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Radiofrequency ablation therapy is an effective endoscopic option for the eradication of Barrett’s esophagus that appears to reduce the risk of esophageal cancer. A concern associated with this technique is the development of subsquamous/buried intestinal metaplasia, whose clinical relevance and malignant potential have not yet been fully elucidated. Fewer than 20 cases of subsquamous neoplasia after the successful radiofrequency ablation of Barrett’s esophagus have been reported to date. Here, we describe a new case of subsquamous neoplasia (high-grade dysplasia) following radiofrequency ablation that was managed with endoscopic resection. Our experience suggests that a meticulous endoscopic inspection prior to and after radiofrequency ablation is fundamental to reduce the risk of buried neoplasia development.

Background: Narrow-band imaging (NBI) allows “in vivo” classification of colorectal polyps. Objectives: We evaluated the optical diagnosis by nonexpert community-based endoscopists in routine clinical practice, the impact of training, and whether the endoscopists could achieve the threshold for the “do not resect” policy. Methods: This was an observational study performed in two periods (P1 and P2). Endoscopists had no prior experience in NBI in P1 and applied the technique on a daily basis for 1 year before participation in P2. Lesions were classified by applying the NBI International Colorectal Endoscopic (NICE) and Workgroup serrAted polyps and Polyposis (WASP) classifications, simultaneously. Results: A total of 290 polyps were analyzed. The overall accuracyof optical diagnosis was 0.75 (95% CI 0.68-0.81) in P1, with an increase to 0.82 (95% CI 0.73-0.89) in P2 (p = 0.260). The accuracy of the NICE/WASP classifications to differentiate adenomatous from nonadenomatous histology was 0.78 (95% CI 0.72-0.84) in P1 and 0.86 (95% CI 0.77-0.92) in P2 (p = 0.164); assignments made with a high confidence level achieved statistical significance (13% improvement, 95% CI 3-22%; p = 0.022). The negative predictive value for adenomatous histology of diminutive rectosigmoid polyps was 81% (95% CI 64-93%) and 80% (95% CI 59-93%) in P1 and P2, respectively. Conclusions: Nonexpert endoscopists achieved moderate accuracy for real-time optical diagnosis of colorectal lesions with the NICE/WASP classifications. The overall performance of the endoscopists improved after sustained use of optical diagnosis, but did not achieve the standards for the implementation of the “do not resect” strategy. Introdução: O narrow-band imaging (NBI) permite a classificação “in-vivo” dos pólipos colo-rectais. Objectivos: Avaliámos o diagnóstico óptico na prática clínica diária em endoscopistas da comunidade, sem experiência prévia em NBI, o impacto do treino e se estes conseguiam atingir o limiar da estratégia de “não ressecar”. Métodos: Estudo observacional, realizado em dois períodos (P1 e P2). Os endoscopistas não apresentavam experiência prévia em NBI em P1 e aplicaram a técnica diariamente durante um ano antes da participação em P2. As lesões foram classificadas aplicando as classificações NBI International Colorectal Endoscopic (NICE) e Workgroup serrated polypS and Polyposis (WASP), simultaneamente. Resultados: Foram analisados 290 pólipos. A acuidade global do diagnóstico óptico foi de 0.75 (IC 95%, 0.68-0.81) em P1, aumentando para 0.82 (IC 95%, 0.73-0.89) em P2 (p = 0.260). A acuidade das classificações de NICE/WASP na diferenciação de histologia adenomatosa de não-adenomatosa foi de 0.78 (IC 95%, 0.72-0.84) em P1, e 0.86 (IC 95%, 0.77-0.92) em P2 (p = 0.164); as predições realizadas com alto grau de confiança alcançaram significado estatístico (melhoria de 13%, IC 95%, 3-22%; p = 0.022). O valor preditivo negativo para histologia adenomatosa dos pólipos diminutos recto-sigmóides foi de 81% (IC 95%, 64-93%) e 80% (IC 95%, 59-93%), em P1 e P2, respetivamente. Conclusões: Endoscopistas sem experiência em NBI alcançaram acuidade moderada no diagnóstico óptico em tempo real de lesões colo-rectais, utilizando as classificações de NICE/WASP. O desempenho global melhorou após a utilização contínua do diagnóstico óptico, mas não alcançou o limiar definido para a implementação da estratégia de “não ressecar”.

