VITOR OTTOBONI BRUNALDI
Projetos de Pesquisa
Unidades Organizacionais
Instituto Central, Hospital das Clínicas, Faculdade de Medicina
LIM/35 - Laboratório de Nutrição e Cirurgia Metabólica do Aparelho Digestivo, Hospital das Clínicas, Faculdade de Medicina
LIM/35 - Laboratório de Nutrição e Cirurgia Metabólica do Aparelho Digestivo, Hospital das Clínicas, Faculdade de Medicina
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- Is Endoscopic Balloon Dilation Still Associated With Higher Rates of Pancreatitis? A Systematic Review and Meta-Analysis(2020) MATSUBAYASHI, Carolina Ogawa; RIBEIRO, Igor Braga; MOURA, Diogo Turiani Hourneaux de; BRUNALDI, Vitor Ottoboni; BERNARDO, Wanderley Marques; HATHORN, Kelly E.; MOURA, Eduardo Guimaraes Hourneaux deThe objective of this study was to compare the efficacy and safety of endoscopic papillary balloon dilation (EPBD), endoscopic sphincterotomy (ES), and the combination of large balloon dilation and ES (ES + EPLBD) in the treatment of common bile duct stones, with a special focus on postendoscopic retrograde cholangiopancreatography (ERCP) pancreatitis (PEP). Individualized search strategies were developed in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. We included randomized controlled trials (RCTs) which evaluated at least one of the following outcomes: PEP, complete stone removal in the first ERCP, need for mechanical lithotripsy, recurrence of common bile duct stones, bleeding, and cholangitis. Twenty-five RCTs were selected for analysis. Pancreatitis rates were higher for EPBD than for ES (P = 0.003), as were severe pancreatitis rates (P = 0.04). However, in the 10-mm or greater balloon subgroup analysis, this difference was not shown (P = 0.82). Rates of PEP were higher in the subgroup of non-Asian subjects (P = 0.02), and the results were not robust when RCTs that used endoscopic nasobiliary drainage were omitted. The incidence of pancreatitis was comparable between EPLBD and ES + EPLBD. All 3 approaches were equally efficacious. Nevertheless, the results should be interpreted with caution, because pancreatitis is a multifactorial pathology, and RCTs can have limited generalizability.
- A rare non-oncological pancreatic mass: eosinophilic pancreatitis diagnosis through EUS-FNA(2019) MOURA, Diogo Turiani Hourneaux De; ROCHA, Rodrigo Silva de Paula; JUKEMURA, Jose; BRUNALDI, Vitor Ottoboni; GUEDES, Hugo Goncalo; TORREZ, Franz Robert Apodaca; RIBEIRO, Igor Braga; GELRUD, Andres; MOURA, Eduardo Guimaraes Hourneaux DeBackground and study aims Eosinophilic pancreatitis (EP) is a rare etiology of chronic pancreatitis, and few cases have been reported. It is characterized by eosinophilic infiltration of the pancreas and elevated IgE levels. EP is difficult to distinguish from pancreatic cancer based on clinical symptoms and auxiliary exams. We present a case of EP and debate the routine performance of endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) for resectable pancreatic mass.
