Comparing outcomes of single-use vs reusable ureteroscopes: a systematic review and meta analysis

Flexible ureterolithotripsy is a frequent urological procedure, usually used to remove stones from the kidney and upper ureter. Reusable uretero-scopes were the standard tool for that procedure, but recent concerns related to sterility and maintenance and repair costs created the opportunity to develop new technologies. In 2016, the first single-use digital flexible ureteroscope was introduced. Since then, other single-use ureteroscopes were developed, and studies compared them with the reusable ureteroscopes with conflicting results. The purpose of this study is to describe the literature that compares the performance of single-use and reusable flexible ureteroscopes in retrograde intrarenal surgery for urinary stones. A Systematic Review was performed in October 2022 in accordance with the Cochrane Handbook and the Preferred Reporting Items for Systematic Reviews and MetaAnalyses (PRISMA). A search in MEDLINE, EMBASE, Web of Science, Google Scholar and LILACS retrieved 10,039 articles. After screening, 12 articles were selected for the Meta-Analysis. No differences were found in stone-free rate (OR 1.31, CI 95% [0.88, 1.97]), operative time (MD 0.12, CI 95% [-5.52, 5.76]), incidence of post-operative fever (OR 0.64, CI 95% [0.22, 1.89]), or incidence of post-operative urinary tract infection (OR 0.63 CI 95% [0.30, 1.32]). No differences were observed in the studied variables. Hence, the device choice should rely on the availability, cost analysis and surgeons' preference.

Antibiotics prophylaxis at the time of catheter removal after radical prostatectomy: a systematic review of the literature and meta-analysis

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.

Comparing financing models for supplementary healthcare in appendectomy: activity-based costing (fee-for-service) vs. diagnosis related group remuneration (bundled payment) - a systematic review and meta-analysis

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.

Does displacement of lower pole stones during retrograde intrarenal surgery improves stone-free status? A systematic review and meta-analysis

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.

Tamsulosin vs. Tadalafil as medical expulsive therapy for distal ureteral stones: a systematic review and meta-analysis

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.

Palliative therapy for malignant gastric outlet obstruction: how does the endoscopic ultrasound-guided gastroenterostomy compare with surgery and endoscopic stenting? A systematic review and meta-analysis

Introduction

The gold-standard procedure to address malignant gastric outlet obstruction (MGOO) is surgical gastrojejunostomy (SGJJ). Two endoscopic alternatives have also been proposed: the endoscopic stenting (ES) and the endoscopic ultrasound-guided gastroenterostomy (EUS-G). This study aimed to perform a thorough and strict meta-analysis to compare EUS-G with the SGJJ and ES in treating patients with MGOO.

Materials and Methods

Studies comparing EUS-G to endoscopic stenting or SGJJ for patients with MGOO were considered eligible. We conducted online searches in primary databases (MEDLINE, EMBASE, Lilacs, and Central Cochrane) from inception through October 2021. The outcomes were technical and clinical success rates, serious adverse events (SAEs), reintervention due to obstruction, length of hospital stay (LOS), and time to oral intake.

Results

We found similar technical success rates between ES and EUS-G but clinical success rates favored the latter. The comparison between EUS-G and SGJJ demonstrated better technical success rates in favor of the surgical approach but similar clinical success rates. EUS-G shortens the LOS by 2.8 days compared with ES and 5.8 days compared with SGJJ. Concerning reintervention due to obstruction, we found similar rates for EUS-G and SGJJ but considerably higher rates for ES compared with EUS-G. As to AEs, we demonstrated equivalent rates comparing EUS-G and SGJJ but significantly higher ones compared with ES.

Conclusion

Despite being novel and still under refinement, the EUS-G has good safety and efficacy profiles compared with SGJJ and ES.

Quality indicators in colonoscopy: observational study in a supplementary health system

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.

EUS-guided choledochoduodenostomy for malignant biliary obstruction: A multicenter comparative study between plastic and metallic stents

Background and Objectives

EUS-guided choledochoduodenostomy (EUS-CDS) is commonly employed to address malignant biliary obstruction (MBO) after a failed ERCP. In this context, both self-expandable metallic stents (SEMSs) and double-pigtail stents (DPSs) are suitable devices. However, few data comparing the outcomes of SEMS and DPS exist. Therefore, we aimed to compare the efficacy and safety of SEMS and DPS at performing EUS-CDS.