Colorectal cancer (CRC) is one of the most common cancers in Europe. Recently, new data from the USA and Europe revealed an increase in the incidence of CRC in individuals aged55 years and a reduction in those aged65 years. Mortality rate was stable in patients aged55 years and decreased after the age of 55 years. Based on the USA data, the American Cancer Society (ACS) published a qualified recommendation advocating the start of CRC screening at the age of 45 years. We aimed to evaluate if the changes in the CRC incidence/mortality observed in the USA and the rest of Europe also occur in Portugal, and then perform a cost-utility analysis of CRC screening that starts at 45 years of age.We evaluated the incidence of CRC by age group using data from the National Cancer Registry, and the mortality rate according to the National Statistics Institute in the periods 1993-2010 and 2003-2016. A cost-utility analysis was performed with a decision tree from a societal perspective comparing biennial fecal immunochemical test (FIT) or a single colonoscopy screening versus nonscreening at the age of 45 years in Portugal.In Portugal, in 1993-2010, there was an increase in CRC incidence of 17% (from 25 to 30/100,000), 35% (from 39 to 54/100,000), and 71% (from 52 to 97/100,000) in patients aged 45-49 years, 50-54 years, and 55-59 years, respectively. The mortality rate of patients aged 45-54 years remained stable between 2003 and 2016 (12/100,000) as a counterpoint to a moderate decrease in those aged 55-64 years (from 38 to 35/100,000) and a sharp reduction in those aged 65-75 years (from 93 to 75/100,000). Screening for CRC at the age of 45 years has no cost utility with the current incidence. FIT screening provided an ICUR of EUR 84,304/quality-adjusted life years (QALY) while colonoscopy provided an ICUR of EUR 3,112,244/QALY. On one-way sensitivity analysis, FIT screening would only have cost utility at the present cost of colonoscopy under sedation (EUR 150) and acceptance rates if the incidence rate rises above 47.5/100,000; colonoscopy at this age would have no cost utility despite changes in costs and/or incidence rates.In Portugal, the incidence of CRC in patients aged 45-55 years has been increasing with a stable mortality rate, in contrast to the decrease in mortality in the age groups covered by the current CRC screening program. However, at present, CRC screening in Portugal at the age of 45 years has no cost utility and will only have this if the incidence rate rises above 47.5/100,000 (vs. the actual incidence of 30/100,000).O cancro colorretal (CCR) é uma das neoplasias mais comuns na Europa. Recentemente, temos observado um aumento da incidencia de cancro colorretal (CCR) em individuos50 anos (não abrangidos pelos programas de rastreio), tanto na europa como nos Estados Unidos da América (EUA). Simultaneamente, a taxa de mortalidade (TM) permaneceu estável em doentes55 anos e diminuiu55 anos. Baseado nestes dados, a American Cancer Society (ACS) publicou uma recomendação qualificada advogando o inicio do rastreio aos 45 anos. Avaliar se as alterações na incidência/mortalidade de CCR observadas nos EUA/Europa também ocorrem em Portugal e realizar uma análise de custo-utilidade do início do rastreio de CCR aos 45 anos.Avaliamos a incidencia de CCR por faixa etária usando dados do Registro Oncológico Nacional (1993–2010) e TM de acordo com o Instituto Nacional de Estatística (2003–2016). A análise de custo-utilidade foi realizada com uma árvore de decisão sob uma perspetiva social, comparando o teste imunoquímico fecal bienal (FIT) com a realização de uma colonoscopia total aos 45 anos.Em Portugal (1993–2010) observou-se um aumento na incidencia de CRC de 17% (25/100.000 vs. 30/100.000), 35% (39/100.000 vs. 54/100.000) e 71% (52/100.000 vs. 97/100.000) em doentes com 45–49 anos, 50–54 anos e 55–59 anos, respetivamente. A TM de indivíduos com 45–54 anos permaneceu estável (12/100.000) ao contrário da diminuição moderada em indivíduos com 55–64 (38/100.000 vs. 35/100.000) e uma acentuada redudo em 65–75 (93/100.000 vs. 75/100.000). O rastreio de CCR aos 45 anos não teve custo-utilidade na presente incidencia (FIT/colonoscopia total). O rastreio com FIT forneceu um RCEI de € 84.304/QALY, enquanto a colonoscopia forneceu um RCEI de € 3.112.244/OALY. Em análise de sensibilidade unilateral, o rastreio com FIT apresentaria custo-utilidade com o custo atual da colonoscopia sob sedação (€ 150) e taxas de aceitado apenas se a incidencia subir acima de 47,5/100.000; o rastreio com colonoscopia nesta idade nunca teria custo-utilidade, apesar das mudanças nos custos e/ou taxas de incidencia.Em Portugal, a incidencia de CCR em doentes com idades entre 45–55 anos tem aumentado (TM estável). Este cenário é semelhante ao descrito nos EUA/restante europa. No entanto, o inicio do rastreio do CCR aos 45 anos em Portugal apenas terá custo-utilidade se incidencia for47.5/100.000 (vs. 30/100.000).

