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OBJECTIVES: Colorectal endoscopic submucosal dissection (ESD) is a technically complex procedure. The scissor knife mechanism may potentially provide easier and safer colorectal ESD. The aim of this meta-analysis is to evaluate the efficacy and safety of scissor-assisted vs. conventional ESD for colorectal lesions. METHODS: A search strategy was conducted in MEDLINE, Embase, and Lilacs databases from January 1990 to November 2023 according to PRISMA guidelines. Fixed and random-effects models were used for statistical analysis. Heterogeneity was assessed using I2 test. Risk of bias was assessed using the ROBINS-I and RoB-2 tools. Quality of evidence was assessed using the Grading of Recommendations Assessment, Development and Evaluation tool. RESULTS: A total of five studies (three retrospective and two randomized controlled trials, including a total of 1575 colorectal ESD) were selected. The intraoperative perforation rate was statistically lower (risk difference [RD] -0.02; 95% confidence interval [CI] -0.04 to -0.01; P = 0.001; I2 = 0%) and the self-completion rate was statistically higher (RD 0.14; 95% CI 0.06, 0.23; P = 0.0006; I2 = 0%) in the scissor-assisted group compared with the conventional ESD group. There was no statistical difference in R0 resection rate, en bloc resection rate, mean procedure time, or delayed bleeding rate between the groups. CONCLUSION: Scissor knife-assisted ESD is as effective as conventional knife-assisted ESD for colorectal lesions with lower intraoperative perforation rate and a higher self-completion rate.
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Purpose: This study aimed to identify the predictive factors of lymph node metastasis (LNM) in patients with early gastric cancer (EGC) and to evaluate the applicability of the Japanese treatment guidelines for endoscopic resection in the western population. Methods: Five hundred-one patients with pathological diagnoses of EGC were included. Univariate and multivariate analyses were conducted to identify the predictive factors of LNM. EGC patients were distributed according to the indications for endoscopic resection of the Eastern guidelines. The incidence of LNM was evaluated in each group. Results: From 501 patients with EGC, 96 (19.2%) presented LNM. In 279 patients with tumors with submucosal infiltration (T1b), 83 (30%) patients had LNM. Among 219 patients who presented tumors > 3 cm, 63 (29%) patients had LNM. Thirty-one percent of patients with ulcerated tumors presented LMN (33 out of 105). In 76 patients and 24 patients with lymphovascular and perineural invasion, the percentage of LMN was 84% and 87%, respectively. In the multivariate analysis, a tumor diameter >3 cm, submucosal invasion, lymphovascular, and perineural invasion were independent predictors of LMN in EGC. No patient with differentiated, non-ulcerated mucosal tumors presented LNM regardless of tumor size. Three of 17 patients (18%) with differentiated, ulcerated mucosal tumors and ≤ 3 cm presented LNM. No LNM was evidenced in patients with undifferentiated mucosal tumors and ≤ 2 cm. Conclusions: The presence of LNM in Western EGC patients was independently related to larger tumors (>3 cm), submucosal invasion, lymphovascular and perineural invasion. The Japanese absolute indications for EMR are safe in the Western population. Likewise, Western patients with differentiated, non-ulcerated mucosal tumors, and larger than 2 cm are susceptible to endoscopic resection. Patients with undifferentiated mucosal tumors smaller than 2 cm presented encouraging results and ESD could be recommended only for selected cases.
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Video 1Wide-field ESD for Barrett's adenocarcinoma.
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Background and Aim: Endoscopic resection (ER) is the preferred approach to treat early gastric cancer (EGC) in patients without suspected lymph node involvement and that meet the criteria for ER. Surgery is a more aggressive treatment, but it may be associated with less recurrence and the need for reintervention. Previous meta-analyses comparing ER with surgery for EGC did not incorporate the most recent studies, making accurate conclusions not possible. Methods: This systematic review and meta-analysis aimed to examine complete resection, length of hospital stay (LOHS), adverse events (AEs), serious AEs, recurrence, 5-year overall survival (OS), and 5-year cancer-specific survival (CSS) in patients with EGC. Results: A total of 29 cohorts studies involving 20559 patients were included. The ER (n = 7709) group was associated with a lower incidence of AEs (RD = -0.07, 95%CI = -0.1, -0.04, p < 0.0001) and shorter LOHS (95% CI -5.89, -5.32; p < 0,00001) compared to surgery (n = 12850). However, ER was associated with lower complete resection rates (RD = -0.1, 95%CI = -0.15, -0.06; p < 0.00001) and higher rates of recurrence (RD = 0.07, 95%CI = 0.06; p < 0.00001). There were no significant differences between surgery and ER in 5-year OS (RD = -0.01, 95%CI = -0.04, 0.02; p = 0.38), 5-year CSS (RD = 0.01, 95%CI = 0.00, 0.02; p < 0.17), and incidence of serious AEs (RD = -0.03, 95%CI = -0.08, 0.01; p = 0.13). Conclusions: ER and surgery are safe and effective treatments for EGC. ER provides lower rates of AEs and shorter LOHS compared to surgery. Although ER is associated with lower complete resection rates and a higher risk of recurrence, the OS and CSS were similar between both approaches. Systematic Review Registration: https://www.crd.york.ac.uk/PROSPERO/, identifier CRD42021255328.
