Background Current guidelines recommend that endoscopic surveillance of Barrett's esophagus (BE) be performed by using a strict biopsy protocol. However, novel methods to improve BE surveillance are ...still needed. Objective To evaluate the impact of Barrett's inspection time (BIT) on yield of surveillance. Design Post hoc analysis of data obtained from a clinical trial. Setting Five tertiary referral centers. Patients Patients undergoing BE surveillance. Interventions Coordinators prospectively recorded the time spent inspecting the BE mucosa with a stopwatch. Main Outcome Measurements Endoscopically suspicious lesions, high-grade dysplasia (HGD)/esophageal adenocarcinoma (EAC). Results A total of 112 patients underwent endoscopic surveillance by 11 individual endoscopists. Patients with longer BITs were more likely to have an endoscopically suspicious lesion ( P < .001) and more endoscopically suspicious lesions ( P = .0001) and receive a diagnosis of HGD/EAC ( P = .001). There was a direct correlation between the endoscopist's mean BIT per centimeter of BE and the detection of patients with HGD/EAC (ρ = .63, P = .03). Endoscopists who had an average BIT longer than 1 minute per centimeter of BE detected more patients with endoscopically suspicious lesions (54.2% vs 13.3%, P = .04), and there was a trend toward a higher detection rate of HGD/EAC (40.2% vs 6.7%, P = .06). Limitations Post hoc analysis of an enriched study population and experienced endoscopists at tertiary referral centers. Conclusions Longer time spent inspecting the BE segment is associated with the increased detection of HGD/EAC. Taking additional time to perform a thorough examination of the BE mucosa may serve as an easy and widely available method to improve the yield of BE surveillance.
Background Missing adenomas and the inability to accurately differentiate between polyp histology remain the main limitations of standard-definition white-light (SD-WL) colonoscopy. Objective To ...compare the adenoma detection rates of SD-WL with those of high-definition white-light (HD-WL) and narrow-band imaging (NBI) as well as the accuracy of predicting polyp histology. Design Multicenter, prospective, randomized, controlled trial. Setting Two academic medical centers in the United States. Patients Subjects undergoing screening or surveillance colonoscopy. Intervention Subjects were randomized to undergo colonoscopy with one of the following: SD-WL, HD-WL, or NBI. Main Outcome Measurements The proportion of subjects detected with adenomas, adenomas detected per subject, and the accuracy of predicting polyp histology real time. Results A total of 630 subjects were included. The proportion of subjects with adenomas was 38.6% with SD-WL compared with 45.7% with HD-WL and 46.2% with NBI ( P = .17 and P = .14, respectively). Adenomas detected per subject were 0.69 with SD-WL compared with 1.12 with HD-WL and 1.13 with NBI ( P = .016 and P = .014, respectively). HD-WL and NBI detected more subjects with flat and right-sided adenomas compared with SD-WL (all P values <.005). NBI had a superior sensitivity (90%) and accuracy (82%) to predict adenomas compared with SD-WL and HD-WL (all P values <.005). Limitations Academic medical centers with experienced endoscopists. Conclusions There was no difference in the proportion of subjects with adenomas detected with SD-WL, HD-WL, and NBI. However, HD-WL and NBI detected significantly more adenomas per subject (>60%) compared with SD-WL. NBI had the highest accuracy in predicting adenomas in real time during colonoscopy. (Clinical Trial registration number: NCT 00614770 .)
Background and Aims The exact cutoff value at which pancreatic cyst fluid carcinoembryonic antigen (CEA) level distinguishes pancreatic mucinous cystic neoplasms (MCNs) from pancreatic nonmucinous ...cystic neoplasms (NMCNs) is unclear. The aim of this multicenter retrospective study was to evaluate the diagnostic accuracy of cyst fluid CEA levels in differentiating between MCNs and NMCNs. Methods Consecutive patients who underwent EUS with FNA at 3 tertiary care centers were identified. Patients with histologic confirmation of cyst type based on surgical specimens served as the criterion standard for this analysis. Demographic characteristics, EUS morphology, FNA fluid, and cytology results were recorded. Multivariate logistic regression analysis to identify predictors of MCNs was performed. Receiver-operating characteristic (ROC) curves were generated for CEA levels. Results A total of 226 patients underwent surgery (mean age, 61 years, 96% white patients, 39% female patients) of whom 88% underwent Whipple’s procedure or distal pancreatectomy. Based on surgical histopathology, there were 150 MCNs and 76 NMCNs cases. The median CEA level was 165 ng/mL. The area under the ROC curve for CEA levels in differentiating between MCNs and NMCNs was 0.77 (95% confidence interval, 0.71–0.84, P < .01) with a cutoff of 105 ng/mL, demonstrating a sensitivity and specificity of 70% and 63%, respectively. The cutoff value of 192 ng/mL yielded a sensitivity of 61% and a specificity of 77% and would misdiagnose 39% of MCN cases. Conclusions Cyst fluid CEA levels have a clinically suboptimal accuracy level in differentiating MCNs from NMCNs. Future studies should focus on novel cyst fluid markers to improve risk stratification of pancreatic cystic neoplasms.
Fundic Gland Polyps (FGPs) are commonly found in familial adenomatous polyposis (FAP) patients and are considered benign. Biopsies are not routinely done, and conventional forceps may be ...time-consuming and/or yield non-representative histology. The purpose of this study was to evaluate the role of a novel endoscopic polypectomy surveillance (EPS), a large volume cold-snare polypectomy technique of random FGPs, on the incidence of dysplasia and gastric cancer (GC) in FAP.
This is a retrospective longitudinal cohort of FAP patients referred to a tertiary care center for duodenal adenoma surveillance and who underwent EPS of FGPs between 2001 to 2019. Demographic, endoscopic, and clinicopathologic information was reviewed.
Thirty-five FAP patients were identified at initial endoscopy by the mean age of 43.4 years (±12.8). 113 surveillance endoscopies were performed in total using EPS. Dysplasia of FGPs was present on initial EGD in seven patients (20%), 13 additional patients (46.4%) progressed to low-grade dysplasia (LGD). Three patients (15%) subsequently had progression to gastric cancer (GC) were found to have signet ring cell cancer within the foci of FGPs through EPS surveillance. One patient presented as metastatic GC. Progression from non-dysplastic FGP to LGD occurred over 63 months (±46.3) with further progression to GC over 34 months (±8.5). Endoscopic risk factors for cancer were polyps >10mm in size (p<.001) and carpeting of polyps (p<.001). The 5-year cumulative incidence of developing dysplasia was 35.7%.
We identified that the incidence of dysplasia and GC is higher than previously reported in FAP patients. Our study utilized a novel EPS technique and was able to identify GC within the foci of FGPs. Upper endoscopic guidelines should include a more rigorous sampling method for FGPs, such as EPS, to optimize early detection of dysplasia and gastric cancer.
PDF