The present evidence-based guidelines are focused on the use of device-assisted enteroscopy in the management of small-bowel diseases. A panel of experts selected by the Spanish and Portuguese small bowel study groups reviewed the available evidence focusing on the main indications of this technique, its role in the management algorithm of each indication and on its diagnostic and therapeutic yields. A set of recommendations were issued accordingly.Estas recomendações baseadas na evidência detalham o uso da enteroscopia assistida por dispositivo no manejo clínico das doenças do intestino delgado. Um conjunto de Gastrenterologistas diferenciados em patologia do intestino delgado foi selecionado pelos grupos de estudos Espanhol e Portugués de intestino delgado para rever a evidência disponível sobre as principais indicações desta técnica, o seu papel nos algoritmos de manejo de cada indicação e sobre o seu rendimento diagnóstico e terapêutico. Foi gerado um conjunto de recomendações pelos autores.

The present evidence-based guidelines are focused on the use of device-assisted enteroscopy in the management of small-bowel diseases. A panel of experts selected by the Spanish and Portuguese small-bowel study groups reviewed the available evidence focusing on the main indications of this technique, its role in the management algorithm of each indication, and its diagnostic and therapeutic yield. A set of recommendations was issued accordingly. info:eu-repo/semantics/publishedVersion

SUMMARY Primary esophageal cancer (EC) frequently presents as a locally advanced disease with airway involvement. Placement of combined esophageal and airway stents has been reported in small series to be an effective palliation strategy. Our aims are to present the largest cohort of EC patients who underwent double stent palliation and to evaluate the safety and efficacy of this approach. Longitudinal cohort study of patients with primary EC undergoing two-stage esophageal and airway stent placement at an oncology referral institute (January 2000–January 2019). Assessments: baseline demographics and clinical variables; baseline and week 2 dysphagia, dyspnea and performance status (PS) scores; baseline and week 8 body mass index (BMI); overall survival. Statistics: paired t-test; Kaplan–Meier method. Seventy patients (89% men, mean age 60.20 ± 8.41) underwent double stenting. Esophageal stent was placed for esophageal stenosis and dysphagia (n = 41; placement of a second stent due to recurrence in nine cases) or esophagorespiratory fistulas (ERFs) (n = 29); airway stent was required for ERF sealing (n = 29 + 7 new ERFs after esophageal stent) and to ensure airway patency due to malignant stenosis (n = 29; placement of a second stent due to recurrence in 13 cases) or compression (n = 5). There were 13, endoscopically managed, major complications after esophageal stent [hemorrage (n = 1), migration (n = 5) and new fistulas (n = 7)]. As for airway stents, four major complications were recorded [hemorrage (n = 1) and three deaths due to respiratory infection and ultimately respiratory failure 3–7 days after the procedure]. Overall, patients showed significant improvement in dysphagia and dyspnea symptoms (3.21 vs. 1.31 e 15.56 vs. 10.87; P

We investigate how political uncertainty affects the geographic distribution of bank lending to small businesses. Using exogenous variation in gubernatorial elections with binding term limits, we show that political uncertainty causes local banks to increase out-of-state lending to small firms, especially to firms located in the wealthiest out-of-state counties. The increase in credit availability in turn leads to an increase in employment growth and net firm creation in sectors that need larger amounts of startup capital. Our results indicate that geographic diversification and financial integration enable banks to sidestep the negative local economic effects of political uncertainty.