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INTRODUCTION AND AIMS: Endoscopic submucosal dissection (ESD) is a well-established treatment for superficial gastrointestinal tumors and enables en bloc resection. Adequate tissue tension is important for safe and effective dissection. Simplified magnetic anchor-guided ESD (MAG-ESD) with a neodymium magnet has potential benefits, compared with other current traction methods. We evaluated the feasibility of simplified MAG-ESD in an ex vivo porcine model. MATERIALS AND METHODS: An experimental study was conducted, utilizing the standard ESD technique. An external magnet and an internal magnet, both neodymium magnets, were used for the magnetic anchoring. The internal magnet was attached to an arm of a hemoclip with a 2-0 silk suture. After the incision, the clip with the internal magnet was placed at the edge of the lesion. The external magnet was maneuvered around the surface to apply adequate tension. RESULTS: A total of 15 en bloc ESDs (5 with no magnetic anchoring and 10 with magnetic anchoring) were carried out. Traction and dissection were feasible in all cases and the procedures were completed in fewer than 90min. Lesion size ranged from 15 to 50mm (mean 30mm). Two cases in the group with magnetic anchoring presented with punctate perforation (13.3%). CONCLUSIONS: Our study demonstrated the feasibility of simplified MAG-ESD and en bloc resection in an ex vivo porcine model.
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Ressecção Endoscópica de Mucosa , Animais , Dissecação , Humanos , Fenômenos Magnéticos , Imãs , Neodímio , SuínosRESUMO
Video 1Endoscopic submucosal dissection (ESD) of large rectal lateral spreading tumors (LSTs) that extend to the dentate line with internal hemorrhoids is a challenging procedure because of the increased risk of bleeding from penetrating and hemorrhoidal vessels and the reduced visual field caused by the dilated venous packages and the narrow anal lumen.This video describes novel technical approaches to minimize the risk of intraoperative bleeding.The described approaches are indicated in large rectal LSTs that extend to the dentate line with large internal hemorrhoids. The described selective-vessel approach is also indicated in any vascularized superficial lesion amenable to endoscopic treatment.ESD was performed in the retroflex view using an Evis Exera II video processor, an H180 gastroscope, an ERBE ICC 200, and CO2 insufflation. As tools, IT-nano, needle knife, hook knife, hemostatic forceps, and a distal cap were used. The lifting solution was a mixture of normal saline, hyaluronic acid, epinephrine, and indigo carmine.A hemicircumferential superficial granular lateral spreading tumor was observed in the lower rectum. Indigo carmine dye spray facilitated the identification of the lesion's margin and demonstrated no ulcer, converging folds, or large nodules. After the submucosal (SM) injection, a shallow mucosal incision was made in the retroflex view using a conventional needle knife, followed by the circumferential incision at the proximal side using an IT-nano. The SM layer was dissected at a superficial level to avoid large SM vessels, thus preventing intraoperative bleeding and maintaining a clean surgical field. Small vessels were selectively coagulated mainly by using the small disc located at the back of the insulated tip as the SM later was superficially dissected. To facilitate precise coagulation, a stepwise dissection technique was used for larger vessels. After identification, the vessel was first exposed by dissecting the surrounding SM layer at the left and right sides using the long blade of IT-nano, with blunt dissection of the surrounding tissue at the vessels' posterior aspect using a Hook knife. Double-vessel sealing using a hemostatic forceps was performed both at the rectal and tumor sides. Lastly, the vessel was transected between sealed segments using the IT-nano, without major bleeding. The circumferential incision was completed at the left side and distally extended to the anal canal where large hemorrhoidal bundles were seen. A needle knife was used to complete the SM dissection and, here, the final cut. En bloc resection was successfully achieved without intraoperative bleeding.The en bloc resected specimen was 85 mm in size, and squamous epithelium of the anal canal was observed at the distal margin. Colonoscopy 5 months post-ESD revealed adequate healing, no stenosis and no hemorrhoids.Coagulation and hemostasia should be promptly carried out whenever inadvertent injury to large vessels and subsequent bleeding occurs during lateral exposure, posterior blunt dissection, double coagulation, and transection of vessels.Curative ESD can be achieved in large rectal LSTs that extend to the dentate line with large internal hemorrhoids. Strategies to minimize intraoperative bleeding during ESD should be considered and include the following:â¢An SM dissection from the proximal tumor margin in the retroflex view to circumvent contact with hemorrhoids.â¢A differential level of dissection to prevent inadvertent vessel injury-shallow first to avoid large SM vessels and deeper above the muscular layer closer to the dentate line to shut off blood supply by penetrating hemorrhoidal vessels.â¢Last but not least, a selective approach to vessels to reduce the risk of bleeding, with direct coagulation for small vessels and with lateral exposure, posterior blunt dissection, double-vessel sealing, and transection between sealed segments for larger vessels.