Methods

We conducted a multicenter retrospective cohort study between March 2014 and March 2019. Patients diagnosed with MBO were considered eligible after at least one failed ERCP attempt. Clinical success was defined as a drop of direct bilirubin levels ≥ 50% at 7 and 30 postprocedural days. Adverse events (AEs) were categorized as early (≤7 days) or late (>7 days). The severity of AEs was graded as mild, moderate, or severe.

Results

Forty patients were included, 24 in the SEMS group and 16 in the DPS group. Demographic data were similar between the groups. Technical success rates and clinical success rates at 7 and 30 days were similar between the groups. Similarly, we found no statistical difference in the incidence of early or late AEs. However, there were two severe AEs (intracavitary migration) in the DPS group and none in the SEMS cohort. Finally, there was no difference in median survival (DPS 117 days vs. SEMS 217 days; P = 0.99).

Conclusion

EUS-guided CDS is an excellent alternative to achieve biliary drainage after a failed ERCP for MBO. There is no significant difference regarding the effectiveness and safety of SEMS and DPS in this context.

DIFFICULT BILIARY CANNULATION: SHOULD WE ALWAYS TRY A SECOND ERCP AFTER A FAILED NEEDLE-KNIFE FISTULOTOMY?

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.

Gastrointestinal mucosal damage in patients with COVID-19 undergoing endoscopy: an international multicentre study

BACKGROUND

Although evidence suggests frequent gastrointestinal (GI) involvement during coronavirus disease 2019 (COVID-19), endoscopic findings are scarcely reported.

AIMS

We aimed at registering endoscopic abnormalities and potentially associated risk factors among patients with COVID-19.

METHODS

All consecutive patients with COVID-19 undergoing endoscopy in 16 institutions from high-prevalence regions were enrolled. Mann-Whitney U, χ2 or Fisher's exact test were used to compare patients with major abnormalities to those with negative procedures, and multivariate logistic regression to identify independent predictors.

RESULTS

Between February and May 2020, during the first pandemic outbreak with severely restricted endoscopy activity, 114 endoscopies on 106 patients with COVID-19 were performed in 16 institutions (men=70.8%, median age=68 (58-74); 33% admitted in intensive care unit; 44.4% reporting GI symptoms). 66.7% endoscopies were urgent, mainly for overt GI bleeding. 52 (45.6%) patients had major abnormalities, whereas 13 bled from previous conditions. The most prevalent upper GI abnormalities were ulcers (25.3%), erosive/ulcerative gastro-duodenopathy (16.1%) and petechial/haemorrhagic gastropathy (9.2%). Among lower GI endoscopies, 33.3% showed an ischaemic-like colitis.Receiver operating curve analysis identified D-dimers >1850 ng/mL as predicting major abnormalities. Only D-dimers >1850 ng/mL (OR=12.12 (1.69-86.87)) and presence of GI symptoms (OR=6.17 (1.13-33.67)) were independently associated with major abnormalities at multivariate analysis.

CONCLUSION

In this highly selected cohort of hospitalised patients with COVID-19 requiring endoscopy, almost half showed acute mucosal injuries and more than one-third of lower GI endoscopies had features of ischaemic colitis. Among the hospitalisation-related and patient-related variables evaluated in this study, D-dimers above 1850 ng/mL was the most useful at predicting major mucosal abnormalities at endoscopy.

TRIAL REGISTRATION NUMBER

ClinicalTrial.gov (ID: NCT04318366).

Robotic endoscopy. A review of the literature

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.

EUS-FNA WITH 19 OR 22 GAUGES NEEDLES FOR GASTRIC SUBEPITHELIAL LESIONS OF THE MUSCLE LAYER

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.

Papillary fistulotomy vs conventional cannulation for endoscopic biliary access: A prospective randomized trial

AIM

To compare the cannulation success, biochemical profile, and complications of the papillary fistulotomy technique vs catheter and guidewire standard access.

METHODS

From July 2010 to May 2017, patients were prospectively randomized into two groups: Cannulation with a catheter and guidewire (Group I) and papillary fistulotomy (Group II). Amylase, lipase and C-reactive protein at T0, as well as 12 h and 24 h after endoscopic retrograde cholangiopancreatography, and complications (pancreatitis, bleeding, perforation) were recorded.

