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You JJ, Shen MY, Chen WTL, Fan JW, Shao YC, Feng CL, Chang CC, Su YH, Fingerhut A. Transanal Minimally Invasive Surgery Versus Endoscopic Submucosal Dissection for Rectal Lesions: A Community Hospital Experience. J Laparoendosc Adv Surg Tech A 2024. [PMID: 39084702 DOI: 10.1089/lap.2024.0201] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/02/2024] Open
Abstract
Background: To compare tumor margins and surgical outcomes between transanal minimally invasive surgery (TAMIS) and endoscopic submucosal dissection (ESD) for large or malignant rectal adenomatous polyps. Methods: Single institution retrospective analysis of patients who underwent TAMIS or ESD surgery. Results: In total, 30 consecutive patients with similar demographics who underwent either TAMIS (n = 19) or ESD (n = 11) were included. The median (interquartile range, IQR) tumor distances from the anal verge for TAMIS and ESD were 5 cm (3.5-8) and 3 cm (2-4.25) (P = 0.016). Four in TAMIS and two in ESD occupied more than half of the circumference of the bowel lumen. Five (four in situ and one stage 1) in TAMIS and two (one in situ and one stage 1) in ESD were malignant. The median specimen length, width, and height were 3.2 cm, 2.6 cm, and 1.0 cm and 3.5 cm, 2.0 cm, and 0.3 cm for TAMIS and ESD, respectively. There were no statistically significant differences in tumor circumference, malignant ratios, or specimen sizes. Resection margins were involved in two of the ESD, while none of the TAMIS were involved (P = 0.041). The median (IQR) operative time was 72 (62-89) minutes and 120 (90-180) minutes for TAMIS and ESD (P = 0.005). The median (IQR) follow-up time was 3.3 (0.3-11.7) and 0.9 (0.3-15.4) months for TAMIS and ESD. There were no morbidities, no mortalities, or local recurrences among the two groups. Conclusions: Both TAMIS and ESD were found to be feasible and safe in community hospital practice. Operative time was shorter, and there were no involved margins in TAMIS (versus ESD).
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Affiliation(s)
- Jau-Jie You
- Department of Colorectal Surgery, China Medical University Hsinchu Hospital, Zhubei, Taiwan
| | - Ming-Yin Shen
- Department of Colorectal Surgery, China Medical University Hsinchu Hospital, Zhubei, Taiwan
- Department of Biomedical Engineering and Environmental Sciences, National Tsing Hua University, Hsinchu, Taiwan
| | - William Tzu-Liang Chen
- Department of Colorectal Surgery, China Medical University Hsinchu Hospital, Zhubei, Taiwan
- College of Medicine, China Medical University, Taichung, Taiwan
| | - Jiun-Wei Fan
- Department of Gastroenterology, China Medical University Hsinchu Hospital, Zhubei, Taiwan
| | - Yen-Chen Shao
- Department of Colorectal Surgery, China Medical University Hsinchu Hospital, Zhubei, Taiwan
| | - Chun-Lung Feng
- Department of Gastroenterology, China Medical University Hsinchu Hospital, Zhubei, Taiwan
| | - Chu-Cheng Chang
- Department of Colorectal Surgery, China Medical University Hsinchu Hospital, Zhubei, Taiwan
| | - Yu-Hao Su
- Department of Colorectal Surgery, China Medical University Hsinchu Hospital, Zhubei, Taiwan
| | - Abe Fingerhut
- College of Medicine, China Medical University, Taichung, Taiwan
- Department of General Surgery, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, P. R. China
- Section for Surgical Research, Department of Surgery, Medical University of Graz, Graz, Austria
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Huang LW, Zhong Y. Endoscopic submucosal dissection vs transanal endoscopic surgery for rectal tumors: A systematic review and meta-analysis. World J Clin Cases 2024; 12:95-106. [PMID: 38292620 PMCID: PMC10824170 DOI: 10.12998/wjcc.v12.i1.95] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2023] [Revised: 12/12/2023] [Accepted: 12/18/2023] [Indexed: 01/02/2024] Open
Abstract