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INTRODUCTION: Non-classical class I human leukocyte antigens (HLA) molecules are known to modulate the function of cytotoxic cells (NK and T CD8+) during viral infection by interacting with inhibitory/activating receptors. However, little is known about the HLA-E/-F genetic variability on arbovirus infections. METHODS: We evaluated by massive parallel sequencing the full HLA-E/-F genetic diversity among patients infected during the arbovirus (ZIKV, DENV, and CHIKV) outbreak leading to a broad range of neurological complications in the Brazilian State of Pernambuco. In parallel, healthy blood donors from the same area were also studied. Plink and R software were used for genetic association study. To limit the false-positive results and enhance the reliability of the results, we adopted P-values <0.01 as significant levels. RESULTS: Compared to controls, the HLA-F alleles: -1610 C (rs17875375), +1383 G (rs17178385), and +3537 A (rs17875384), all in complete linkage disequilibrium with each other (r2 = 1), were overrepresented in patients presenting peripheral spectrum disorders (PSD). The HLA-F*Distal-D haplotype that harbored the -1610 C allele exhibited a trend increase in PSD group. No associations were found for HLA-E. CONCLUSIONS: Our findings showed that the HLA-F genetic background seems to be more important than HLA-E on the susceptibility to PSD complications.
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Infecções por Arbovirus/genética , Infecções por Arbovirus/virologia , Predisposição Genética para Doença/genética , Variação Genética/genética , Antígenos de Histocompatibilidade Classe I/genética , Doenças do Sistema Nervoso/genética , Doenças do Sistema Nervoso/virologia , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Alelos , Arbovírus/patogenicidade , Brasil , Criança , Feminino , Frequência do Gene/genética , Estudos de Associação Genética/métodos , Haplótipos/genética , Humanos , Desequilíbrio de Ligação/genética , Masculino , Pessoa de Meia-Idade , Adulto JovemRESUMO
Resumen Introducción: Los adenomas vellosos son lesiones del tubo digestivo con tendencia alta a la malignidad. Su ubicación en parches de mucosa gástrica ectópica en el esófago cervical determina una presentación atípica de interés tanto clínico como patológico. Objetivo: Presentar un caso de adenoma velloso en la mucosa gástrica ectópica del esófago cervical. Métodos: Describir el caso de un paciente con diagnóstico de adenoma velloso y realizar una revisión de la literatura disponible hasta el momento. Resultados: Se identificó mediante un estudio histopatológico un adenoma tubulovelloso con displasia de bajo grado, cuya ubicación endoscópica era un parche de mucosa ectópica gástrica en el esófago cervical. Conclusiones: La ubicación de los adenomas vellosos en el esófago cervical puede predisponer al desarrollo de lesiones neoplásicas. La evaluación detallada de este segmento, con técnicas como la cromoendoscopia digital de alta definición, permiten la detección temprana de estas lesiones y su oportuna intervención.
Abstract Introduction: Villous adenomas are lesions of the digestive tract with a high tendency to malignancy. Its location in ectopic gastric mucosa patches in the cervical esophagus is an atypical presentation of clinical and pathological interest. Objective: To present a case of villous adenoma in ectopic gastric mucosa of the cervical esophagus. Methods: A case study of a patient with a diagnosis of villous adenoma is presented, as well as a review of the current literature. Results: A tubulovillous adenoma with low-grade dysplasia was identified by histopathological study. Its endoscopic location was a gastric ectopic mucosa patch in the cervical esophagus. Conclusions: The location of villous adenomas in the cervical esophagus may predispose to the development of neoplastic lesions. Detailed evaluation of this segment using techniques, such as high-definition digital chromoendoscopy, would allow for early detection and treatment of these lesions.
