The reference surveillance method in patients with Barrett's esophagus is careful endoscopic observation, with targeted as well as random four-quadrant biopsies. Autofluorescence endoscopy (AFE) may ...make it easier to locate neoplasia. The aim of this study was to elucidate the diagnostic accuracy of surveillance with AFE-guided plus four-quadrant biopsies in comparison with the conventional approach.
A total of 187 of 200 consecutive Barrett's esophagus patients who were initially enrolled (73 % male, mean age 67 years, mean Barrett's segment length 4.6 cm), who underwent endoscopy for Barrett's esophagus in four study centers, were randomly assigned to undergo either AFE-targeted biopsy followed by four-quadrant biopsies or conventional endoscopic surveillance, also including four-quadrant biopsies (study phase 1). After exclusion of patients with early cancer or high-grade dysplasia, who underwent endoscopic or surgical treatment, as well as those who declined to participate in phase 2 of the study, 130 patients remained. These patients were examined again with the alternative method after a mean of 10 weeks, using the same methods described. The main study parameter was the detection of early cancer/adenocarcinoma or high-grade dysplasia (HGD), comparing both approaches in study phase 1; the secondary study aim in phase 2 was to assess the additional value of the AFE-guided approach after conventional surveillance, and vice versa. Test accuracy measures were derived from study phase 1.
In study phase 1, the AFE and conventional approaches yielded adenocarcinoma/HGD rates of 12 % and 5.3 %, respectively, on a per-patient basis. With AFE, four previously unrecognized adenocarcinoma/HGD lesions were identified (4.3 % of the patients); with the conventional approach, one new lesion (1.1 %) was identified. Of the 19 adenocarcinoma/HGD lesions detected during AFE endoscopy in study phase 1, eight were visualized, while 11 were only detected using untargeted four-quadrant biopsies (sensitivity 42 %). Of the 766 biopsies classified at histology as being nonneoplastic, 58 appeared suspicious (specificity 92 %, positive predictive value 12 %, negative predictive value 98.5 %). In study phase 2, AFE detected two further lesions in addition to the initial alternative approach in 3.2 % of cases, in comparison with one lesion with conventional endoscopy (1.7 %).
In this referral Barrett's esophagus population with a higher prevalence of neoplastic lesions, the AFE-guided approach improved the diagnostic yield for neoplasia in comparison with the conventional approach using four-quadrant biopsies. However, AFE alone was not suitable for replacing the standard four-quadrant biopsy protocol.
Background and study aims
Patients with achalasia or malignancies of the head and neck are at increased risk for esophageal squamous cell carcinoma. The discussion of a screening and surveillance ...program is controversial. The aim of the present study was to determine the diagnostic potential of Lugol chromoendoscopy combined with brush cytology to diagnose esophageal squamous cell carcinoma and high-grade dysplasia. Secondly, the benefit of additional biomarkers was investigated.
Patients and methods
A total of 61 patients (21 patients with achalasia and 40 patients with malignancies of the head and neck) were included. Chromoendoscopy with 1.2% Lugol iodine solution with targeted biopsies and brush cytology processed by digital image cytometry (DICM) and fluorescence in situ hybridization (FISH) from unstained lesions (USLs) and stained mucosa were performed.
Results
Six of the 61 patients had USLs ≥2 cm. Four patients had high-grade dysplasia (HGD) or carcinoma in situ (CIS). One patient with HGD and one patient with CIS were detected only after Lugol chromoendoscopy. The sensitivity and specificity for detected HGD or CIS in USLs ≥2 cm were 100% and 96.5%. No dysplasia was found in USLs <2 cm. DNA ploidy by DNA cytometry and
p53
loss of heterozygosity (LOH) by fluorescence in situ hybridization showed no additional impact on diagnostic accuracy.
Conclusions
Lugol chromoendoscopy enhances the detection rate of high-risk lesions with dysplasia or carcinoma in situ in large unstained lesions. Biomarkers such as aneuploidy and
p53
LOH from brush cytology were not of additional benefit in this setting.
