Polyp miss rates during colonoscopy have been calculated in a few tandem or back-to-back colonoscopy studies. Our objective was to assess the adenoma miss rate while limiting technique or operator ...expertise biases, i. e. by performing a large multicenter study, with same-day back-to-back video colonoscopy, done by two different operators in randomized order and blinded to the other examination.
294 patients at 11 centers were included. Among the 286 analyzable tandem colonoscopies, miss rates were calculated in both a lesion- and patient-based analysis. Each of these rates was determined for polyps overall, for adenomas, and then for lesions larger than 5 mm, and for advanced adenomas. Univariate and logistic regression analysis were performed to define independent variables associated with missed polyps or adenomas.
The miss rates for polyps, adenomas, polyps > or = 5 mm, adenomas > or = 5 mm, and advanced adenomas were, respectively, 28 %, 20 %, 12 %, 9 % and 11 %. None of the masses with a carcinomatous (n = 3) or carcinoid component (n = 1) was missed. The specific lesion miss rates for patients with polyps and adenomas were respectively 36 % and 26 % but the corresponding rates were 23 % and 9.4 % when calculated for all 286 patients. The diameter (1-mm increments) and number of polyps (> or = 3) were independently associated with a lower polyp miss rate, whereas sessile or flat shape and left location were significantly associated with a higher miss rate. Adequacy of cleansing, presence of diverticula, and duration of withdrawal for the first procedure were not associated with adenoma miss rate.
We confirm a significant miss rate for polyps or adenoma during colonoscopy. Detection of flat polyps is an issue that must be focused on to improve the quality of colonoscopy.
Endoscopic submucosal dissection (ESD) is a technique for "en bloc" resection of superficial tumors of the gastrointestinal tract. In France, experience with this technique is still limited. We ...wanted to assess the development of ESD in France, with special attention to short term outcomes.
Members of the Société Française d'Endoscopie Digestive (SFED) who declared performing ESD reported their cases prospectively on a voluntary basis. Demographic, clinical, and technical data, and the results of immediate complications were collected. Case reports were completed prospectively by each investigator before pooled analysis.
A total of 188 consecutive case reports were collected from 16 centers. The median case mix per center was 6 patients (range 1-43). The lesion sites treated by ESD were the stomach (n = 75), esophagus (n = 27), duodenum (n = 1), cecum (n = 2), right colon (n = 3), transverse colon (n = 5), sigmoid (n = 3), and rectum (n = 72). The median size of the lesions was 26 mm (range 2-150 mm). En bloc resection was achieved in 77.1% of cases, with complete R0 resection in 72.9%. Histopathology results showed high grade dysplasia or superficial cancer in 71.2%. The median duration of ESD was 105 minutes (range 20-450 minutes). The short term morbidity was 29.2% including 34 cases of perforation (18.1%), and 21 hemorrhages (11.2%) during the 24 hours following ESD, 89% of which were managed conservatively or endoscopically.
In this early experience, the feasibility of ESD appeared to be good but R0 resection and complication rates did not match those reported by Japanese authors and must be improved by an extended practice.
The prevalence of esophageal squamous-cell carcinoma in high-risk patients and the advantages of systematic Lugol staining during esophagoscopy have not yet been evaluated in a large prospective ...study. In this study we aimed to assess the prevalence of this type of tumor in high-risk patients, to examine the role of Lugol staining in endoscopic screening for esophageal squamous-cell carcinoma, and to establish whether it is possible to identify a particularly high-risk group which would benefit from systematic screening.
A prospective study was undertaken in 62 endoscopy centers. A total of 1095 patients were enrolled, none of whom had any esophageal symptoms. These patients had presented with either a past history of or a recent head and neck or tracheobronchial squamous-cell carcinoma (group 1), with alcoholic chronic pancreatitis (group 2), with alcoholic cirrhosis (group 3), or were alcohol and tobacco addicts (group 4). The patients underwent a meticulous endoscopic examination of the esophagus, followed by Lugol staining.
The prevalence of esophageal squamous-cell carcinoma was 3.2 %. The group 1 patients showed the highest prevalence of carcinoma (5.3 %) and the highest prevalence of dysplasia (4.5 %). Of the 35 carcinomas detected in the 1095 patients, seven (20 %) were early lesions, and 20 % were only detected after Lugol staining (P = 0.02). High-grade dysplasia was only observed in group 1 patients and two-thirds of these lesions were only diagnosed after Lugol staining. The overall prevalence of low-grade dysplasia was 2.4 %, and 77 % of these were detected only after Lugol staining (P < 0.001).