BACKGROUND Endoscopic submucosal dissection (ESD) and transanal endoscopic submucosal dissection (TES) are widely employed surgical techniques. However, the comparative efficacy and safety of both remain inconclusive. AIM To comprehensively analyze and discern differences in surgical outcomes between ESD and TES. METHODS We conducted a systematic search of the electronic databases PubMed, Embase, Cochrane Central Register of Controlled Trials, Scopus, and CINAHL from inception till August 2023. We analyzed outcomes including recurrence rate, en bloc resection, R0 resection rate, perforation rate, procedure length, and hospital stay length applying a random-effects inverse-variance model. We assessed publication bias by conducting an Egger's regression test and sensitivity analyses. RESULTS We pooled data from 11 studies involving 1013 participants. We found similar recurrence rates, with a pooled odds ratio of 0.545 (95%CI: 0.176-1.687). En bloc resection, R0 resection, and perforation rate values were also similar for both ESD and TES. The pooled analysis for procedure length indicated a mean difference of -4.19 min (95%CI: -22.73 to 14.35), and the hospital stay was on average shorter for ESDs by about 0.789 days (95%CI: -1.671 to 0.093). CONCLUSION Both ESD and TES displayed similar efficacy and safety profiles across multiple outcomes. Our findings show that individualized patient and surgeon preferences, alongside specific clinical contexts, can be considered when selecting between these two techniques.
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Affiliation(s)
- Long-Wu Huang
- Department of Gastroenterology, Huzhou Third Municipal Hospital, the Affiliated Hospital of Huzhou University, Huzhou 313000, Zhejiang Province, China
| | - Ying Zhong
- Department of Gastroenterology, Huzhou Third Municipal Hospital, the Affiliated Hospital of Huzhou University, Huzhou 313000, Zhejiang Province, China
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Kwik C, El-Khoury T, Pathma-Nathan N, Toh JWT. Endoscopic and trans-anal local excision vs. radical resection in the treatment of early rectal cancer: A systematic review and network meta-analysis. Int J Colorectal Dis 2023; 39:13. [PMID: 38157077 DOI: 10.1007/s00384-023-04584-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/21/2023] [Indexed: 01/03/2024]
Abstract
PURPOSE The management of early-stage rectal cancer in clinical practice is controversial. The aim of this network meta-analysis was to compare oncological and postoperative outcomes for T1T2N0M0 rectal cancers managed with local excision in comparison to conventional radical resection. METHODS A systematic review of Medline, Embase and Cochrane electronic databases was performed. Relevant studies were selected using PRISMA guidelines. The primary outcomes measured were 5-year local recurrence and overall survival. Secondary outcomes included rates of postoperative complication, 30-day mortality, positive margin and permanent stoma formation. RESULTS Three randomized controlled trials and 27 observational studies contributed 8570 patients for analysis. Radical resection was associated with reduced 5-year local recurrence in comparison to local excision. This was statistically significant in comparison to trans-anal local excision (odds ratio (OR) 0.23; 95% confidence interval 0.16-0.30) and favourable in comparison to endoscopic techniques (OR 0.40; 95% confidence interval 0.13-1.23) although this did not reach clinical significance. Positive margin rates were lowest for radical resection. However, 30-day mortality rates, perioperative complications and permanent stoma rates all favoured local excision with no statistically significant difference between endoscopic and trans-anal techniques. CONCLUSION Radical resection of early rectal cancer is associated with the lowest 5-year local recurrence rates and the lowest rate of positive margins. However, this must be balanced with its higher 30-day mortality and complication rates as well as the increased risk of permanent stoma. The emerging potential role of neoadjuvant therapy prior to local resection, and the heterogeneity of its use, as an alternative treatment for early rectal cancer further complicates the treatment paradigm and adds to controversy in this field.