The small bowel is affected in the vast majority of patients with Crohn's Disease (CD). Small bowel capsule endoscopy (SBCE) has a very high sensitivity for the detection of CD-related pathology, including early mucosal lesions and/or those located in the proximal segments of the small bowel, which is a major advantage when compared with other small bowel imaging modalities. The recent guidelines of European Society of Gastrointestinal Endoscopy (ESGE) and European Crohn's and Colitis Organisation (ECCO) advocate the use of validated endoscopic scoring indices for the classification of inflammatory activity in patients with CD undergoing SBCE, such as the Lewis Score or the Capsule Endoscopy Crohn's Disease Activity Index (CECDAI). These scores aim to standardize the description of lesions and capsule endoscopy reports, contributing to increase inter-observer agreement and enabling a stratification of the severity of the disease. On behalf of the Grupo de Estudos Portugues do Intestino Delgado (GEPID) - Portuguese Small Bowel Study Group, we aimed to summarize the general principles and clinical applications of current endoscopic scoring systems for SBCE in the setting of CD, covering the topic of suspected CD as well as the evaluation of disease extent (with potential prognostic and therapeutic impact), evaluation of mucosal healing in response to treatment and evaluation of post-surgical recurrence in patients with previously established diagnosis of CD., O intestino delgado encontra-se envolvido pela doença na maioria dos pacientes com Doença de Crohn (DC). A enteroscopia por cápsula (EC) apresenta uma elevada sensibilidade na detecção de lesões relacionadas com a DC, incluindo as lesões superficiais mais precoces e/ou localizadas no segmentos proximais do intestino delgado, o que representa uma clara mais-valia comparativamente com os demais exames imagiológicos do intestino delgado. As recentes recomendações da ESGE (European Society of Gastrointestinal Endoscopy) e da ECCO (European Crohn's and Colitis Organisation) recomendam a utilização dos scores endoscópicos validados para a classificação da actividade inflamatória em doentes com DC submetidos a EC, nomeadamente o Score de Lewis ou o CECDAI (Capsule Endoscopy Crohn's Disease Activity Index). Estes scores permitem uniformizar a descrição das lesões e os relatórios em EC, contribuindo para uma melhoria da concordância entre observadores e possibilitando a estratificação da gravidade da doença. Em nome do GEPID (Grupo de Estudos Português do Intestino Delgado - Portuguese Small Bowel Study Group), os autores pretendem sumariar neste documento os princípios gerais e as aplicações clínicas actuais dos scores endoscópicos em EC no contexto da DC, incluindo quer a suspeita de DC, quer a avaliação da extensão da doença (com potencial impacto prognóstico e na decisão terapêutica), avaliação da cicatrização da mucosa em resposta ao tratamento e avaliação da recorrência pós-cirúrgica em doentes com um diagnóstico prévio de DC., (undefined), info:eu-repo/semantics/publishedVersion

Endoscopic full-thickness resection (EFTR) is an emerging technique for the treatment of various conditions for which classic endoscopic resection techniques have failed or were considered to be at high risk for perforation. The full-thickness resection device (FTRD) is an over-the-scope system which allows a single-step EFTR. The aim of our study is to describe our experience in EFTR of colorectal lesions using the FTRD.Nine patients (10 colorectal lesions) were proposed for EFTR. Safety, R0 resection and endoscopic treatment success were evaluated.Reasons for referral included nonlifting adenomas (EFTR is a feasible, reasonable time-consuming, safe, and promising endoscopic resection technique.FTRD is an additional tool for difficult-to-treat colorectal lesions.A ressecção endoscópica transmural (RET) é uma técnica promissora para o tratamento de várias lesões não passíveis de ressecção endoscópicapelas técnicas convencionais ou naquelas em que estes procedimentos apresentam elevado risco de complicações.O “full-thickness resection device” (FTRD) é um sistema pré-montado, que se acopla ao colonoscópio e que permite efetuar RET com um procedimento único. Pretende-se descrever a experiência do nosso centro na realização de RET com o FTRD.Nove doentes (10 lesões cólicas) foram propostos para RET. Foram avaliadas a segurança, ressecção R0 e taxa de sucesso do procedimento endoscópico.As indicações para o procedimento incluíram adenomas (A RET é uma técnica exequível e segura para a terapêutica de lesões coloretais.A RET parece ser uma promissora ferramenta adicional para manejo de lesões colo-rectais difíceis de tratar.