Background
Reflux monitoring using combined multichannel intraluminal impedance (MII) and pH-metry increases the sensitivity for identifying gastroesophageal reflux episodes. The likelihood of a ...positive symptom index (SI) for patients with reflux disease (gastroesophageal reflux disease GERD or nonerosive reflux disease NERD) receiving proton pump inhibitor (PPI) treatment has been used to select candidates for antireflux surgery. Little is known about the advantages of MII-pH monitoring compared with pH monitoring alone for evaluating GERD/NERD patients off PPI treatment considered as candidates for antireflux surgery or for assessing changes in MII-pH-detected reflux episodes after antireflux surgery. This study aimed to determine the additional value of MII over pH-metry alone for patients off PPI treatment before and after antireflux surgery.
Methods
For this study 12 patients (4 women and 8 men; mean age, 45 years; range, 27–74 years) were evaluated using ambulatory MII-pH monitoring before and 3 months after mesh-augmented hiatoplasty. Reflux events were identified by MII-pH (A) and pH-metry (B) as patients recorded symptoms on a data logger. For each symptom, a symptom index was calculated for reflux events identified by MII-pH and by pH-monitoring alone.
Results
Preoperatively, MII-pH monitoring identified 71.9 ± 8.4 reflux episodes, whereas pH monitoring identified only 51.0 ± 7.8 (
p
< 0.05). Postoperatively, MII-pH monitoring identified 35.5 ± 6.6 reflux episodes, whereas pH monitoring identified only 19.6 ± 4.7 (
p
< 0.05). The pre- and postoperative symptom index for MII-pH monitoring was higher than pH monitoring (preoperative 91.7% vs 25%,
p
= 0.006; postoperative 50% vs 16.7%,
p
= 0.012).
Conclusion
Combined MII-pH-metry improves the pre- and postoperative assessment of GERD patients off PPI and results in a higher symptom-reflux association.
To compare the value of endosonography (endoscopic ultrasound US), dynamic computed tomography (CT), and magnetic resonance (MR) imaging in the evaluation of pancreatic tumors.
Forty-nine consecutive ...patients with clinical suspicion of pancreatic tumor underwent endoscopic US (n = 49), CT (n = 46), and MR imaging (n = 25). The final diagnosis of a malignant (n = 22), benign (n = 2), or inflammatory (n = 9) tumor, or no (n = 16) tumor was made at surgery (n = 28) and/or a combination of biopsy (n = 9) and 9-24-month follow-up (n = 12).
The sensitivity was 94% for endoscopic US, 69% for CT, and 83% for MR imaging. Specificity was 100% for endoscopic US, 64% for CT, and 100% for MR imaging. Accuracy was 96% for endoscopic US, 67% for CT, and 84% for MR imaging. The sensitivity for the detection of tumors less than 3 cm in diameter was 93% for endoscopic US (n = 15), 53% for CT (n = 15), and 67% for MR imaging (n = 12).
Endoscopic US is more accurate than dynamic CT and MR imaging in the diagnosis of pancreatic tumor, particularly for tumors less than 3 cm in diameter.
Background: Radiation proctitis is a complication of radiotherapy for malignant pelvic disease. Argon beam coagulation is a new and rapidly evolving technology that permits a “no-touch” ...electrocoagulation of diseased tissue.
Methods: We analyzed retrospectively the records of 7 patients with prostatic and endometrial cancers treated with irrradiation (median radiation dose was 6840 cGy, range 2400 to 7200 cGy). The median time to onset of symptoms after the conclusion of radiotherapy was 20 months (range 16 to 48 months); symptoms consisted of rectal bleeding and tenesmus in all patients. The patients underwent argon beam coagulation after colonoscopic evaluation. The usual treatment interval was 3 weeks (range 1 to 3 weeks).
Results: A median of 2 treatment sessions (range 2 to 4) was necessary for complete symptom relief. All interventions were well tolerated without complications. During follow-up (median 24 months, range 18 to 24 months), there was no recurrence of symptoms (bleeding, tenesmus).
Conclusions: Argon beam coagulation is a safe, well tolerated, and effective treatment option in symptomatic radiation proctitis.
Management of the complications and sequelae of acute and chronic pancreatitis is a clinical challenge. We report a case of successful transgastric drainage of splenic necrosis after occlusion of the ...splenic vessels during an acute episode in chronic pancreatitis.
Endoscopic ultrasonography (EUS) is a technique that is well established in gastroenterology for tumor staging, but so far very few data have been reported concerning the staging of anal carcinomas ...using EUS. The aim of this study is to underline the value of EUS in the staging and follow-up of anal carcinoma.
