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BACKGROUND: A common site of neuroendocrine tumors (NETs) is the rectum. The technique most often used is endoscopic mucosal resection with saline injection. However, deep margins are often difficult to obtain because submucosal invasion is common. Underwater endoscopic mucosal resection (UEMR) is a technique in which the bowel lumen is filled with water rather than air, precluding the need for submucosal lifting. OBJECTIVE: This study aimed to evaluate the efficacy and safety of UEMR for removing small rectal neuroendocrine tumors (rNETs). METHODS: Retrospective study with patients who underwent UEMR in two centers. UEMR was performed using a standard colonoscope. No submucosal injection was performed. Board-certified pathologists conducted histopathologic assessment. RESULTS: UEMR for small rNET was performed on 11 patients (nine female) with a mean age of 55.8 years and 11 lesions (mean size 7 mm, range 3-12 mm). There were 9 (81%) patients with G1 rNET and two patients with G2, and all tumors invaded the submucosa with only one restricted to the mucosa. None case showed vascular or perineural invasion. All lesions were removed en bloc. Nine (81%) resections had free margins. Two patients had deep margin involvement; one had negative biopsies via endoscopic surveillance, and the other was lost to follow-up. No perforations or delayed bleeding occurred. CONCLUSION: UEMR appeared to be an effective and safe alternative for treatment of small rNETs without adverse events and with high en bloc and R0 resection rates. Further prospective studies are needed to compare available endoscopic interventions and to elucidate the most appropriate endoscopic technique for resection of rNETs.

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Background and aims: Occurrence of metastasis to the gastrointestinal tract (GIT) is rare. The studies on the endoscopic findings of metastatic tumors are usually restricted to small case series. As a consequence of the improved in the survival time for cancer patients over recent years, it is expected that progressively more cancer patients could present for diagnosis, by endoscopy, of secondary tumors of the GIT. With this regard, it would be useful to better characterize the endoscopic aspects of metastases to the GIT. Methods: observational study conducted in an oncological referral center between January 2009 and August 2017. The study included patients with metastasis to the GIT, submitted to endoscopic exam (upper gastrointestinal endoscopy, colonoscopy, enteroscopy, endoscopic ultrasound) with histological confirmation. Patients with lymphoma, leukemia, multiple myeloma, Kaposi sarcoma or direct invasion from adjacent organs were excluded. Results: From January 2009 to august 2017, 53.675 endoscopic exams were performed. A total of 184 cases were suspected gastrointestinal metastasis. In 94 patients the diagnosis was confirmed. The baseline characteristics of the patients are summarized in Table 1. Common indications for endoscopy were abdominal pain (29 cases -30.8%), gastrointestinal bleeding (28 cases -29.8%) and vomiting (18 cases -19.1%). The most common site of metastasis was the stomach (60 cases -59.6%), followed by small bowel (29 cases -29.8%) and colon (7 cases -7.4%). Eight patients (8.5%) had metastasis in more than one site in the GIT. As indicated in Table 2, the most common primary malignancy was melanoma (25 cases -26.6%), followed by breast (14 cases -14.9%) and lung (14 cases -14.9%). If considered just the gastric metastasis, the most common primary malignancy was melanoma (17 cases -28.3%), breast (11 cases -18.3 %) and lung (7 -11.3%). The most common endoscopic presentation of the metastatic lesions in the stomach was a solitary (32 cases -53.3 %), ulcerated (31 cases -51.6%) lesion located in the gastric body (75%). If considered just the small bowel metastasis the most common primary malignancy was lung (7 cases -24.1%) and melanoma (7 cases -24.1%) followed by breast (3 cases -10.4%). The most common endoscopic presentation of the metastatic lesions in small bowel was the presence of a solitary (22 cases 84.6 %), polypoid (10 cases -38.5%) lesion located in the second portion of duodenum (17 cases -65.4%). Conclusions: Melanoma, breast and lung cancer were the most common metastasis to the GIT. The stomach was the main site of the metastatic lesions and the most common endoscopic presentation of stomach metastasis was solitary, ulcerated lesions in the gastric body. Despite the rarity of this condition, endoscopists should be aware of this differential diagnosis.

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Instituição: HC FMUSP Apresentação de caso: Relatamos dois casos de pacientes com queixas de disfagia decorrente de Pseudodiverticulose esofágica. Paciente do sexo masculino de 65 anos com quadro de disfagia alta intermitente para sólidos e perda de peso nos últimos 5 anos. Apresenta história de esofagite erosiva grave, uso de álcool e transtorno depressivo. Uma endoscopia digestiva alta mostrou subestenose esofágica a 17 cm da arcada dentária superior, além de vários pequenos pseudodivertículos intramurais, de 01 até 03 mm de diâmetro, associados a retrações cicatriciais esofágicas ao nível da região da subestenose. A biópsia demonstrou apenas esofagite moderada crônica. O paciente foi tratado com duas sessões de dilatação esofágica e inibidores de bomba de prótons, com importante melhora clínica e endoscópica. O segundo paciente, de 57 anos, masculino, referindo dois anos de disfagia para sólidos. Apresentou, nesse período, duas impactações de bolo alimentar em esôfago proximal, com necessidade de retirada endoscópica. Em endoscopia no nosso serviço foram evidenciados inúmeros pseudodivertículos intramurais, de 1-2mm, em todo órgão, associados a placas esbranquiçadas, aderidas a mucosa, menores que 2mm (biópsia confirmou diagnóstico de candidíase), sem áreas de estenose ou diminuição do calibre. Em ambos os casos o estudo radiográfico contrastado com bário não evidenciou anormalidades Discussão: A pseudodiverticulose intramural esofágica é uma doença benigna e rara, caracterizada por diversos e diminutos divertículos falsos localizados na parede esofágica. A sua fisiopatologia ainda é desconhecida e a relação com monilíase esofágica é alta. O sintoma mais comum é disfagia sendo a estenose a complicação mais comum. Estudo radiográfico do esôfago contrastado com bário é um método mais sensível do que o exame endoscópico para diagnóstico. Biópsias de esôfago por endoscopia são inespecíficas, geralmente mostrando esofagite. Nos casos de estenose de esôfago por pseusodiverticulose intramural esofágica, a dilatação endoscópica é o tratamento mais efetivo, associado com o tratamento das comorbidades associadas, da inflamação esofágica e da monilíase. Comentários finais: A pseudodiverticulose é uma condição benigna rara associada a alguns fatores de risco, o tratamento consiste em tratar os fatores associados e realizar dilatação endoscópica nos casos de estenose. Os pacientes em geral apresentam boa resposta clinica. ABCDExpress 2017;1(2):716Codigo: 63769 Acesso está disponível em www.revistaabcd.com.br e www.sbad2017.com.br Acesso pelo