Background/Objectives: Vitamin B12 (VB12) deficiency is a common complication after total gastrectomy which may be associated with megaloblastic anemia and potentially irreversible neurologic symptoms. Intramuscular supplementation of VB12 has been considered the standard treatment, although it is associated with high costs and patient discomfort. Patients/Methods: We performed a prospective uncontrolled study (ACTRN12614000107628) in order to evaluate the clinical and laboratory efficacy of long-term oral VB12 supplementation in patients submitted to total gastrectomy. All patients received daily oral VB12 (1 mg/day) and were evaluated every 3 months (clinical and laboratory evaluation: hemoglobin, VB12, total iron, ferritin, and folate). Results: A total of 26 patients were included with a mean age of 64 years (29-79). Patients were included with a mean period of 65 months (3-309) after total gastrectomy. At inclusion time, 17/26 patients were under intramuscular VB12, and 9 had not started supplementation yet. There were normal serum VB12 levels in 25/26 patients (mean VB12 serum levels: 657 pg/mL). The mean follow-up period was 20 (8.5- 28) months. During follow-up, all patients had normal VB12 levels and there was no need for intramuscular supplementation. The patient with low VB12 levels had an increase to adequate levels, which remained stable. There were no differences with statistical significance among VB12 levels at 6 (867 pg/mL), 12 (1,008 pg/mL), 18 (1,018 pg/mL), and 24 (1,061 pg/mL) months. Iron and folate supplementation was necessary in 21 and 7 patients, respectively. Conclusions: Oral VB12 supplementation is effective and safe in patients who underwent total gastrectomy and should be considered the preferential form of supplementation. Introdução: O défice de vitamina B12 (vitB12) ocorre de forma quase universal e precocemente após gastrectomia total (GT), podendo associar-se a anemia megaloblástica e alterações neurológicas potencialmente irreversíveis. A administração intramuscular de vitB12 é considerada a forma de suplementação adequada, sendo, contudo, desconfortável, dispendiosa e, atualmente, de acesso difícil. Métodos/Objetivo: Estudo prospetivo, não controlado (ACTRN12614000107628), cujo objetivo principal foi avaliar a eficácia clínica e laboratorial a longo prazo da suplementação oral com vitB12 em doentes com GT. O objetivo secundário foi avaliar outros défices nutricionais (ferro e folatos). Os doentes foram medicados com vitB12 oral (1mg/dia) e sujeitos a avaliação clínica e laboratorial trimestral (hemoglobina, vitB12, ferro, ferritina e ácido fólico). SPSS 23 (Wilcoxon test). Resultados: Incluídos 26 doentes (M-18; F-8), idade média 64 anos (29-79), com diagnósticos de adenocarcinoma (n = 25) e linfoma MALT (n = 1). Os doentes foram incluídos em média 65 meses (3-309) após GT. À data de inclusão, 17/25 doentes encontravam-se medicados com vitB12 intramuscular e 9 ainda não tinham iniciado suplementação, verificando-se níveis séricos adequados de vitB12 em 25/26 doentes (1/26 com níveis de vitB12 baixos por incumprimento da terapêutica intramuscular), sendo o valor médio de 657 pg/mL (136-1,642). Os doentes foram avaliados durante uma mediana de 23 meses (IQR 8,8). No follow-up todos os doentes apresentaram níveis normais de vitB12, não sendo necessária terapêutica intramuscular. O doente com vitB12 baixa registou um incremento para níveis adequados, que se mantiveram estáveis. Não houve diferenças com significado estatístico nos níveis de vitB12 aos 6 (867 pg/mL), 12 (1,008 pg/mL) e 24 (1,061 pg/mL) meses, embora com aumento progressivo dos mesmos. A suplementação com ferro e folatos foi necessária em 21 e 7 doentes, respetivamente. Conclusão: A suplementação oral de vitB12 é eficaz e segura em doentes com GT, pelo que esta deve ser considerada a forma preferencial de administração neste grupo de doentes.