RESULTS

We included 102 patients (66 females and 36 males, mean age 59.11 ± 18.7 years). Group I and Group II had 51 patients each. The successful cannulation rates were 76.5% and 100%, respectively (P = 0.0002). Twelve patients (23.5%) in Group I had a difficult cannulation and underwent fistulotomy, which led to successful secondary biliary access (Failure Group). The complication rate was 13.7% (2 perforations and 5 mild pancreatitis) vs 2.0% (1 patient with perforation and pancreatitis) in Groups I and II, respectively (P = 0.0597).

CONCLUSION

Papillary fistulotomy was more effective than guidewire cannulation, and it was associated with a lower profile of amylase and lipase. Complications were similar in both groups.

Endoscopic Ultrasonography-Guided Hemostasis Techniques

Endoscopic ultrasonography (EUS)-guided hemostasis is an evolving technique that has the potential to improve the care of patients with refractory variceal and nonvariceal gastrointestinal bleeding. EUS-guided treatment of fundal varices with coil and/or cyanoacrylate seems to be highly effective in active bleeding, as well as for primary and secondary bleeding prophylaxis. Reports of EUS-guided treatment of refractory nonvariceal sources of bleeding are more scarce, but show high success rates. The procedures involve a medium to high technical difficulty level, and this has been replicated worldwide.

SEDATION IN COLONOSCOPY BY USING THREE DIFFERENT PROPOFOL INFUSION METHODS AND ANALYSIS OF PLASMA CONCENTRATION LEVELS: A PROSPECTIVE COMPARATIVE STUDY

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.

Endoscopic approach for management of biliary strictures in liver transplant recipients: A systematic review and meta-analysis

The most common biliary complication after liver transplantation is anastomotic stricture (AS) and it can occur isolated or in combination with other complications. Liver graft from a cadaveric donor or a living donor has an influence on the incidence of biliary strictures as well as on the response to endoscopic treatment. Endoscopic treatment using balloon dilation and insertion of biliary stents by endoscopic retrograde cholangiopancreatography (ERCP) is the initial approach to these complications.

AIM

The aim of this article is to compare different endoscopic techniques to treat post-liver transplantation biliary strictures.

METHODS

The search was carried out on MEDLINE, EMBASE, Scielo-LILACS and Cochrane Library databases through June 2015. A total of 1100 articles were retrieved. Ten clinical trials were analyzed, and seven were included in the meta-analysis.

CONCLUSIONS

The endoscopic treatment of AS was equally effective when compared the use of fully covered self-expandable metal stents (FCSEMS) vs. plastic stents, but the use of FCSEMS was associated with a lower complication risk. The treatment of AS with balloon dilation or balloon dilation associated with plastic stents presented similar results. Deceased donor liver transplantation reduced the risk of biliary stenosis and the endoscopic treatment in these patients was more effective when compared with Living donor liver transplantation.

ENDOSCOPIC ULTRASOUND IN THE EVALUATION OF UPPER SUBEPITHELIAL LESIONS

BACKGROUND

Endoscopic ultrasound is considered the best imaging test for the diagnosis and evaluation of subepithelial lesions of the gastrointestinal tract.

OBJECTIVE

The present study aims to describe the endosonographic characteristics of upper gastric subepithelial lesions and our experience using endoscopic ultrasound for evaluation of such lesions.

METHODS

Retrospective data study of 342 patients who underwent endoscopic ultrasound evaluation of subepithelial lesions.

RESULTS

Lesions 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.

CONCLUSION

Stomach 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.

Endoscopic stenting for inoperable malignant biliary obstruction: A systematic review and meta-analysis

AIM: To analyze through meta-analyses the benefits of two types of stents in the inoperable malignant biliary obstruction.