- Nonsteroidal anti-inflammatory drugs versus placebo for post-endoscopic retrograde cholangiopancreatography pancreatitis: a systematic review and meta-analysis(2019) SERRANO, Juan Pablo Roman; MOURA, Diogoturiani Hourneaux de; BERNARDO, Wanderley Marques; RIBEIRO, Igor Braga; FRANZINI, Tomazo Prince; MOURA, Eduardo Turiani Hourneaux de; BRUNALDI, Vitor Ottoboni; SALESSE, Marianne Torrezan; SAKAI, Paulo; MOURA, Eduardo Guimaraes Hourneaux DeBackground and study aims Endoscopic retrograde cholangiopancreatography (ERCP) is the primary therapeutic procedure for treatment of diseases that affect the biliary tree and pancreatic duct. While the therapeutic success rate of ERCP is high, the procedure can cause complications, such as acute pancreatitis (PEP), bleeding, and perforation. This meta-analysis aimed to assess the efficacy of nonsteroidal anti-inflammatory drugs (NSAIDs) in preventing PEP following (ERCP). Materials and methods We searched databases, such as MEDLINE, Embase, and Cochrane Central Library. Only randomized controlled trials (RCTs) that compared the efficacy of NSAIDs and placebo for the prevention of PEP were included. Outcomes assessed included incidence of PEP, severity of pancreatitis, route of administration, and type of NSAIDs. Results Twenty-one RCTs were considered eligible with a total of 6854 patients analyzed. Overall, 3427 patients used NSAIDs before ERCP and 3427 did not use the drugs (control group). In the end, 250 cases of acute pancreatitis post-ERCP were diagnosed in the NSAIDs group and 407 cases in the placebo group. Risk for PEP was lower in the NSAID group (risk difference (RD): -0.05; 95% confidence interval (CI): -0.07 to -0.03; number need to treat (NNT), 20; P<0.05). Use of NSAIDs effectively prevented mild pancreatitis compared with use of placebo (2.5% vs. 4.1%; 95% CI, -0.05 to -0.01; NNT, 33; P<0.05), but the information on moderate and severe PEP could not be completely elucidated. Only rectal administration reduced incidence of PEP (6.8% vs. 13 %; 95% CI, -0.10 to -0.04; NNT, 20; P<0.05). Furthermore, only diclofenac or indomethacin use was effective in preventing PEP. Conclusions Rectal administration of diclofenac and indomethacin significantly reduced risk of developing mild PEP. Further RCTs are needed to compare efficacy between NSAID administration pathways in prevention of PEP after ERCP.
- EUS-Guided Intragastric Injection of Botulinum Toxin A in the Preoperative Treatment of Super-Obese Patients: a Randomized Clinical Trial(2019) MOURA, Eduardo Guimaraes Hourneaux de; RIBEIRO, Igor Braga; FRAZAO, Mariana Souza Varela; MESTIERI, Luiz Henrique Mazzonetto; MOURA, Diogo Turiani Hourneaux de; BO, Creusa Maria Roveri Dal; BRUNALDI, Vitor Ottoboni; MOURA, Eduardo Turiani Hourneaux de; NUNES, Gabriel Cairo; BUSTAMANTE, Fabio Alberto Castillo; GALVAO NETO, Manoel dos Passos; MATUGUMA, Sergio Eiji; BERNARDO, Wanderley Marques; SANTO, Marco AurelioBackgroundObesity is a disease that is highly prevalent in Brazil, and the associated comorbidities represent a major global public health challenge. Botulinum toxin type A (BTX-A) is a potent neurotoxin and inhibitor of gastric smooth muscle activity. In theory, BTX-A administration should promote early satiety and weight loss because it delays gastric emptying by inhibiting acetylcholine-mediated peristalsis, which is primarily responsible for gastric motility. Because results in the literature are discrepant, the efficacy of intragastric injections of BTX-A as a primary treatment for obesity remains unknown. The objective of this prospective, double-blind, single-center randomized study was to evaluate the effects of endoscopic ultrasound-guided intragastric BTX-A injections, as a bridge to bariatric surgery, in super-obese patients.MethodsThirty-two super-obese patients were randomized to one of two groups: BTX-A, in which 200units of BTX-A were injected into the gastric antrum and body; and control, in which the same injections were performed with 0.9% saline. Weight, body mass index (BMI), and loss of excess weight were measured monthly over a 6-month period. Gastric emptying scintigraphy was performed before and after the procedure.ResultsThe patients in both groups showed significant weight loss over the course of the study (p<0.001). There were no statistically significant differences between the groups regarding weight loss, excess weight, total loss of excess weight, total weight loss, or change in BMI.ConclusionsIntragastric injection of BTX-A does not appear to be an effective method of achieving preoperative weight loss in super-obese patients.