Pyogenic granuloma is a benign vascular lesion, uncommon in the gastrointestinal tract, and extremely rare in the small bowel. The diagnosis can be challenging prior to surgery, because of its unusual endoscopic appearance. We present a case of pyogenic granuloma of the jejunum diagnosed by capsule endoscopy and double-balloon enteroscopy and successfully managed by surgical resection.

Familial adenomatous polyposis (FAP) and Crohn's disease (CD) are two entities with no known etiologic or physiopathogenic relation. The rarity of the former makes the coincidence of both diagnoses in one patient very unlikely. Nevertheless, management in such cases can be puzzling as surgical options must be considered, and immunosuppression/immunomodulation is set in a territory of accelerated carcinogenesis. We report the case of a 29-year-old male with a diagnosis of FAP since adolescence, already submitted to prophylactic proctocolectomy, presenting with anemia and bloody diarrhea, revealing small bowel CD. This case allows for a rich discussion of the clinical dilemmas presenting when FAP and CD are diagnosed in the same patient and for a deep analysis of the concerns inherent to the available therapeutic options.

In this project we propose a computer vision method, based on background subtraction, to estimate the number of zebrafish inside a tank. We addressed questions related to the best choice of parameters to run the algorithm, namely the threshold blob area for fish detection and the reference area from which a blob area in a threshed frame may be considered as one or multiple fish. Empirical results obtained after several tests show that the method can successfully estimate, within a margin of error, the number of zebrafish (fries or adults) inside fish tanks proving that adaptive background subtraction is extremely effective for blob isolation and fish counting.

Patients presenting familial adenomatous polyposis (FAP), attenuated familial adenomatous polyposis (AFAP) or multiple colorectal adenomas (MCRAs) phenotype are clinically difficult to distinguish. We aimed to genetically characterize 107 clinically well-characterized patients with FAP-like phenotype, and stratified according to the recent guidelines for the clinical management of FAP: FAP, AFAP, MCRA (10-99 colorectal adenomas) without family history of colorectal cancer or few adenomas (FH), MCRA (10-99) with FH, MCRA (3-9) with FH. Overall, APC or MUTYH mutations were detected in 42/48 (88%), 14/20 (70%) and 10/38 (26%) of FAP, AFAP and MCRA patients, respectively. APC and MUTYH mutations accounted for 81% and 7% of FAP patients and for 30% and 40% of AFAP patients, respectively. Notably, MCRA patients did not present APC mutations. In 26% of these patients, an MUTYH mutation was identified and the detection rate increased with the number of adenomas, irrespectively of family history, being significantly higher in MCRA patients presenting more than 30 adenomas [7/12 (58%) vs 2/14 (14%), p = 0.023]. We validate the recently proposed guidelines in our patient's cohort and show that APC or MUTYH germline defects are responsible for the majority of clinically well-characterized patients with FAP and AFAP phenotype, and patients with more than 30 colorectal adenomas. The different mutation frequencies according to family history and to the number of adenomas underscore the importance of an adequate familial characterization, both clinically and by colonoscopy, in the management of FAP-like phenotypes. The phenotypes of the mutation-negative patients suggest distinct etiologies in these cases.

MYH-associated polyposis is an inherited autosomal recessive disease, linked to biallelic germline MYH mutations, which predisposes to the development of multiple colorectal adenomas and cancer. The colonic and extracolonic phenotype of this syndrome is very heterogeneous. We report the case of a young male patient with an aggressive MYH-associated polyposis phenotype. He presented at aged 30 years with more than 100 colonic polyps and 4 colonic adenocarcinomas. At aged 35 years, Spigelman Stage IV duodenal adenomatosis was detected. When he was 39 years old, he developed three synchronous jejunal adenocarcinomas and a mesenteric desmoid tumor. Based on this report, we believe that screening of the entire small bowel should be recommended in MYH-associated polyposis patients, especially in those with duodenal adenomas. Similar to patients with familial adenomatous polyposis, desmoid tumors also may be part of the clinical spectrum of MYH-associated polyposis and may prove to be a significant clinical problem in patients submitted to prophylactic colectomy.