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Humanos , Masculino , Adulto , Adenoma Viloso , Esôfago , Mucosa Gástrica , Trato Gastrointestinal , LiteraturaRESUMO
INTRODUCTION AND AIMS: Endoscopic submucosal dissection (ESD) is a well-established treatment for superficial gastrointestinal tumors and enables en bloc resection. Adequate tissue tension is important for safe and effective dissection. Simplified magnetic anchor-guided ESD (MAG-ESD) with a neodymium magnet has potential benefits, compared with other current traction methods. We evaluated the feasibility of simplified MAG-ESD in an ex vivo porcine model. MATERIALS AND METHODS: An experimental study was conducted, utilizing the standard ESD technique. An external magnet and an internal magnet, both neodymium magnets, were used for the magnetic anchoring. The internal magnet was attached to an arm of a hemoclip with a 2-0 silk suture. After the incision, the clip with the internal magnet was placed at the edge of the lesion. The external magnet was maneuvered around the surface to apply adequate tension. RESULTS: A total of 15 en bloc ESDs (five with no magnetic anchoring and 10 with magnetic anchoring) were carried out. Traction and dissection were feasible in all cases and the procedures were completed in fewer than 90 min. Lesion size ranged from 15 to 50 mm (mean 30 mm). Two cases in the group with magnetic anchoring presented with punctate perforation (13.3%). CONCLUSIONS: Our study demonstrated the feasibility of simplified MAG-ESD and en bloc resection in an ex vivo porcine model.
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BACKGROUND AND AIM: Endoscopic submucosal dissection and transanal endoscopic microsurgery are good options for the treatment of rectal adenomas and early rectal carcinomas, but whether long-term outcomes of these procedures are comparable is not known. The aim of this study was to address this question. METHODS: A retrospective single-center study evaluating 98 consecutive procedures between June 2008 and December 2017 was performed in a tertiary cancer center. Consecutive patients who had undergone either endoscopic submucosal resection or transanal endoscopic microsurgery for rectal adenomas and early rectal carcinomas were evaluated, and long-term recurrence and complication rates were compared. RESULTS: Both groups were similar regarding sex, age, preoperative surgical risk, and en bloc resection rate (95.7% in the endoscopic and 100% in the surgical group, P = 0.81). Mean follow-up period was 37.6 months. Lesions resected endoscopically were significantly larger (68.5 mm) than those resected by transanal resection (44.5 mm), P = 0.003. Curative resections occurred in 97.2% of endoscopic resections and 85.2% of the surgical ones (P = 0.04). Comparing resections that fulfilled histologic curative criteria, there were no recurrences in the endoscopic group (out of 69 cases) and two recurrences in the transanal group (8.3% of 24 cases), P = 0.06. Late complications occurred in 12.7% of endoscopic procedures and 25.9% of surgical procedures (P = 0.13). CONCLUSIONS: In our experience, endoscopic submucosal resection seems to have advantages over transanal endoscopic microsurgery, with similar en bloc resection rate and lower rate of late complications and recurrences. Multicenter randomized controlled trials are needed to support our findings.
