Adriana V. Safatle-Ribeiro

Gastric Stump Cancer: What Is the Risk?

Patients who have undergone partial gastric resections are at an increased risk for the development of cancer in the gastric remnant. The overall risk increases over time and is higher in patients with an initial diagnosis of gastric rather than duodenal ulcer, in men and following partial gastrectomy with Billroth II reconstruction. The site of tumor growth is predominantly in the anastomotic area, but may occur anywhere in the stump. Enterogastric reflux, achlorhydria, bacteria overgrowth, and Helicobacter pylori appear to be the major factors involved in the etiopathogenesis of the gastric stump cancer. Surveillance of these patients with endoscopy and multiple biopsies may provide the means to diagnose tumors at an early stage, but the cost-benefit ratio of surveillance requires further study. Despite the magnitude of alterations in gastric stump mucosa, unfortunately, at this time we do not have good predictors of patients who will develop a cancer.

Expression of p53, PCNA, and C-erbB-2 in Barrett's metaplasia and adenocarcinoma

We sought to determine if an immunohistochemicalpanel of p53, PCNA, and c-erbB-2 was a useful biomarkerof transformation in Barretts metaplasia. P53, PCNA,and c-erbB-2 immunohistochemistry was performed on resected Barretts specimens selected toshow discrete grades of dysplasia and then onprospectively obtained biopsies. In resection specimens,p53 was positive in 36% with no dysplasia, in 30% with low-grade dysplasia, in 85% with high-gradedysplasia, and in 90% of adenocarcinomas. While anevaluation of proliferation throughout the specimen didnot differ between groups, surface proliferation was significantly higher in high-grade dysplasiathan in low-grade or no dysplasia. All high-gradedysplasia specimens were positive for at least onemarker, compared to 44% with no or low-grade dysplasia. C-erbB-2 was only seen in 31% with high-gradedysplasia and in 10% of adenocarcinomas. Prospectively,the panel had a sensitivity of 100%, a specificity of81% and an overall accuracy of 83% in identifying patients who developed high-grade dysplasia orcancer. Thus, overexpression of p53 occurs early in themalignant transformation of Barretts and increases withhistologic progression, and proliferation at the surface of Barretts epitheliumincreases with progressive grades of dysplasia. Animmunohistochemical panel of p53 and PCNA is a usefulbiomarker for Barretts metaplasia.

Does the intraoperative peritoneal lavage cytology add prognostic information in patients with potentially curative gastric resection

Peritoneal recurrence is the foremost pattern of failure after potentially curative resection for gastric cancer. Our aim was to evaluate the prognostic value of intraperitoneal free cancer cells (IFCCs) in peritoneal lavage of patients who underwent potentially curative resection for gastric carcinoma. Two hundred twenty patients with gastric cancer stage I, II, or III were prospectively evaluated with peritoneal lavage and cytologic examination. Aspirated fluid from the abdominal cavity was centrifuged and subjected to Papanicolaou staining. The mean age was 60.9 years (range, 21–89 years), and 63.6% were men. IFCCs were detected in 6.8% of the patients; suspicious in 2.7%, and negative in 84.5%. No judgment could be given in 5.9% of the cases. Invasion of the gastric serosa (pT3) was observed in all positive cytology patients. Patients with IFCCs had a mean survival time of 10.5 months, while those with negative IFCC had a mean survival time of 61 months (P = 0.00001). There was no correlation between the presence of IFCCs and tumor size, histology, pN, or tumor site. Our conclusions are that (1) positive cytology indicates a poor prognosis in patients who underwent potentially curative gastric resection and (2) peritoneal lavage cytology improves staging in assessing these patients and may alter their therapeutic approach.

Prognostic significance of intraperitoneal free cancer cells obtained by laparoscopic peritoneal lavage in patients with gastric cancer