METHODS: A systematic review of randomized clinical trials (RCT) was conducted, with the last update on March 2015, using EMBASE, CINAHL (EBSCO), MEDLINE, LILACS/CENTRAL (BVS), SCOPUS, CAPES (Brazil), and gray literature. Information of the selected studies was extracted in sight of six outcomes: primarily regarding dysfunction, complication and re-intervention rates; and secondarily costs, survival, and patency time. The data about characteristics of trial participants, inclusion and exclusion criteria and types of stents were also extracted. The bias was mainly assessed through the JADAD scale. This meta-analysis was registered in the PROSPERO database by the number CRD42014015078. The analysis of the absolute risk of the outcomes was performed using the software RevMan, by computing risk differences (RD) of dichotomous variables and mean differences (MD) of continuous variables. Data on RD and MD for each primary outcome were calculated using the Mantel-Haenszel test and inconsistency was qualified and reported in χ² and the Higgins method (I²). Sensitivity analysis was performed when heterogeneity was higher than 50%, a subsequent assay was done and other findings were compiled. Student’s t-test was used for the comparison of weighted arithmetic means regarding secondary outcomes.

RESULTS: Initial searching identified 3660 studies; 3539 were excluded through title, repetition, and/or abstract, while 121 studies were fully assessed and were excluded mainly because they did not compare self-expanding metal stents (SEMS) and plastic stents (PS), leading to thirteen RCT selected, with 13 articles and 1133 subjects meta-analyzed. The mean age was 69.5 years old, that were affected mostly by bile duct (proximal) and pancreatic tumors (distal). The preferred SEMS diameter used was the 10 mm (30 Fr) and the preferred PS diameter used was 10 Fr. In the meta-analysis, SEMS had lower overall stent dysfunction compared to PS (21.6% vs 46.8%, P < 0.00001) and fewer re-interventions (21.6% vs 56.6%, P < 0.00001), with no difference in complications (13.7% vs 15.9%, P = 0.16). In the secondary analysis, the mean survival rate was higher in the SEMS group (182 d vs 150 d, P < 0.0001), with a higher patency period (250 d vs 124 d, P < 0.0001) and a lower cost per patient (4193.98 vs 4728.65 Euros, P < 0.0985).

CONCLUSION: SEMS are associated with lower stent dysfunction, lower re-intervention rates, better survival, and higher patency time. Complications and costs showed no difference.

Reality named endoscopic ultrasound biliary drainage

Endoscopic ultrasound (EUS) is used for diagnosis and evaluation of many diseases of the gastrointestinal (GI) tract. In the past, it was used to guide a cholangiography, but nowadays it emerges as a powerful therapeutic tool in biliary drainage. The aims of this review are: outline the rationale for endoscopic ultrasound-guided biliary drainage (EGBD); detail the procedural technique; evaluate the clinical outcomes and limitations of the method; and provide recommendations for the practicing clinician. In cases of failed endoscopic retrograde cholangiopancreatography (ERCP), patients are usually referred for either percutaneous transhepatic biliary drainage (PTBD) or surgical bypass. Both these procedures have high rates of undesirable complications. EGBD is an attractive alternative to PTBD or surgery when ERCP fails. EGBD can be performed at two locations: transhepatic or extrahepatic, and the stent can be inserted in an antegrade or retrograde fashion. The drainage route can be transluminal, duodenal or transpapillary, which, again, can be antegrade or retrograde [rendezvous (EUS-RV)]. Complications of all techniques combined include pneumoperitoneum, bleeding, bile leak/peritonitis and cholangitis. We recommend EGBD when bile duct access is not possible because of failed cannulation, altered upper GI tract anatomy, gastric outlet obstruction, a distorted ampulla or a periampullary diverticulum, as a minimally invasive alternative to surgery or radiology.

Cholangioscopy in bile duct disease: a case series

CONTEXT

Direct endoscopic visualization of biliopancreatic duct is certainly one of the greatest advances of therapeutic endoscopy. The use of a single-operator cholangioscopy platform (SpyGlass) is a promising technique in the evaluation of diseases such as indeterminate biliary stricture and giant choledocholitiasis. This is the first Brazilian case series using this technology.

METHODS

We report a case series of 20 patients in whom SpyGlass was used with diagnostic and therapeutic intention.

RESULTS

Most patients were female (60%) and the median age was 48 years (ranging from 14 to 94). Choledocholitiasis was the most common indication (12/20), and electrohydraulic lithotripsy was applied in eight (66%). Electrohydraulic lithotripsy was successful in seven (87.5%) patients. Partial stone fragmentation occurred in one patient with large stone causing stone-choledochal disproportion, which was conducted with biliary plastic stent placement and a second scheduled endoscopic approach in 3 months. In cases of undefined etiology of biliary strictures, it was possible to exclude malignancy due to direct visualization (7/8) or biopsy (1/8). One complication occurred (duodenal perforation) after papillary balloon dilation.