- Endoscopic submucosal dissection versus transanal endoscopic surgery for the treatment of early rectal tumor: a systematic review and meta-analysis(2020) SAGAE, Vitor Massaro Takamatsu; RIBEIRO, Igor Braga; MOURA, Diogo Turiani Hourneaux de; BRUNALDI, Vitor Ottoboni; LOGIUDICE, Fernanda Prado; FUNARI, Mateus Pereira; BABA, Elisa Ryoka; BERNARDO, Wanderley Marques; MOURA, Eduardo Guimaraes Hourneaux deBackground Minimally invasive treatment of early-stage rectal lesion has presented good results, with lower morbidity than surgical resection. Transanal endoscopic microsurgery (TEM) and transanal minimally invasive surgery (TAMIS) are the main methods of transanal surgery. However, endoscopic submucosal dissection (ESD) has been gaining ground because it allows en bloc resections with low recurrence rates. The aim of this study was to analyze ESD in comparison with transanal endoscopic surgery. Methods We searched MEDLINE, EMBASE, SciELO, Cochrane CENTRAL, and Lilacs/Bireme with no restrictions on the date or language of publication. The outcomes evaluated were recurrence rate, complete (R0) resection rate, en bloc resection rate, length of hospital stay, duration of the procedure, and complication rate. Results Six retrospective cohort studies involving a collective total of 326 patients-191 in the ESD group and 135 in the transanal endoscopic surgery group were conducted. There were no statistically significant differences between the groups for any of the outcomes evaluated. Conclusions For the minimally invasive treatment of early rectal tumor, ESD and surgical techniques do not differ in terms of local recurrence, en bloc resection rate, R0 resection rate, duration of the procedure, length of hospital stay, or complication rate, however, evidence is very low.
- Cholangioscopy-guided lithotripsy vs. conventional therapy for complex bile duct stones: a systematic review and meta-analysis(2020) GALETTI, Facundo; MOURA, Diogo Turiani Hourneaux de; RIBEIRO, Igor Braga; FUNARI, Mateus Pereira; CORONEL, Martin; SACHDE, Amit H.; BRUNALDI, Vitor Ottoboni; FRANZINI, Tomazo Prince; BERNARDO, Wanderley Marques; MOURA, Eduardo Guimaraes Hourneaux deIntroduction: Endoscopic removal of common bile duct stones has a high success rate ranging from 85% to 95%. Bile duct stones >15 mm are difficult and frequently require lithotripsy. Peroral cholangioscopy (POC) allows lithotripsy with similar success rates. Aim: To determine the efficacy and safety of cholangioscopy-guided lithotripsy used in the treatment of difficult to remove bile duct stones vs. conventional therapy. Methods: Search was based in Medlin, Embase, Cochrane Central, Lilacs/Bireme. Studies enrolling patients referred for the removal of difficult bile duct stones via POC were considered eligible. Two analyses were carried out separately, one included randomized controlled trials (RCTs) and another observational studies. Results: Forty-six studies were selected (3 RTC and 43 observational). In the analysis there was no statistical significant difference between successful endoscopic clearance (RD=-0.02 CI: -0.17, 0.12/I-2-0%), mean fluoroscopy time (MD--0.14 CI -1.60, 1.32/I-2 -21%) and adverse events rates (RD=-0.06 CI: -0.14, 0.02/I-2=0%), by contrast, the mean procedure time favored conventional therapy with statistical significance (MD-27.89 CI: 16.68, 39.10/I-2-096). In observational studies, the successful endoscopic clearance rate was 8829% (CI95: 86.996-90.7%), the first session successful endoscopic clearance rate was 72.7 % (CI95: 69.9%-75.3%), the mean procedure time was 47.50 +/- 6 min for session and the number of sessions to clear bile duct was 15 +/- 0.18. The adverse event rate was 8.7% (C195: 7%-10.9%). Concussions: For complex common bile duct stones, cholangioscopy-guided lithotripsy has a success rate that is similar to traditional ERCP techniques in terms of therapeutic success, adverse event rate and means fluoroscopy time. Conventional ERCP methods have a shorter mean procedure time.
