Background and Objectives:Endoscopic retrograde cholangiopancreatography (ERCP) is the method of choice for drainage in patients with distal malignant biliary obstruction, but it fails in up to 10% of cases. Percutaneous transhepatic cholangiography (PTC) and surgical bypass are the traditional drainage alternatives. This study aimed to compare technical and clinical success, quality of life, and survival of surgical biliary bypass or hepaticojejunostomy (HJT) and endoscopic ultrasound (EUS)-guided choledochoduodenostomy (CDT) in patients with distal malignant bile duct obstruction and failed ERCP.Patients and Methods:A prospective, randomized trial was conducted. From March 2011 to September 2013, 32 patients with malignant distal biliary obstruction and failed ERCP were studied. The HJT group consisted of 15 patients and the CDT group consisted of 14 patients. Technical and clinical success, quality of life, and survival were assessed prospectively.Results:Technical success was 94% (15/16) in the HJT group and 88% (14/16) in the CDT group (P = 0.598). Clinical success occurred in 14 (93%) patients in the HJT group and in 10 (71%) patients in the CDT group (P = 0.169). During follow-up, a statistically significant difference was seen in mean functional capacity scores, physical health, pain, social functioning, and emotional and mental health aspects in both techniques (P < 0.05). The median survival time in both groups was the same (82 days).Conclusion:Data relating to technical and clinical success, quality of life, and survival were similar in patients who underwent HJT and CDT drainage after failed ERCP for malignant distal biliary obstruction.

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Paciente do sexo feminino, 51 anos, submetida à colonoscopia em outubro de 2008, com diagnóstico de colite segmentar do ângulo esplênico e pólipo do cólon descendente. O exame histopatológico revelou, respectivamente, colite crônica da flexura esplênica e adenoma tubular com displasia de baixo grau de cólon descendente. Iniciou uso de mesalazina e foi solicitada nova colonoscopia em junho de 2009 para avaliação do processo inflamatório do ângulo esplênico, que revelou a presença de inúmeras lesões subepiteliais, localizadas no ângulo esplênico e cólon descendente, preenchidas por ar e entremeadas por áreas de aspecto endoscópico normal, sugestivas de pneumatose intestinal.Pneumatose intestinal constitui-se pela presença de gás no interior da parede intestinal. Sua incidência é desconhecida, pois a maioria dos pacientes apresenta-se sem sintomas clínicos. Pode ser encontrada tanto em crianças quanto em adultos, porém a maioria dos casos em crianças é secundário à enterocolite necrotizante, doença que se apresenta com alta mortalidade. A patogênese não é claramente conhecida, no entanto, o caráter multifatorial é sugerido, incluindo causas mecânicas, infecciosas e auto-imune 1

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Male individual, 68 years old, married and living in São Paulo (state of São Paulo, Brazil) was referred to Hospital Sírio-Libanês for investigation of episodes of melena. A colonoscopy was requested. The colonoscopy was performed with introduction of the colonoscope up to the terminal ileum. This intestinal part showed normal endoscopic appearance. The colonoscopy revealed an ulcerated fungating lesion with an infiltrative appearance in the rectosigmoid transition. Biopsies were performed in this region. The histopathological diagnosis was infiltrative adenocarcinoma. A rectal sessile polyp was found measuring 0.3 cm and showing regular margins and smooth surface. A polypectomy was carried out. The histopathological diagnosis was tubular adenoma with low-grade dysplasia. In the transverse colon, there was a tiny ring-like parasite that was motionless and was not attached to the colon mucosa. Parasite removal was attempted using a biopsy forceps, but there was fragmentation of the specimen. The photos of the examination were analyzed by a pathologist who concluded that it was a myiasis.