Preoperative chemoradiotherapy is the standard of care for locally advanced esophageal cancer, causing persistent deterioration in the nutritional status. We performed a prospective study to evaluate the safety and efficacy of esophageal double-covered self-expandable metal stents in patients with esophageal cancer before chemoradiotherapy. The nutritional status and dysphagia were prospectively recorded. Eleven patients were included: eight were moderate and three were severely malnourished. After stent placement, dysphagia improved in all patients. With regard to complications, one patient developed an esophageal perforation that required urgent esophagectomy. Four patients presented stent migration. Three of these patients required enteral nutrition and none was submitted to surgery because of poor nutritional status. Of the other six patients, only four were operated upon. Stent placement presented a high complication rate and did not prevent weight loss or malnutrition. Other alternatives, including naso-gastric tube placement or endoscopic percutaneous gastrostomy or jejunostomy, should be considered.

Background and objective: Little is known about the clinical impact of double-balloon enteroscopy (DBE) in patients with Peutz-Jeghers syndrome (PJS). The aim of this study was to assess the efficacy and safety of DBE in the management of small-bowel polyps in PJS patients. Patients and methods: We conducted a multicentre, retrospective cohort study, which included all consecutive patients diagnosed with PJS who underwent DBE for polypectomy between January 2006 and August 2012. In all cases, previous videocapsule enteroscopy had shown at least one polyp ≥ 10 mm in size. Results: Twenty-five patients (13 men; median age 36 years; 14 with prior laparotomy) underwent 46 DBE procedures (1 to 5 per patient, 44 via oral route). Polypectomy was performed in 39/46 DBEs. A total of 214 polyps were removed (median-size 30 mm), with a median number of polypectomies per procedure of 5.0 (range 1-18). The estimated maximum-sizes of resected polyps significantly decreased at each session: 30.0, 25.0, 20.0, 15.0, and 17.5 mm (p = 0.02). In 7 DBEs no polypectomy was performed (4-only minor polyps detected; 3-endoscopic irresecability). Complications occurred in 3/39 of therapeutic procedures (2-minor delayed bleeding; 1-mucosal tear), all of them dealt with conservative or endoscopic therapy. Six patients underwent elective surgery post DBE due to polyps not amenable for endoscopic resection. There were no small-bowel polyp related complications during a median follow-up of 56.5 months. Conclusion: DBE showed to be a safe and effective technique in the management of small-bowel polyps in PJS patients, allowing a presymptomatic and non-surgical approach.

AIM: To investigate whether, under the influence of polypectomy, the incidence of adenoma decreases with age. METHODS: Consecutive patients with colonic adenomas identified at index colonoscopy were retrospectively selected if they had undergone three or more complete colonoscopies, at least 24 mo apart. Patients who had any first-degree relative with colorectal cancer were excluded. Data regarding number of adenomas at each colonoscopy, their location, size and histological classification were recorded. The monthly incidence density of adenomas after the index examination was estimated for the study population, by using the person-years method. Baseline adenomas were excluded from incidence calculations but their characteristics were correlated with recurrence at follow-up, using the χ 2 test. RESULTS: One hundred and fifty-six patients were included (109 male, mean age at index colonoscopy 56.8 ± 10.3 years), with follow-up that ranged from 48 to 232 mo. No significant correlations were observed between the number, the presence of villous component, or the size of adenomas at index colonoscopy and the presence of adenomas at subsequent colonoscopies (P = 0.49, 0.12 and 0.78, respectively). The incidence of colonic adenomas was observed to decay from 1.4% person-months at the beginning of the study to values close to 0%, at 12 years after index colonoscopy. CONCLUSION: Our results suggest the sporadic formation of adenomas occurs within a discrete period and that, when these adenomas are removed, all neoplasia-prone clones may be extinguished. publishersversion published