conferenceObject THE EFFECTIVENESS OF ENDOSCOPIC GASTROPLASTY FOR OBESITY TREATMENT ACCORDING TO FDA THRESHOLDS: SYSTEMATIC REVIEW AND META-ANALYSIS BASED ON RANDOMIZED CONTROLLED TRIALS(2018) MADRUGA NETO, Antonio C.; BERNARDO, Wanderlei M.; MOURA, Diogo T. de; BRUNALDI, Vitor O.; SOUZA, Thiago F.; RIBEIRO, Igor B.; MARTINS, Rafael K.; CORONEL, Martin A.; NETO, Manoel Galvao; CAMPOS, Josemberg M.; SANTO, Marco Aurelio; MOURA, Eduardo G. de- Use of hemostatic powder in treatment of upper gastrointestinal bleeding: a systematic review and meta-analysis(2019) REZENDE, Daniel Tavares de; BRUNALDI, Vitor Ottoboni; BERNARDO, Wanderley Marques; RIBEIRO, Igor Braga; MOTA, Raquel Cristina Lins; BARACAT, Felipe Iankelevich; MOURA, Diogo Turiani Hourneaux de; BARACAT, Renato; MATUGUMA, Sergio Eiji; MOURA, Eduardo Guimaraes Hourneaux deBackground and study aims TC-325 is a novel mineral hemostatic powder that creates a mechanical barrier by absorbing blood components and promoting clotting. Recently approved for use in humans, it has shown promise for treatment of upper gastrointestinal bleeding (UGIB). However, because there have been no large studies of TC-325, its true efficacy and safety profile remain unknown. We performed a systematic review and meta-analysis to determine the safety and efficacy of TC-325 in treating UGIB, based on rates of initial hemostasis, rebleeding, and adverse events (AEs). Methods We searched the MEDLINE/PubMed, EMBASE, CENTRAL, Latin-American and Caribbean Health Sciences Literature databases, as well as the gray literature, to identify articles describing use of TC-325 up to October 2018.Primary outcomes were initial hemostasis and rebleeding. AEs were described as a secondary outcome. Risk of bias was assessed with international scores. Results We identified 2077 records after removal of duplicates. We included 50 studies, involving a collective total of 1445 patients, in the quantitative synthesis. Primary hemostasis and rebleeding rates were 90.7% and 26.1%, respectively. Subgroup analyses showed similar results. Only eight AEs were reported. Conclusions TC-325 appears to be a safe, effective treatment for UGIB. The overall rate of initial hemostasis after TC-325 use is high, regardless of etiology of bleeding or whether TC-325 is used as a primary or rescue therapy. Although it is also associated with high rebleeding rates, rates of AEs and equipment failure after TC-325 use are extremely low.
- Endoscopic Dilation with Bougies versus Balloon Dilation in Esophageal Benign Strictures: Systematic Review and Meta-Analysis(2018) JOSINO, Iatagan R.; MADRUGA-NETO, Antonio C.; RIBEIRO, Igor B.; GUEDES, Hugo G.; BRUNALDI, Vitor O.; MOURA, Diogo T. H. de; BERNARDO, Wanderley M.; MOURA, Eduardo G. H. deBackground. The use of bougies and balloons to dilate benign esophageal strictures (BES) is a consolidated procedure. However, the amount of evidence available in scientific literature supporting which is the best technique is very low, despite the great prevalence and importance of such pathology. This systematic review with meta-analysis aims at comparing both techniques, providing good quality of evidence. Methods. We searched for randomized clinical trials (RCTs) published from insertion to November 2017, using MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials, LILACS, and grey literature. After the data extraction, a meta-analysis was performed. The main outcomes were symptomatic relief and recurrence rate. The secondary outcomes were bleeding, perforation, and postprocedure pain. Results. We included 5 randomized clinical trials (RCTs), totalizing 461 patients. Among them, 151 were treated with bougie dilation and 225 underwent balloon dilation. Regarding symptomatic relief, recurrence, bleeding, and perforation rates, there were no differences between the methods. Concerning postprocedure pain, patients submitted to balloon dilation had less intense pain (RD 0.27, 95% IC -0.42 to -0.07, P = 0 007). Conclusion. We conclude that there is no difference between bougie and balloon dilation of BESs regarding symptomatic relief, recurrence rate at 12 months, bleeding, and perforation. Patients undergoing balloon dilation present less severe postprocedure pain.