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Affiliation(s)
- Charlotte Kwik
- Department of Colorectal Surgery, Westmead Hospital, Cnr Hawkesbury Road and Darcy Road, Westmead, NSW, Australia.
| | - Toufic El-Khoury
- Department of Colorectal Surgery, Westmead Hospital, Cnr Hawkesbury Road and Darcy Road, Westmead, NSW, Australia
| | - Nimalan Pathma-Nathan
- Department of Colorectal Surgery, Westmead Hospital, Cnr Hawkesbury Road and Darcy Road, Westmead, NSW, Australia
| | - James Wei Tatt Toh
- Department of Colorectal Surgery, Westmead Hospital, Cnr Hawkesbury Road and Darcy Road, Westmead, NSW, Australia.
- Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia.
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Moreira P, Cardoso PM, Macedo G, Santos-Antunes J. Endoscopic Submucosal Dissection, Endoscopic Mucosal Resection, and Transanal Minimally Invasive Surgery for the Management of Rectal and Anorectal Lesions: A Narrative Review. J Clin Med 2023; 12:4777. [PMID: 37510892 PMCID: PMC10381236 DOI: 10.3390/jcm12144777] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2023] [Revised: 07/11/2023] [Accepted: 07/14/2023] [Indexed: 07/30/2023] Open
Abstract
Endoscopic submucosal dissection (ESD), endoscopic mucosal resection (EMR), and transanal minimally invasive surgery (TAMIS) are modern techniques that now play a crucial role in the treatment of colorectal lesions. ESD is a minimally invasive endoscopic procedure that allows for the resection of lesions of any size in a single piece, with clear advantages regarding oncological outcomes and recurrences. However, it is a complex technique, requiring high endoscopic skills, expertise, and specialized training, with higher rates of adverse events expected compared with EMR. EMR is another endoscopic technique used to remove superficial gastrointestinal tumors, particularly those that are limited to the mucosal layer. It is a faster and more accessible procedure, with fewer adverse events, although it only allows for an en-bloc resection of lesions measuring 15-20 mm. TAMIS is a minimally invasive surgical technique used to remove rectal tumors, involving the insertion of a single-port device through the anus, allowing for a better visualization and removal of the tumor with minimal disruption. This article reviews the current applications and evidence regarding these techniques, in search for the most adequate treatment for the removal of lesions in the rectum and anorectal junction, as these locations possess distinct characteristics that demand a more specific approach.
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Affiliation(s)
- Pedro Moreira
- Faculty of Medicine, University of Porto, 4200-450 Porto, Portugal
| | - Pedro Marílio Cardoso
- Faculty of Medicine, University of Porto, 4200-450 Porto, Portugal
- Gastroenterology Department, Centro Hospitalar São João, 4200-319 Porto, Portugal
| | - Guilherme Macedo
- Faculty of Medicine, University of Porto, 4200-450 Porto, Portugal
- Gastroenterology Department, Centro Hospitalar São João, 4200-319 Porto, Portugal
| | - João Santos-Antunes
- Faculty of Medicine, University of Porto, 4200-450 Porto, Portugal
- Gastroenterology Department, Centro Hospitalar São João, 4200-319 Porto, Portugal
- i3S-Instituto de Investigação e Inovação em Saúde, University of Porto, 4099-030 Porto, Portugal
- IPATIMUP-Institute of Molecular Pathology and Immunology, University of Porto, 4200-450 Porto, Portugal
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Berger NF, Sylla P. The Role of Transanal Endoscopic Surgery for Early Rectal Cancer. Clin Colon Rectal Surg 2022; 35:113-121. [PMID: 35237106 PMCID: PMC8885158 DOI: 10.1055/s-0041-1742111] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
Transanal endoscopic surgery (TES), which is performed through a variety of transanal endoluminal multitasking surgical platforms, was developed to facilitate endoscopic en bloc excision of rectal lesions as a minimally invasive alternative to radical proctectomy. Although the oncologic safety of TES in the treatment of malignant rectal tumors has been an area of vigorous controversy over the past two decades, TES is currently accepted as an oncologically safe approach for the treatment of carefully selected early and superficial rectal cancers. TES can also serve as both a diagnostic and potentially curative treatment of partially resected unsuspected malignant polyps. In this article, indications and contraindications for transanal endoscopic excision of early rectal cancer lesions are reviewed, as well as selection criteria for the most appropriate transanal excisional approach. Preoperative preparation and surgical technique for complications of TES will be reviewed, as well as recommended surveillance and management of upstaged tumors.