In this retrospective study, 30 consecutive patients with carcinoma of the anal canal (nine men, 21 women) were examined using EUS, and the tumors were classified according to the 1985 TNM classification. EUS was carried out either before the start of treatment (15 patients); after the initial treatment in order to plan further treatment; or during follow-up examinations (15 patients). The treatment given was based on the results of the EUS examination.
The following tumor stages were diagnosed: four lesions in stage uT0, seven in stage uT1, seven in stage uT2, nine in stage uT3, and three in stage uT4. In seven patients, suspect lymph nodes were also detected by EUS. In all but three of the patients (lost to follow-up), EUS had a direct impact on the treatment selected. Depending on the tumor stage, patients either underwent surgery (four patients: one uT1, one uT2, two uT3); received radiotherapy alone (five patients: three uT2, two uT3); combined chemoradiotherapy (eight patients: three uT2, three uT3, two uT4); interstitial booster radiotherapy (four patients: three uT1, one uT3); or no therapy at all (six patients: four uT0, one uT3, one uT4), respectively. In two patients, the tumor was understaged at EUS: in one, a uT1 tumor proved to be a pT2 tumor, and in the other, a uT3 tumor proved to be a pT4 tumor.
The advantage of EUS in the staging of anal cancer is that it allows precise assessment of the depth of infiltration and tumor spread into adjacent tissue, facilitating the choice of stage-dependent treatment decisions-particularly in determining the extent of interstitial booster radiotherapy needed. It also allows follow-up examinations after the initial treatment, with fine-needle aspiration biopsies of suspicious areas. Wider acceptance of this method might further decrease the performance of extensive surgery, with the impaired quality of life associated with rectal amputation. In addition, it might allow improved quality control of the various treatment modalities.
Brunneroma is a rare, benign, proliferative lesion arising from the Brunner’s glands of the duodenum that exceptionally may evolve towards a malignant transformation, usually discovered incidentally ...at endoscopy. Occasionally, these lesions manifest as a rare cause of duodenal obstruction or upper gastrointestinal bleeding and require resection, usually for tumors larger than 4 cm. The special aspect of our case is the technically difficult but successful dual transoral endoscopic resection of a giant (6.5 × 4 × 2.4 cm) brunneroma with a very thick and long peduncle located extremely close to the pylorus, highlighting the possibilities of endosurgery. Distal stomach resection with Roux-en-Y reconstruction as an alternative would have caused higher morbidity and costs.
Endoscopic ultrasound has become the best available method for local staging of primary rectal cancer and diagnosing recurrent local disease. The aim of this study is to compare the value of ...endoscopic ultrasound (EUS) to magnetic resonance imaging with an endorectal coil (EMRI).
Twenty-one patients (11 women, 10 men, mean age 63 years, range 31-79) with primary rectal cancer (n = 6) or follow-up examinations for recurrent local disease (n = 15) were investigated by EUS using an echo colonoscope (CF-UM 20, Olympus Optical) and by endorectal coil MRI on a 1.5 tesla MR system (General Electric). T2-weighted and contrast-enhanced T1-weighted images were obtained. The results of preoperative examinations were compared to histopathological findings regarding the T staging, with special focus on the transmural tumor infiltration.
EUS identified all tumors, whereas one tumor was missed by EMRI. EUS was superior to EMRI in T staging (accuracy 83%/40%), due to the better differentiation between T1 and T2 tumors, as the endorectal coil could not differentiate between stage T1 and stage T2. The accuracy of EMRI in assessing perirectal infiltration was 80%, compared to EUS with 100%. Local tumor recurrence was found in six of 15 patients, without endoscopic signs of recurrent disease in four of them. All were detected by EUS. Only one recurrence was missed by EMRI. Accuracy and positive and negative predictive values in follow-up examinations for recurrent disease for EUS were 93%, 86%, and 100%, and for both the T2-weighted and T1-weighted contrast-enhanced sequences of endorectal coil MRI, they were 93%, 100%, and 90%, respectively.
Endoscopic ultrasound and endorectal coil MRI are comparable methods in the preoperative staging and early diagnosis of recurrent rectal cancer. The advantages of EUS are the small diameter of the instrument, availability, and lower costs. In contrast, EMRI is operator-independent, and may become important for combined local and distant staging and follow-up examination in rectal cancer, if contrast-enhanced imaging can improve the sensitivity for liver metastases.
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