Lugol dye staining increases the sensitivity of esophageal endoscopy for the detection of high-grade dysplasia and cancer. The prevalence of dysplasia and cancer reached 9.9 % in group 1, and we therefore believe that an endoscopic screening program could be justified for patients with head and neck or tracheobronchial cancer.
Introduction:
Self-expanding metal stents (SEMS) are commonly used in the palliation of dysphagia in patients with inoperable esophageal carcinoma. However, they predispose to gastroesophageal reflux ...when deployed across the gastroesophageal junction. The aims of this study were to: 1) assess the influence of the antireflux valve on trans-prosthetic reflux (primary outcome); and 2) compare the results of SEMS with and without antireflux valve in terms of reflux symptoms, quality of life (QOL), improvement of dysphagia and adverse events (secondary outcomes).
Patients and methods:
Thirty-eight patients were enrolled in nine centers. Carcinomas were locally advanced (47 %) or metastatic. After randomization, patients received either a covered SEMS with antireflux valve (n = 20) or a similar type of SEMS with no antireflux device but assigned to standard proton pump inhibitor therapy and postural advice (n = 18). Trans-prosthetic reflux was assessed at day 2 using a radiological score based on barium esophagography performed after Trendelenburg maneuver and graded from 0 (no reflux) to 12 (maximum). Monthly telephone interviews were conducted for Organisation Mondiale de la Santé (OMS) scoring from 0 (excellent) to 5 (poor), QOL assessment (based on the Reflux-Qual Simplifié scoring system) from 0 (poor) to 100 (excellent), dysphagia scoring from 0 (no dysphagia) to 5 (complete dysphagia) and regurgitation scoring from 0 (no regurgitation) to 16 (maximum).
Results:
No difference was noted in terms of age, sex, size of lesion, prosthesis length or need for dilation prior to SEMS placement. No difficulty in placing SEMS nor complications were noted. Radiological scores of reflux were found to be significantly lower in patients with an antireflux stent compared to the conventional stent and associated measures. The regurgitation scores were significantly decreased in patients with antireflux stents during the first 2 months after stent placement and thereafter, they were similar in the two groups. QOL and dysphagia were improved in both groups. Survival rates were comparable in the two groups.
Conclusions:
No difference was observed between the two types of SEMS regarding the palliation of dysphagia and improvement of QOL. However, SEMS with an antireflux valve were more effective in preventing trans-prosthetic gastroesophageal reflux but at the cost of an increased likehood of minor adverse events (migrations and/or obstruction of the SEMS).
Several studies have suggested that nitroglycerin promotes pancreatic drainage and thereby helps to prevent pancreatitis occurring after endoscopic retrograde cholangiography (ERC). We performed a ...multicenter, double-blind, randomized, placebo-controlled trial to evaluate the efficacy of intravenous nitroglycerin for preventing acute pancreatitis in moderate- to high-risk patients undergoing ERC.
The patients underwent therapeutic ERC for gallstone removal, bile duct stenosis, or sphincter of Oddi dysfunction (SOD). They were randomly allocated to receive an intravenous nitroglycerin bolus of 0.1 mg, then 35 microg/kg per minute intravenously (maximum dose 9 mg) for 6 h, or an identical placebo regimen. Serum amylase and lipase levels were determined before and 24 h after ERC.
The study was terminated after the interim analysis. The intention-to-treat population consisted of 208 patients enrolled in 20 centers, of whom 105 received nitroglycerin and 103 placebo therapy. Post-ERC pancreatitis (mild/moderate/severe) occurred in 25 patients, comprising 10 (3/5/2) in the nitroglycerin arm and 15 (5/6/4) in the placebo arm (OR 0.62, 95 % CI 0.26 - 1.45; P = 0.26). Pancreatitis-related hospital stays were similar in the two groups (median 4 days, range 2 - 13 days in the nitroglycerin group; median 5 days, range 2 - 20 days in the placebo group). The incidence of pancreatitis in patients with SOD did not differ between the groups (4/11 in the nitroglycerin arm, and 4/15 in the placebo arm). Adverse events were more frequent in the nitroglycerin group and led to cessation of drug infusion in 10 patients in the nitroglycerin arm and in 2 patients in the placebo arm ( P = 0.019).
In this study, nitroglycerin offered a limited and clinically nonsignificant benefit for the prevention of post-ERC pancreatitis. Its use did not improve the technical success rate of ERC.