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Affiliation(s)
| | - Patricia Sylla
- Icahn School of Medicine at Mount Sinai, New York, New York,Division of Colon and Rectal Surgery, Department of Surgery, Mount Sinai Hospital, New York, New York,Address for correspondence Patricia Sylla, MD, FACS, FASCRS Division of Colon and Rectal Surgery, Department of Surgery, Mount Sinai Hospital5 East 98th Street, Box 1259, New York, NY 10029
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Jin R, Bai X, Xu T, Wu X, Wang Q, Li J. Comparison of the efficacy of endoscopic submucosal dissection and transanal endoscopic microsurgery in the treatment of rectal neuroendocrine tumors ≤ 2 cm. Front Endocrinol (Lausanne) 2022; 13:1028275. [PMID: 36704035 PMCID: PMC9873240 DOI: 10.3389/fendo.2022.1028275] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2022] [Accepted: 12/19/2022] [Indexed: 01/11/2023] Open
Abstract
INTRODUCTION Currently, complete tumor resection is considered the most effective treatment for rectal neuroendocrine tumors (NETs). Endoscopic submucosal dissection (ESD) and transanal endoscopic microsurgery (TEM) are recommended for rectalNETs ≤2 cm, but it is not clear which method is better. Thus, we evaluated the efficacy of ESD and TEM in the treatment of rectal neuroendocrine tumors (NETs) ≤ 2 cm. METHODS We conducted a single-centre retrospective cohort study between 2010 and 2021 of rectal NETs ≤ 2 cm in 114 patients with long-term follow-up data who were divided into ESD (n=55) and TEM groups (n=59). Our study assessed differences between groups in the complete resection rate of lesions, recurrence rate, surgical complications, procedure time, and length of hospital stay. RESULTS The co-primary outcomes were the complete resection rate of lesions and the recurrence rate. Compared to that in the ESD group, the complete resection rate was significantly higher in the TEM group (91.5% vs. 70.9%, p=0.005). The median follow-up time was 22 months in our study, and the follow-up outcomes suggested that the rates of recurrence were 1.8% (1/55) and 6.8% (4/59) in the ESD and TEM groups, respectively, with no significant difference between the two groups. The secondary outcomes of the evaluation were surgical complications, procedural time, and length of hospital stay. The rate of complications (gastrointestinal bleeding and perforation) was low in both the ESD (7.3%, 4/55) and TEM (5.1%, 3/59) groups. No difference in hospitalization duration was observed between the two groups in our study. However, the procedure time was significantly shorter in the ESD group than in the TEM group (27.5 min vs. 56 min, p<0.001). CONCLUSIONS Although the rate of complete resection in the TEM group was higher than that in the ESD group, there was no difference in recurrence rates between the two modalities during long-term follow-up. Depending on the qualities of the available hospital resources in the area, one of the two approaches can be adopted.