CONCLUSION

The use of SpyGlass demonstrated the benefits, especially in cases of large bile duct stones and indeterminate biliary strictures. Other potencial improvements such as reduction on radiation exposure should be confirmed in prospective studies.

Is there a correlation between right bronchus length and diameter with age?

OBJECTIVE

Right main bronchial anatomy knowledge is essential to guide endoscopic stent placement in modern era. The aim is to describe right bronchial anatomy, cross-area and its relation with the right pulmonary artery and patient's age.

METHODS

One hundred thirty four cadaveric specimens were studied after approval by the Research and Ethics Committee at the University of São Paulo Medical School and Medical Forensic Institute of São Paulo. All necropsies were performed in natura after 24 hours of death and patients with previous pulmonary disease were excluded. Landmarks to start measurement were the first tracheal ring, vertex of carina, first right bronchial ring, and right pulmonary artery area over the right main bronchus. After mobilization, the specimens were measured using a caliper and measurement of distances was recorded in centimeters at landmarks points. All the measures (distances, cross sectional area and planes) were performed by three independent observers and recorded as mean, standard error and ranges. Student t test was used to compare means and linear regression was applied to correlate the measurements.

RESULTS

From 134 specimens studied, 34 were excluded (10 with previous history of pulmonary diseases, surgery or deformities and 24 of female gender). Linear regression showed proportionality between tracheal length and right bronchus length; with the area at first tracheal ring and carina and also between the cross sectional area at these points. Linear regression analysis between tracheal length and age (R=0.593 P<0.005), right bronchus length and age (R=0.523, P<0.005), area of contact between right bronchus and right pulmonary artery and age (R=0.35, P<0.005).

CONCLUSIONS

We can conclude that large airways grow progressively with increasing age in male gender. There was a direct correlation between age and tracheal length; as has age and right bronchus length. There was a direct correlation between age and the area of the right bronchus covered by the right pulmonary artery.

Effects of plastic stenting in commom bile duct of rats: a quantitative reaction analysis using collagen and elastin morphometry

PURPOSE: To evaluate the effects of biliary stenting in rats through analysis of collagen and elastin deposition in the bile ducts. METHODS: Twenty male rats underwent midline laparotomy, duodenotomy and transampullary stenting of the common bile duct with a 22Fr plastic stent. Animals were randomized in 4 groups, with 5 components in each: (I) control, (II) biliary stenting for 7 days, (III) biliary stenting for 14 days, and (IV) biliary stenting for 30 days. Sections of the common bile duct were stained using Hematoxylin Eosin; Sirius Red to quantitate the amount of collagen present; and Weigert's Resorcin-fuchsin to quantitate the amount of elastin present. RESULTS: The percentage of area stained for collagen was 13.4; 21.5; 29.5 and 32.8, for groups I to IV, respectively. The percentage of area stained for elastin fibers was 7.0; 5.2; 4.0 and 2.9, for groups I to IV, respectively. Collagen/Elastin ratio was 2.4; 5.1; 11.0 and 14.4 for groups I to IV, respectively. CONCLUSIONS: The biliary stenting leads to collagen and elastin deposition in the bile ducts; and collagen deposition and collagen/elastin ratio are proportional to the period of stenting.

Symptomatic pneumoperitoneum after endoscopic removal of adjustable gastric band

Endoscopic removal of an adjustable gastric band is a feasible procedure with few complications, according to our series of 8 patients. We report the case of a 56 year-old woman who underwent endoscopic removal of a gastric band which had eroded through the gastric wall; this procedure was performed under general anesthesia, while the surgical group removed the subcutaneous port. The patient developed a large pneumoperitoneum after the procedure, and complained of back, shoulder and epigastric pain. A plain abdominal X-ray confirmed the pneumoperitoneum, and esophagogastric radiography with water-soluble contrast did not show a perforation. The treatment approach was conservative. This experience demonstrates an expected complication of endoscopic removal of an adjustable gastric band, and that the treatment may be conservative. The technique of band removal and the mechanism of pneumoperitoneum are discussed.