Portuguese Society of Digestive Endoscopy: Prizes for best research work at national meeting

With the aim to establish a state of art of several technical procedures and clinical topics, as well as promoting contact with some of the most recent advances on digestive endoscopy, from new methods on optical biopsy to the most modern technology on luminal and transvisceral endotherapy. for gastroenterology specialists and trainees, surgeons, radiologists and pathologists the 6th National Meeting of Digestive Endoscopy and 5th Course on Digestive Endoscopy will occur next March 5th and 6th, 20009 at the University Hospitals of Coimbra, under the organization of Sociedade Portuguesa de Endoscopia Digestiva

This newsletter comprises abstracts from the Research Works rewarded with the prizes for Best Oral Communications both in Clinical (1) and Basic Research (2), Best Clinical Case (3) and Best Poster (4) presented at the XXVIII Congresso Nacional de Gastrenterologia e Endoscopia Digestiva, June 2008 in Vilamoura, Portugal.

1. New data on early postoperative evolution after liver transplantation (OLT) in familial amyloidotic polyneuropathy (FAP) M. Bispo1, P. Marcelino1, A. Freire2, A. Martins2, L. Mourão1, E. Barroso2 1 Intensive-Care Unit and 2 Liver Transplant Centre, Curry Cabral Hospital, Lisbon, Portugal Background: OLT remains the only established treatment that halts FAP progression. Although long-term outcome after OLT in FAP is well-known, early postoperative evolution is not characterized in the literature. Aim: To analyse early postoperative complications after OLT in FAP. Methods: This retrospective analysis included 223 OLTs performed on 213 patients in a 30-month period: 86 (78 primary and 8 retransplantations) in FAP patients. The observation period ended 30 days post-OLT, until discharge or in-hospital death. Results: FAP patients were younger, had shorter operative times, fewer intraoperative blood transfusion requirements, and lower severity scores (APACHE II and SAPS II) on ICU admission. The 3 most challenging complications in the total sample were: haemorrhagic events requiring blood transfusion (19 %), acute renal failure requiring dialysis (9 %) and thrombotic complications of the graft confirmed by angiography or surgery (7 %). In FAP patients, there was a lower incidence of haemorrhagic complications (12 % versus 23 %, p = 0.029), but a significantly higher incidence of thrombotic complications: 14% (n = 12) versus 3 % (n = 4) (p = 0.002). Hepatic artery thrombosis was the most frequent early thrombotic event (n = 12, ten cases in FAP patients). By multivariate analysis, FAP turned out to be an independent risk factor for early thrombotic complications (p = 0.015). Conclusion: FAP was identified in this study as an independent risk factor for early thrombotic complications after OLT, a new datum not yet described in the literature.

2. Genic expression of innate immunity receptors in alcoholic chronic liver disease (ACLD) P. Pimentel-Nunes1,2, R. Roncon-Albuquerque Jr.2, N. Gonçalves2, C. Cerqueira2, H. Cardoso4, P. Bastos4, M. Marques4, M. Dinis-Ribeiro1,3, C. Costa-Santos4, A. F. Leite-Moreira2 1 Gastroenterology Dept., Portuguese Oncology Institute; 2 Physiology Dept., and 3 CINTESIS/Biostatistics and Medical Informatics Dept. of Porto Faculty of Medicine; 4 Gastroenterology Dept. Hospital de S. João, Porto, Portugal Background: Bacterial infection incidence is raised in ACLD representing one of the major causes of morbi-mortality. Aim: To estimate genic expression of innate immunity receptors Toll-like 2 (TLR2; bacterial lipoprotein receptor), Toll-like 4 (TLR4; Gram negative lipopolysaccharide receptor) and TLR4 co-receptors CD14 and MD2 in order to explain the molecular mechanisms that support that susceptibility. Methods: Cross-sectional study in: a consecutive sample of male patients with stable ACLD [Child-Turcotte-Pugh (CTP) grade A (n = 15) and B (n = 14)] without clinical or analytical evidence of recent alcohol intake; and a control group composed by blood donors (n = 20) matched for gender and age (mean age of 55). Laboratorial protocol included: isolation of peripheral blood monocytes by Ficoll-Paque gradient centrifugation followed by positive selection with magnetized anti-CD11 monoclonal antibody; and RT-PCR, normalized for GAPDH for relative quantification of mRNA for TLR2, TLR4, CD14 and MD2. Results: (see Table) Results: Controls ACLD p* CTP-A CTP-B p** TLR 2 1,0 ± 0,14 0,51 ± 0,1 < 0,001 0,34 ± 0,05 0,55 ± 0,16 0,2 TLR 4 1,0 ± 0,11 0,68 ± 0,1 0,01 0,69 ± 0,16 0,67 ± 0,12 0,9 CD 14 1,0 ± 0,18 1,74 ± 0,35 0,06 1,53 ± 0,30 2,0 ± 0,73 0,4 MD 2 1,0 ± 0,23 1,57 ± 0,38 0,13 1,53 ± 0,45 1,75 ± 0,55 0,9 Values as mean (SEM); * t student for control vs. ACLD and **CTP-A vs. CTP-B Conclusions: ACLD is associated with innate immunity changes, with genic expression reduction of TLR2 and TLR4, without significant modifications of co-receptors MD2 and CD14. These changes can represent an acquired immunity deficiency mechanism that can help to explain the elevated infection risk of patients with ACLD. Acknowledgement: D. Manuel de Mello 2007 and APEF 2008 Research Grants.