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Adenoma/cirurgia , Carcinoma/cirurgia , Ressecção Endoscópica de Mucosa/métodos , Neoplasias Retais/cirurgia , Microcirurgia Endoscópica Transanal/métodos , Adenoma/patologia , Idoso , Carcinoma/patologia , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Recidiva Local de Neoplasia/epidemiologia , Recidiva Local de Neoplasia/prevenção & controle , Complicações Pós-Operatórias/epidemiologia , Complicações Pós-Operatórias/prevenção & controle , Neoplasias Retais/patologia , Estudos Retrospectivos , Fatores de Tempo , Resultado do TratamentoRESUMO
La morbilidad y alteración de la calidad de vida asociadas a la resección anterior del recto y amputación abdominoperineal determinaron un gran interés en el desarrollo del abordaje transanal. En los últimos años se ha visto un marcado desarrollo tecnológico en los dispositivos disponible para este abordaje. La cirugía por vía transanal ofrece ventajas en cuanto a sus resultados y complicaciones cuando se la compara a la cirugía por vía abdominal. La cirugía transanal mini-invasiva surge como una alternativa de abordaje videoendoscópico del recto. La resección local por cirugía endoscópica para los pólipos grandes de recto se ha convertido en un nuevo estándar de tratamiento en la mayoría de los centros, obteniendo piezas no fragmentadas con una alta tasa de márgenes negativos. En el presente estudio realizamos una revisión sobre la aplicación de TAMIS (TransAnal Minimally Invasive Surgery) al tratamiento de los pólipos de recto. (AU)
A great interest has developed in implementing trans anal minimally invasive surgery for the treatment of rectal adenomas and early rectal tumors. It present advantages when compare to radical surgery and peace meal endoscopic resections. TAMIS delivers non-fragmented specimens with clear resection margin in the majority of the cases. Such good technical results are mirrored with a low recurrence rate when evaluating rectal adenomas. This is a review of the application of TAMIS for the treatment of rectal adenomas. (AU)
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Humanos , Pessoa de Meia-Idade , Reto/cirurgia , Pólipos Intestinais/cirurgia , Pólipos Intestinais/epidemiologia , Cirurgia Endoscópica Transanal/instrumentação , Cirurgia Endoscópica Transanal/métodos , Complicações Pós-Operatórias , Qualidade de Vida , Neoplasias Retais/cirurgia , Neoplasias Retais/epidemiologia , Morbidade , Resultado do Tratamento , Sobreviventes , Incontinência Fecal/epidemiologiaRESUMO
Achalasia and Treatment of esophageal Adenocarcinoma are commonly associated to surgical resection. Newer technologies in interventional endoscopy gave way to a substantial paradigm shift in the management of these conditions. In the case of achalasia, endoscopic myotomy is rapidly displacing Heller's myotomy as the gold standard in many centers. Early stage neoplasia in Barrett's esophagus (BE) comprising high-grade dysplasia (HGD), intramucosal and, in some cases, submucosal carcinoma is now being treated without the need of esophagectomy. This review presents a summary of the most relevant endoscopic techniques for both achalasia and esophageal cancer. Endoscopic advances in diagnostic and therapeutic arenas allow for minimally invasive therapies and organ preservation in most settings of achalasia and early stage neoplasia of the esophagus provided that the clinical setting and physician's expertise are prepared for this approach.
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Introducción: La disección submucosal endoscópica con Hybrid Knife (DSEH) es una técnica prometedora para la resección de tumores en etapa temprana. Hay poca data en Latinoamérica. Pacientes y métodos: Estudio prospectivo-descriptivo (marzo 2011 - marzo 2012). Se incluyeron 25 pacientes (16 hombres, 9 mujeres), edades comprendidas entre 52-72 años (X=62,52 años). Se realizaron 25 procedimientos DSEH. Las indicaciones fueron: tumores subepiteliales (7), neoplasia de colon y recto (16), neoplasia precoz gástrica (2). Resultados: DSEH fue técnicamente posible en todas (25) las lesiones (100%). La resección en bloque y márgenes libres de lesión se obtuvieron en todos los casos. El tamaño de la mucosa disecada fue entre 2-7 cms (X=3,8 cms). El tiempo endoscópico fue entre 45-120 minutos(X=84,4 minutos). Perforación ocurrió en 2 casos, siendo resuelta con tratamiento endoscópico (clips). Mortalidad no fue reportada. Conclusiones: Los resultados preliminares sugieren que la DSE con Hibrid Knife (DSEH), parece ser una buena opción para el tratamiento endoscópico de tumores en etapa temprana gástricos, recto colónico y tumores carcinoides. Estudios controlados, aleatorizados de la DSE con Hibrid Knife, en comparación con otros dispositivos son necesarios.
Introduction: Endoscopic submucosal dissection Hybrid Knife (ESD-HK) is a promising technique for resection of early stage tumors. Few data in Latin America. Patients and methods: Prospective, descriptive study (March 2011-2012). 25 patients (16 men, 9 women), mean age 62.52 years (52-72 years).25 procedures were performed. Indications: sub-epithelial tumors (7), colorectal neoplasia (16) early gastric neoplasia (2) Results: ESD-HK was technically possible in all (25) lesions (100%). En bloc resection and free margins were obtained in all cases. The diameter of dissected mucosa was between 2-7 cms(X=3.8 cms) The time was between 45-120 minutes(X= 84.4 minutes). Perforation occurred in 2 cases being resolved with endoscopic treatment (clips). Mortality was not reported. Conclusions: Our preliminary results suggest that the DSE with Hibrid Knife (DSEH) seems to be a good option for endoscopic treatment of early stage gastric tumors, colon and rectal carcinoid tumors. Studies controlled, randomized DSE with Hibrid Knife, compared with other devices are needed.
