cholangiography is highly accurate in diagnosing choledocholithiasis, but it is the most invasive of the available methods. Endoscopic ultrasonography is a very accurate test for the diagnosis of choledocholithiasis with a risk of complications similar to that of upper gastrointestinal endoscopy. AIM: To compare the accuracy of endoscopic ultrasonography and endoscopic retrograde cholangiography in the diagnosis of common bile duct stones before laparoscopic cholecystectomy and to analyze endoscopic ultrasound results according to stone size and common bile duct diameter. PATIENTS AND METHODS: Two hundred and fifteen patients with symptomatic gallstones were admitted for laparoscopic cholecystectomy. Sixty-eight of them (31.7%) had a dilated common bile duct and/or hepatic biochemical parameter abnormalities. They were submitted to endoscopic ultrasonography and endoscopic retrograde cholangiography. Sphincterotomy and sweeping of the common bile duct were performed if endoscopic ultrasonography or endoscopic retrograde cholangiography were considered positive for choledocholithiasis. After sphincterotomy and common bile duct clearance the largest stone was retrieved for measurement. Endoscopic or surgical explorations of the common bile duct were considered the gold-standard methods for the diagnosis of choledocholithiasis. RESULTS: All 68 patients were submitted to laparoscopic cholecystectomy with intraoperative cholangiography with confirmation of the presence of gallstones. Endoscopic ultrasonography was a more sensitivity test than endoscopic retrograde cholangiography (97% vs. 67%) for the detection of choledocholithiasis. When stones >4.0 mm were analyzed, endoscopic ultrasonography and endoscopic retrograde cholangiography presented similar results (96% vs. 90%). Neither the size of the stone nor the common bile duct diameter had influence on endoscopic ultrasonographic performance. CONCLUSIONS: For a group of patients with an intermediate or moderate risk with respect to the likelihood of having common bile duct stones, endoscopic ultrasonography is a better test for the diagnosis of choledocholithiasis when compared to endoscopic retrograde cholangiography mainly for small-sized calculi.