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Affiliation(s)
- Rui Jin
- Department of Gastroenterology, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China
| | - Xiaoyin Bai
- Department of Gastroenterology, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China
| | - Tianming Xu
- Department of Gastroenterology, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China
- Key Laboratory of Gut Microbiota Translational Medicine Research, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China
| | - Xi Wu
- Department of Gastroenterology, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China
| | - Qipu Wang
- Department of Gastroenterology, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China
- Key Laboratory of Gut Microbiota Translational Medicine Research, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China
| | - Jingnan Li
- Department of Gastroenterology, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China
- Key Laboratory of Gut Microbiota Translational Medicine Research, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China
- *Correspondence: Jingnan Li,
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7
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Naughton AP, Ryan ÉJ, Bardon CT, Boland MR, Aherne TM, Kelly ME, Whelan M, Neary PC, McNamara D, O'Riordan JM, Kavanagh DO. Endoscopic management versus transanal surgery for early primary or early locally recurrent rectal neoplasms-a systematic review and meta-analysis. Int J Colorectal Dis 2020; 35:2347-2359. [PMID: 32860082 DOI: 10.1007/s00384-020-03715-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/10/2020] [Indexed: 02/04/2023]
Abstract
BACKGROUND Both endoscopic techniques and transanal surgery are viable options that allow organ preservation for early rectal neoplasms. Whilst endoscopic approaches are less invasive and carry less morbidity, it is unclear whether they are as oncologically effective. AIM To compare endoscopic techniques with transanal surgery in the management of early rectal neoplasms. METHODS A systematic literature search was performed for randomised and observational studies comparing these techniques. The pre-specified main outcomes measured were en bloc and R0 resection rates and recurrence. Pair-wise meta-analysis was performed. RESULTS This review included 1044 patients. Transanal surgery had increased R0 resection rates (odds ratio (OR) 2.66; 95% CI 1.64; 4.31; p < 0.001) versus endoscopic management. The latter was associated with higher rates of incomplete resection (OR 2.25; 95% CI 1.14, 4.46; p = 0.02) and further intervention (OR 1.78; 95% CI 1.09, 2.88; p = 0.02). There was no difference in the rates of late recurrence (OR 1.01; 95% CI 0.53, 1.91; p = 0.99) or further major surgery (OR 0.87; 95% CI 0.39, 1.94; p = 0.73) between the groups. Endoscopic treatment was associated with a shorter operating time (weighted mean difference (WMD) - 12.08; 95% CI - 18.97, - 5.19; p < 0.001) and LOS (WMD - 1.94; 95% CI - 2.43, - 1.44; p < 0.001), as well as lower rates of urinary retention post-operatively (OR 0.12; 95% CI 0.02, 0.63; p = 0.01). CONCLUSION Endoscopic techniques should be favoured in the setting of benign early rectal neoplasms given their decreased morbidity and increased cost-effectiveness. However, where malignancy is suspected transanal surgery should be the preferred option given the superior R0 resection rate.
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Affiliation(s)
- Ailish P Naughton
- Department of Surgery, Tallaght University Hospital, Dublin, Ireland
| | - Éanna J Ryan
- Department of Surgery, Tallaght University Hospital, Dublin, Ireland.
| | | | - Michael R Boland
- Department of Surgery, Tallaght University Hospital, Dublin, Ireland
| | - Thomas M Aherne
- Department of Surgery, Tallaght University Hospital, Dublin, Ireland
| | - Michael E Kelly
- Department of Surgery, Tallaght University Hospital, Dublin, Ireland
| | - Maria Whelan
- Department of Surgery, Tallaght University Hospital, Dublin, Ireland
| | - Paul C Neary
- Department of Surgery, Tallaght University Hospital, Dublin, Ireland
- School of Medicine, Trinity College Dublin, The University of Dublin, Dublin, Ireland
| | - Deirdre McNamara
- School of Medicine, Trinity College Dublin, The University of Dublin, Dublin, Ireland
- Department of Gastroenterology, Tallaght University Hospital, Dublin, Ireland
| | - James M O'Riordan
- Department of Surgery, Tallaght University Hospital, Dublin, Ireland
- School of Medicine, Trinity College Dublin, The University of Dublin, Dublin, Ireland
| | - Dara O Kavanagh
- Department of Surgery, Tallaght University Hospital, Dublin, Ireland
- School of Medicine, Trinity College Dublin, The University of Dublin, Dublin, Ireland
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Sagae VMT, Ribeiro IB, de Moura DTH, Brunaldi VO, Logiudice FP, Funari MP, Baba ER, Bernardo WM, de Moura EGH. Endoscopic submucosal dissection versus transanal endoscopic surgery for the treatment of early rectal tumor: a systematic review and meta-analysis. Surg Endosc 2019; 34:1025-1034. [PMID: 31754850 DOI: 10.1007/s00464-019-07271-2] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2019] [Accepted: 11/12/2019] [Indexed: 12/14/2022]
Abstract
BACKGROUND Minimally invasive treatment of early-stage rectal lesion has presented good results, with lower morbidity than surgical resection. Transanal endoscopic microsurgery (TEM) and transanal minimally invasive surgery (TAMIS) are the main methods of transanal surgery. However, endoscopic submucosal dissection (ESD) has been gaining ground because it allows en bloc resections with low recurrence rates. The aim of this study was to analyze ESD in comparison with transanal endoscopic surgery. METHODS We searched MEDLINE, EMBASE, SciELO, Cochrane CENTRAL, and Lilacs/Bireme with no restrictions on the date or language of publication. The outcomes evaluated were recurrence rate, complete (R0) resection rate, en bloc resection rate, length of hospital stay, duration of the procedure, and complication rate. RESULTS Six retrospective cohort studies involving a collective total of 326 patients-191 in the ESD group and 135 in the transanal endoscopic surgery group were conducted. There were no statistically significant differences between the groups for any of the outcomes evaluated. CONCLUSIONS For the minimally invasive treatment of early rectal tumor, ESD and surgical techniques do not differ in terms of local recurrence, en bloc resection rate, R0 resection rate, duration of the procedure, length of hospital stay, or complication rate, however, evidence is very low.