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BACKGROUND: To investigate the available data on the treatment of early colorectal cancer (CRC), either endoscopically or surgically. METHODS: Two independent reviewers searched MEDLINE, EMBASE, CENTRAL COCHRANE, LILACS and EBSCO for articles published up to August 2015. No language or dates filters were applied. Inclusion criteria were studies with published data about patients with early colonic or rectal cancer undergoing either endoscopic resection (i.e., mucosectomy or submucosal dissection) or surgical resection (i.e., open or laparoscopic). Extracted data items undergoing meta-analysis were en bloc resection rate, curative resection rate, and complications. A complementary analysis was performed on procedure time. The risk of bias among studies was evaluated with funnel-plot expressions, and sensitivity analyses were carried out whenever a high heterogeneity was found. The risk of bias within studies was assessed with the Newcastle score. RESULTS: A total of 12,819 articles were identified in the preliminary search. After applying inclusion and exclusion criteria, three cohort studies with a total of 768 patients undergoing endoscopic resection and 552 patients undergoing surgical resection were included. The en bloc resection rate risk difference was -11% [-13%, -8% confidence interval (CI)], demonstrating worse outcome results for the endoscopic resection group as compared to the surgical resection group [number need to harm (NNH) =10]. The curative resection rate risk difference was -9% [(-12%, 6% CI)] after a sensitivity analysis was performed, which also demonstrated worse outcomes in the intervention group (NNH =12). The complications rate exhibited a -7% risk difference [(-11%, -4% CI)], denoting a lesser number of complications in the endoscopic group [Number Need to Treat (NNT =15). A complementary analysis of procedure time with two of the selected studies demonstrated a mean difference of -118.32 min [(-127.77, -108.87 CI)], in favor of endoscopic resection, even though such data lacks homogeneity across studies, and could be heavily influenced by local expertise. Long-term results were found in only one study and therefore were not included in the final analysis. CONCLUSIONS: According to the current available data, the treatment of early CRC by surgical resection is associated with higher curative resection rates and higher en bloc resection rates, despite of higher complications rates, as compared to endoscopic resection. Shorter procedure times are associated with the endoscopic methods of treatment, however high heterogeneity levels limit this conclusion.
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BACKGROUND: Endoscopic submucosal dissection (ESD) of extensive superficial cancers of the esophagus may progress with high rates of postoperative stenosis, resulting in significantly decreased quality of life. Several therapies are performed to prevent this, but have not yet been compared in a systematic review. METHODS: A systematic review of the literature and meta-analysis were performed using the MEDLINE, Embase, Cochrane, LILACS, Scopus, and CINAHL databases. Clinical trials and observational studies were searched from March 2014 to February 2015. Search terms included: endoscopy, ESD, esophageal stenosis, and esophageal stricture. Three retrospective and four prospective (three randomized) cohort studies were selected and involved 249 patients with superficial esophageal neoplasia who underwent ESD, at least two-thirds of the circumference. We grouped trials comparing different techniques to prevent esophagus stenosis post-ESD. RESULTS: We conducted different meta-analyses on randomized clinical trials (RCT), non-RCT, and global analysis. In RCT (three studies, n = 85), the preventive therapy decreased the risk of stenosis (risk difference = -0.36, 95 % CI -0.55 to -0.18, P = 0.0001). Two studies (one randomized and one non-randomized, n = 55) showed that preventative therapy lowered the average number of endoscopy dilatations (mean difference = -8.57, 95 % CI -13.88 to -3.25, P < 0.002). There were no significant differences in the three RCT studies (n = 85) in complication rates between patients with preventative therapy and those without (risk difference = 0.02, 95 % CI -0.09 to 0.14, P = 0.68). CONCLUSIONS: The use of preventive therapy after extensive ESD of the esophagus reduces the risk of stenosis and the number of endoscopic dilatations for resolution of stenosis without increasing the number of complications.