3. Endoscopic treatment of intra-abdominal abcess after migration of a adjustable gastric band (AGB) J. Campos, L. F. Evangelista, L. T. Siqueira, G. Pagnossin, A. Fernandes, C. Vasconcelos, A. Ferraz, E. Ferraz Serviço de Cirurgia Geral – Hospital das Clínicas da Universidade Federal de Pernambuco e Hospital da Polícía Nilitar – Recife – Brasil Background: Migration of Adjustable Gastric Bands (AGB) is a complication which usually receives definite treatment only after further intragastric penetration except when there is associated infection or bleeding. Aims and Methods: To present a case with video showing an endoscopic approach on a patient with initial AGB migration and with serious intra-abdominal infection. Results: This patient presented to us with with epigastric pain, fever and leukocytosis. Upper GI endoscopy showed bulging of the gastric wall and CT scan a perigastric abscess surrounding the band tube. Antibiotic therapy was initiated and emergency endoscopy for transgastric drainage of the abscess performed. Using a needle-knife and dilatation balloon in order to expand the connection between the gastric cavity and the abscess, the passage of the endoscope was possible to clean the area and to remove debris and to further grip the connection tube into the stomach. In addition, mucosa covering the partially migrated AGB was sectioned, in order to promote a greater intragastric penetration of the prosthesis. The band tube was tractioned into the gastric cavity to prevent the drainage orifice from closing. This made possible a safe displacement for later endoscopic removal of the band. Therapeutic response was positive with the infection brought under control after a 5 months follow up, when endoscopic removal of the prosthesis was finally performed according to the usual technique. Conclusion: Similar to the transgastric NOTES technique (Natural Orifice Transluminal Endoscopic Surgery) and to the peripancreatic abscess drainage, endoscopic drainage of perigastric abscess due to AGB is also feasible and avoids repeated abdominal operations, an approach which is more aggressive and may cause gastric fistulae and other complications.

4. NSAID and gastric protection in potugal A. Dias Pereira, A. Banhudo, C. Nobre Leitao, M. Areia, M. J. Monteiro, G. Coutinho The GAP Project, Portugal Background: Treatment with NSAIDs is associated with gastrointestinal complications (GIC). Gastric protection in patients with risk factors can prevent these complications though not always used. Aim: To evaluate among General Practitioners (GP) clinical practice the use of NSAID as well as the awareness and importance of the risk factors for GIC; and to determine the factors that influence the decision for gastro-protection therapy and the magnitude of the lack of gastric protection (GAP) in high risk patients. Methods: Face-to-face interviews (with a pre-tested questionnaire) to 300 randomly selected Portuguese GP (CI 95% ± 5.5 %). Results: On average, GP saw 503 patients per month. 38 % of patients are NSAID users. Of these, 40 % are prescribed with gastric protective drugs. The main risk factors for GIC identified by GP were: history of ulcer with complications (98 %), more than 65 years old (96 %), smoking and alcohol consumption (96 %) and history of dyspepsia (95 %). In their clinical practice, 82 % of GP always prescribe gastric protection to patients with past history of peptic ulcer complications, 60 % in the case of NSAID high-dose or use of 2 or more NSAID and 51 % when patients are over 65 years old. Helicobacter Pylori status was considered a decisive factor to do gastric protection by 53 % of the GP, although the test is not usually performed (38 %) in this context. The existence of national guidelines about GIC associated with NSAID and its prevention were considered very important. Preferred sources of information about NSAID complications and prevention were: scientific papers (88 %), scientific meetings (76 %) and representatives of pharmaceutical companies (52 %). Conclusion: Risk factors for GIC from NSAID use are widely known by Portuguese GP, as well as the indications for their prevention. However, one half of the patients in need of prevention are not doing any gastric protective treatment. These results stress the need of continuous medical information and training on the risks and extremely high costs associated with GIC from NSAID therapy, and on the effectiveness of their prevention. Acknowledgement: Grant from Nycomed Portugal.