- Adverse events after biliary sphincterotomy: Does the electric current mode make a difference? A systematic review and meta-analysis of randomized controlled trials(2020) FUNARI, Mateus Pereira; RIBEIRO, Igor Braga; MOURA, Diogo Turiani Hourneaux de; BERNARDO, Wanderley Marques; BRUNALDI, Vitor Ottoboni; REZENDE, Daniel Tavares; RESENDE, Ricardo Hannum; MARCO, Michele Oliveira de; FRANZINI, Tomazo Antonio Prince; MOURA, Eduardo Guimaraes Hourneaux deBackground: Biliary sphincterotomy is an invasive method that allows access to the bile ducts, however, this procedure is not exempt of complications. Studies in the literature indicate that the mode of electric current used for sphincterotomy may carry different incidences of adverse events such as pancreatitis, hemorrhage, perforation, and cholangitis. Aim: To evaluate the safety of different modes of electrical current during biliary sphincterotomy based on incidence of adverse events. Methods: We searched articles for this systematic review in Medline, EMBASE, Central Cochrane, Lilacs, and gray literature from inception to September 2019. Data from studies describing different types of electric current were meta-analyzed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). The following electric current modalities were evaluated: endocut, blend, pure cut, pure cut followed by blend, monopolar, and bipolar. Results: A total of 1791 patients from 11 randomized clinical trials evaluating the following comparisons: 1. Endocut vs Blend: No statistical difference in the incidence of bleeding (7% vs 13.4%; RD: -0.11 [-0.31, 0.08], P=0.27, I-2=86%), pancreatitis (4.4% vs 3.5%; RD: 0.01 [-0.03, 0.04], P=0.62, I-2=48%) and perforation (absence of cases in both arms). 2. Endocut vs Pure cut: Higher incidence of mild bleeding (without drop in hemoglobin levels, clinical repercussion or need for endoscopic intervention) in the pure cut group (9.2% vs 28.8%; RD: -0.19 [-0.27, -0.12], P<0.00001, I-2=0%). No statistical difference regarding pancreatitis (5.2% vs 0.9%; RD: 0.05 [-0.01, 0.11], P=0.12, I-2=57%), perforation (0.4% vs 0%; RD: 0.00 [-0.01, 0.02], P=0.7, I-2=0%) or cholangitis (1.8% vs 3.2%; RD: -0.01 [-0.09, 0.06], P=0,7). 3. Pure cut vs blend: higher incidence of mild bleeding in the pure cut group (40.4% vs 16.7%; RD: 0.24 [0.15, 0.33], P<0.00001, I-2=0%). No statistical difference concerning incidence of pancreatitis or cholangitis. 4. Pure cut vs Pure cut followed by Blend: No statistical difference regarding incidence of bleeding (22.5% vs 11.7%; RD: -0.10 [-0.24, 0.04], P=0.18, I-2=61%) and pancreatitis (8.9% vs 14.8%; RD 0.06 [-0.02, 0.13], P=0.12, I-2=0%). 5. Blend vs pure cut followed by blend: no statistical difference regarding incidence of bleeding and pancreatitis (11.3% vs 10.4%; RD -0.01 [-0.11, 0.09], P=0.82, I-2=0%). 6. Monopolar vs bipolar: higher incidence of pancreatitis in the monopolar mode group (12% vs 0%; RD 0.12 [0.02, 0.22], P=0.01). Conclusion: Pure cut carries higher incidences of mild bleeding compared to endocut and blend. However, this modality might present a lower incidence of pancreatitis. The monopolar mode elicits higher rates of pancreatitis in comparison with the bipolar mode. There is no difference in incidence of cholangitis or perforation between different types of electric current. There is a lack of evidence in the literature to recommend one method over the others, therefore new studies are warranted. As there is no perfect electric current mode, the choice in clinical practice must be based on the patient risk factors.