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Adenocarcinoma/cirurgia , Carcinoma de Células Escamosas/cirurgia , Ressecção Endoscópica de Mucosa/métodos , Neoplasias Esofágicas/cirurgia , Estenose Esofágica/prevenção & controle , Esofagoscopia/métodos , Complicações Pós-Operatórias/prevenção & controle , Ressecção Endoscópica de Mucosa/efeitos adversos , Estenose Esofágica/etiologia , Esofagoscopia/efeitos adversos , Humanos , Complicações Pós-Operatórias/etiologia , Qualidade de VidaRESUMO
The relevance and interest in discussing on flat polyps is mainly due to the various challenges involved in its diagnosis and therapeutical difficulties, being the endoscopic route the state of the art nowadays, as well as their follow up and subsequent controls. Available diagnostic technologies have improved significantly and are widespread among digestive endoscopy units. Endoscopy treatment includes EMR(endoscopic mucosal resection), ESD(endoscopic submucosal dissection), ablation and even transmural resections. Prevention and treatment of complications is a major issue in these endoscopic solutions. Multiple variables related with flat lesions are analysed in this review, such as serrated lesions, laterally spreading tumors, and flat lesions meaning dysplasia and cancer in inflammatory bowel disease patients, among others. Complete resections should be ensured in order to avoid interval colon polyps and cancer, preventing the development of colon cancer, which is our major goal.
El interés actual y la relevancia de discutir sobre el pólipo planoestá en los desafíos que se enfrentan tanto en el terreno del diagnóstico como en su resolución terapéutica, mayormente endoscópica, su seguimiento y controles posteriores. Los medios diagnósticos endoscópicos se han perfeccionado y se encuentran disponibles en muchos centros. Las armas disponibles en esta terapia incluyen hoy la EMR (endoscopic mucosal resection), ESD (endoscopic submucosal dissection), la ablación y terapias transmurales. Se cuenta con elementos para prevenir y tratar complicaciones de su manejo. Múltiples variables de las lesiones planas se discutirán en esta revisión, como las lesiones serradas, los tumores de extensión lateral (laterally spreading tumors; LSTs) y las lesiones planas que significan displasia y cáncer en pacientes portadores de enfermedad inflamatoria intestinal, entre otros. Debemos preocuparnos de su resección completa, evitando así recidivas y cáncer colorrectal de intervalo, avanzando en nuestra lucha en la prevención de esta patología.
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Humanos , Pólipos do Colo/diagnóstico , Pólipos do Colo/cirurgia , Colonoscopia/métodos , Neoplasias Colorretais/diagnóstico , Neoplasias Colorretais/cirurgia , Colectomia , Mucosa Intestinal/cirurgiaRESUMO
El cáncer gástrico es la causa más frecuente de cáncer en países de Asia Oriental, Europa Oriental y algunas regiones de Latino América. El pronóstico del cáncer gástrico avanzado es pobre, sin embargo, el pronóstico del cáncer gástrico temprano (CGT) es muy favorable con datos de sobrevida libre de enfermedad a cinco años, que alcanzan el 100%. El diagnóstico temprano se logra realizando una endoscopia de tamizaje completa, detallada y de alta calidad. Recientemente, se ha propuesto la endoscopia sistemática alfanumérica codificada (SACE), la cual ha probado su eficacia en Colombia al diagnosticar CGT a una tasa de 0,3% en individuos sanos de riesgo medio. Una vez diagnosticado el CGT, la endoscopia terapéutica desempeña un papel fundamental en el tratamiento curativo de la enfermedad. Entre las diferentes técnicas de resección, la disección endoscópica de la submucosa (ESD) ha demostrado excelentes tasas de curabilidad y resultados de sobrevida a cinco años similares a la gastrectomía, pero con menos morbilidad, constituyéndose actualmente en el tratamiento de elección en estos casos. Fundamentos espaciales y visuales, además de entrenamiento bajo la dirección de expertos calificados en centros de formación acreditados, son necesarios para adquirir competencia en ESD. Estas bases educacionales, tanto para el diagnóstico, como para el tratamiento del CGT, son fundamentales para aumentar la frecuencia y la tasa de curabilidad del cáncer gástrico en Latino América y el mundo.
Gastric cancer ranks as the most common malignant tumor in East Asia, Eastern Europe, and parts of Latin America. Although advanced gastric cancer carries a poor prognosis, survival rates of early gastric cancer, however, are favourable with a 5-year disease-free survival reaching almost 100%. High quality screening esophagogastroduodenoscopy is a key stone for early diagnosis. Recently, systematic alphanumeric coded endoscopy (SACE) has been proposed as a new method to improve detection of early gastric cancer. SACE has proved its efficacy in Colombia, diagnosing early gastric cancer at a rate of 0.3% in healthy average risk individuals. After the diagnosis, therapeutic endoscopy is essential to achieve minimally invasive curative treatment. Among other methods, the endoscopic submucosal dissection technique has demonstrated excellent curability and disease-free survival rates, with less morbidity when compared to gastrectomy, currently constituting the preferred treatment for early gastric cancer. Spatial and visual fundaments, along with special training under the supervision of qualified experts and in recognised institutions, are necessary to obtain proficiency in ESD. This educational basis constitutes the fundaments to increase early diagnosis and curative treatment for gastric cancer in Latin America and the world.