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Affiliation(s)
- Vitor Massaro Takamatsu Sagae
- Gastrointestinal Endoscopy Unit, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo - HC/FMUSP, Av. Dr. Enéas de Carvalho Aguiar, 255 - Instituto Central - Prédio dos Ambulatórios - Cerqueira César, São Paulo, SP, CEP: 05403-000, Brazil
| | - Igor Braga Ribeiro
- Gastrointestinal Endoscopy Unit, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo - HC/FMUSP, Av. Dr. Enéas de Carvalho Aguiar, 255 - Instituto Central - Prédio dos Ambulatórios - Cerqueira César, São Paulo, SP, CEP: 05403-000, Brazil.
| | - Diogo Turiani Hourneaux de Moura
- Gastrointestinal Endoscopy Unit, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo - HC/FMUSP, Av. Dr. Enéas de Carvalho Aguiar, 255 - Instituto Central - Prédio dos Ambulatórios - Cerqueira César, São Paulo, SP, CEP: 05403-000, Brazil
- Division of Gastroenterology, Hepatology and Endoscopy, Harvard Medical School, Brigham and Women's Hospital, Boston, MA, USA
| | - Vitor Ottoboni Brunaldi
- Gastrointestinal Endoscopy Unit, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo - HC/FMUSP, Av. Dr. Enéas de Carvalho Aguiar, 255 - Instituto Central - Prédio dos Ambulatórios - Cerqueira César, São Paulo, SP, CEP: 05403-000, Brazil
| | - Fernanda Prado Logiudice
- Gastrointestinal Endoscopy Unit, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo - HC/FMUSP, Av. Dr. Enéas de Carvalho Aguiar, 255 - Instituto Central - Prédio dos Ambulatórios - Cerqueira César, São Paulo, SP, CEP: 05403-000, Brazil
| | - Mateus Pereira Funari
- Gastrointestinal Endoscopy Unit, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo - HC/FMUSP, Av. Dr. Enéas de Carvalho Aguiar, 255 - Instituto Central - Prédio dos Ambulatórios - Cerqueira César, São Paulo, SP, CEP: 05403-000, Brazil
| | - Elisa Ryoka Baba
- Gastrointestinal Endoscopy Unit, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo - HC/FMUSP, Av. Dr. Enéas de Carvalho Aguiar, 255 - Instituto Central - Prédio dos Ambulatórios - Cerqueira César, São Paulo, SP, CEP: 05403-000, Brazil
| | - Wanderley Marques Bernardo
- Gastrointestinal Endoscopy Unit, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo - HC/FMUSP, Av. Dr. Enéas de Carvalho Aguiar, 255 - Instituto Central - Prédio dos Ambulatórios - Cerqueira César, São Paulo, SP, CEP: 05403-000, Brazil
| | - Eduardo Guimarães Hourneaux de Moura
- Gastrointestinal Endoscopy Unit, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo - HC/FMUSP, Av. Dr. Enéas de Carvalho Aguiar, 255 - Instituto Central - Prédio dos Ambulatórios - Cerqueira César, São Paulo, SP, CEP: 05403-000, Brazil
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