Summary Lymphomatous polyposis of the gastrointestinal tract is rare. It refers to a heterogeneous group of small B-cell lymphomas including mantle cell lymphoma, follicular lymphoma and MALT ...lymphoma. It is characterized by the presence of multiple lymphomatous polyps along one or more segments of the digestive tract. Clinical symptoms are non-specific. We herein report the case of a 74-year old man initially admitted for an upper and lower gastrointestinal endoscopy to explore a positive Hemoccult® test. The endoscopy revealed multiple polyps all along the gastrointestinal tract. Histopathological study showed a diffuse lymphomatous proliferation of small B-cells whose immunohistochemical features were compatible with a mantle cell lymphoma. Tumoral B-cells showed a positivity of cyclin D1 markers but negativity for CD5. Immunochemotherapy with R-CHOP (rituximab, cyclophosphamide, adriamycine, vincristine and prednisone) was initiated. Based on this case study, the pitfalls of gastrointestinal tract lymphomatous polyposis diagnosis, prognosis and treatment options are discussed.
La mucosectomie permet l'exérèse complète des lésions planes ou sessiles de la muqueuse digestive, bénignes ou malignes. La résection passe au travers du plan sous-muqueux et, contrairement aux ...techniques de destruction, permet d'obtenir une pièce de résection, autorisant une étude histopathologique précise et complète des lésions. Cette technique a introduit le concept de résection endoscopique carcinologiquement satisfaisante. En cas de lésion maligne, des critères histopathologiques permettent de moduler l'attitude thérapeutique, résection endoscopique ou chirurgicale, en fonction de la profondeur de l'atteinte pariétale, donc du risque d'extension ganglionnaire et métastatique (au mieux évalué par l'endosonographie), de son extension latérale et de l'organe considéré. Dans la majorité des cas, lorsque la lésion atteint ou franchit la sous-muqueuse, le recours à une chirurgie d'exérèse est nécessaire. L'évaluation préthérapeutique de la lésion est donc capitale. La qualité du traitement et de l'étude anatomopathologique de la pièce de résection l'est également. Différentes techniques de résection ont été décrites, mais toutes comportent trois étapes principales : repérer et marquer la périphérie de la lésion, la décoller par rapport au plan musculaire, réséquer celle-ci en suivant le plan sous-muqueux. La mucosectomie permet une résection complète, carcinologique, des lésions superficielles du tube digestif avec un taux de succès de 80 à 90 %. Les complications sont rares, en général contrôlables endoscopiquement : clips pour arrêter une hémorragie ou traiter une perforation limitée, dilatations pour les sténoses œsophagiennes.
Endoscopic mucosal resection allows excising flat or polypoid, benign or malignant mucosal lesion of the digestive tract. The resection passes through the submucosal layer. Early and superficial cancer are expected to be completely cured by local treatment using endoscopic mucosal resection. But a pretreatment staging is essential and also a rigorous histopathologic examination of the resected specimen. In case of malignant lesion, to obtain successful result of endoscopic therapy there are some important factors to be considered : lesion must be confined to the mucosal layer, localised and without lymph node metastases (endoscopic ultrasonography), size must be less than 2 cm and less than 1 cm in case of a depressed tumour, and the carcinoma must be well differentiated. The assessment of complete removal of cancer lesions should be carried out both macroscopically and histology to confirm whether the lesion has been resected with normal mucosa surrounding it. Different techniques have been described, all as 3-step procedures: the tumour size and morphology are first evaluated (staining), the lesion is then lift by submucosal saline injection, then it is resected by a snare. In case of submucosal layer invasion, surgical treatment is indicated. Complete cancer endoscopic resection can be performed in 80-90 % of the lesions. Complications are rare and in most cases, they can be controlled endoscopically: clips for haemorrhage stoppage or limited perforation treatment, dilation for oesophageal stenoses.
Biliary stents are liable to clog. We investigated whether a choleretic plus an antibiotic could delay clogging. 20 consecutive patients with a malignant biliary stricture were randomised after ...endoscopic insertion of a polyethylene stent to receive ursodeoxycholic acid plus norfloxacin (13-15 mg/kg and 400 mg, daily) or conservative treatment. The drug combination was associated with: a longer median patency of first (49 vs 6 weeks) and all stents (38 vs 7 weeks); a prolonged median survival (67 vs 18 weeks); and a shorter mean hospital stay (0 2 vs 1 0 days per week of survival). Thus ursodeoxycholic acid plus norfloxacin may prevent stent clogging.
Celotno besedilo
Dostopno za:
DOBA, IZUM, KILJ, NUK, PILJ, PNG, SAZU, SBJE, SIK, UILJ, UKNU, UL, UM, UPUK, VSZLJ
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