Assuntos
Humanos , Neoplasias Gástricas/cirurgia , Neoplasias Gástricas/diagnóstico , Endoscopia Gastrointestinal/métodos , Endoscopia Gastrointestinal/instrumentação , Ressecção Endoscópica de MucosaRESUMO
El tratamiento del cáncer gástrico temprano ha experimentado cambios revolucionarios en las décadas desde la aparición del tratamiento endoscópico. En la actualidad, la mayoría de estas lesiones tempranas son tratados con disección endoscópica de la submucosa (ESD). Debido a la excelente programa de detección implementado en Japón casi la mitad de todos los casos de cáncer gástrico no se tratan con la EDS. El objetivo de este artículo de revisión es facilitar el uso de esta técnica por endoscopistas latinoamericanos y así beneficiar a nuestros pacientes. Para ello ofrecemos una descripción detallada de la EDS, mostrar el estado actual de las indicaciones de esta técnica, y explicar las limitaciones de esta técnica. Este estudio fue realizado por endoscopistas entrenados en la EDS en Japón y bajo la supervisión de un endoscopista experto japonés (TT) que se habían realizado más de 4.000 con disección endoscópica de la submucosa a partir de principios de 2012.
The treatment of early gastric cancer has undergone revolutionary changes in the decades since the advent of endoscopic management. Currently, most of these early lesions are treated with endoscopic submucosal dissection (ESD). Due to the excellent screening program implemented in Japan almost half of all cases of gastric cancer there are treated with ESD. The aim of this review article is to facilitate the use of this technique by Latin American endoscopists and thus benefit our patients. To this end we provide a detailed description of ESD, show the current state of indications for this technique, and explain the limitations of this technique. This study was conducted by endoscopists trained in ESD in Japan and supervised by an expert Japanese endoscopist (TT) who had performed more than 4,000 with endoscopic submucosal dissections as of the beginning of 2012.
Assuntos
Humanos , Masculino , Feminino , Adulto , Dissecação , Neoplasias GástricasRESUMO
OBJETIVO. Reportar el primer caso de disección submucosa endoscópica (DSE) en Costa Rica y analizar el futuro impacto de esta técnica en el abordaje del cáncer gástrico precoz en este país. Pacientes y métodos. Presentamos el caso de una paciente de 67 años, quien tras una endoscopia digestiva alta por leve epigastralgia, se le encuentra una lesión elevada sésil no ulcerada (0-IIa) de aproximadamente 12 milímetros localizada en el antro hacia la curvatura mayor. Posterior al resultado histopatológico de adenocarcinoma bien diferenciado limitado a mucosa, la paciente fue sometida a una disección submucosa en una pieza (en-bloc) de la lesión por vía endoscópica. RESULTADOS. La DSE fue realizada sin ninguna complicación, como sangrado o perforación, intra o postoperatoria. El tiempo operatorio fue de 65 minutos. Con el análisis histopatológico del especimen en-bloc se confirmó el diagnóstico de adenocarcinoma intramucoso con márgenes negativos. CONCLUSIÓN. La DSE promete ser una excelente alternativa para el tratamiento curativo del cáncer gástrico precoz, siendo un método más costo-efectivo, y menos invasivo, ofreciendo una mejor calidad de vida al paciente con iguales resultados a largo plazo que la cirugía convencional a cielo abierto.
OBJECTIVES. To report the first case of endoscopic submucosal dissection (ESD) in Costa Rica and to analyze the future impact of this technique for the treatment of early gastric cancer in this country. PATIENTS AND METHODS. We present the case of a 67-year-old woman who underwent an upper endoscopy for mild epigastralgia, resulting in a 12 mm non-ulcerated sessile lesion (0-IIa) located in the antrum at the greater curvature. After biopsy confirmation of a well-differentiated adenocarcinoma limited to the mucosa, the patient underwent anendoscopic submucosal dissection for the en-bloc resection of the lesion. RESULTS. The ESD was successfully performed without intra- or postoperative complications such as bleeding and perforation. Operation time was 65 minutes. Histopathological analysis of the en-bloc specimen confirmed the diagnosis of intramucosal well differentiated adenocarcinoma with negative margins. CONCLUSION. ESD is novel alternative for the curative treatment of early gastric cancer, due to its cost-effectiveness, less invasiveness, which provides a better quality of life for the patient than that of conventional open surgery with same long-term results.