Laparoscopy is a safe and useful method for examining the local extent and regional spread of disease in patients with gastric cancer. Peritoneal dissemination remains a frequent type of recurrence after surgical treatment. The aim of this study was to determine the prognostic value of intraperitoneal free cancer cells (IFCCs) detected by laparoscopic peritoneal lavage. Forty-nine patients with advanced gastric cancer underwent laparoscopy with cytologic examination for staging. Peritoneal lavage was performed when ascites was not present. Aspirated fluid from the peritoneal cavity was centrifuged and subjected to cytologic examination using Giemsa and Papanicolaou staining methods. Patients were surgically treated and followed for a minimum of 5 years. IFCCs were detected in 41% of the patients. In eight cases (16.3 %) laparoscopy revealed carcinomatosis and/or multiple liver metastases, so laparotomy was not performed. Patterns of recurrence after curative resection included the following: peritoneal (n = 3), local (n = 4), liver (n = 1), and other (n = 1). All patients who tested positive for IFCCs had peritoneal recurrence. The absence of IFCCs was associated with improved overall survival (2 1 months for a 95% confidence interval of 7.4 to 34.6 vs 4 months for a 95% confidence interval of 2.4 to 5.6). Overall survival adjusted for type of resection also demonstrated a favorable outcome for patients who were negative for IFCCs. The following conclusions were drawn: (1) laparoscopic peritoneal lavage cytology may be useful in identifying patients at high risk for peritoneal relapses and may alter treatment, and (2) IFCCs provide additional prognostic information in patients with gastric cancer.

EUS-Guided Antegrade Transhepatic Placement of a Self-Expandable Metal Stent in Hepatico-Jejunal Anastomosis

CONTEXT To demonstrate an EUS-guided biliary drainage in patient with gastrointestinal tract modified surgically. CASE REPORT An EUS guided access to the left intra hepatic duct, followed by an antegrade passage of a partially self-expandable metal stent that was removed by using an enteroscope, in one patient with hepatico-jejunal anastomosis. There were no early or delayed complications and the procedure was effective in relieving jaundice until the self-expandable metal stent was removed, 3 months later. A cholangiogram was obtained via enteroscopy, after removal of self-expandable metal stent, and found to be normal. The patient had an uneventful evaluation afterwards. CONCLUSION The indication of these procedures must be made under a multidisciplinary view while sharing information with the patient or legal guardian. EUS-guided biliary drainage is feasible when performed by professionals with expertise in biliopancreatic endoscopy and advanced echo-endoscopy and should be performed currently under rigorous protocol in educational institutions.

Relationship Between Persistence of Helicobacter pylori and Dysplasia, Intestinal Metaplasia, Atrophy, Inflammation, and Cell Proliferation Following Partial Gastrectomy

Helicobacter pylori and partial gastricresection are risk factors for gastric cancer. Our aimswere to investigate the presence of H. pylori inpostgastrectomy patients and to correlate that withalterations in mucosal architecture and cell proliferation.One hundred fifty-one endoscopic biopsies from 22patients, (15-47 years of age, mean 29.2 years)following partial gastrectomy with Billroth IIreconstruction for peptic ulcer disease, were examined for thepresence of H. pylori using Giemsa staining. Sectionswere scored for grade of hyperplasia, intestinalmetaplasia, dysplasia, inflammation, and atrophy.Immunohistochemistry for proliferative cell nuclear antigen (PCNA)was used to characterize cell proliferation. H. pyloriwas observed in 17/22 (77.3%) of patients or in 57/151(37.7%) of biopsies. Metaplasia was seen in 18/22, chronic atrophic gastritis in 20/22, and cysticglandular dilation in 21/22 patients. The highest typeof metaplasia in each patient was: four Type I, fiveType IIA and nine Type IIB. Dysplasia was present in 16 biopsies from nine patients. H. pyloriwas more prevalent in intestinal metaplasia type I(44.8% of biopsies), than in type IIA (32.7%) or typeIIB (25%). No H. pylori was detected in regions showing dysplasia or cystic glandular dilation. H.pylori colonization was associated with degree ofinflammation (P = 0.00001) and cell proliferation (P =0.0001). In conclusion, H. pylori is commonly seen many years after gastrectomy, it is associated withan increased epithelial cell proliferation, and it isnot present in areas of histologic markers ofpremalignancy (type IIB metaplasia anddysplasia).

Small Bowel Endoscopy Using the Double-Balloon Technique: Four-Year Results in a Tertiary Referral Hospital in Brazil

Background: Double-balloon enteroscopy (DBE) allows evaluation and therapy for various small bowel diseases. In this series the outcome of a 4-year experience in a tertiary hospital school in Brazil is reported. Methods: A total of 457 consecutive DBE were performed in 418 patients from August 2004 to August 2008. 93 patients with several indications, whose aim was not the evaluation of suspected diseases of the small bowel mucosa, were excluded, therefore leaving 364 DBE in 325 patients for analysis. Data were retrospectively collected with regard to clinical, endoscopic findings, therapy and complications. Results: Among the 364 DBE performed in 325 patients, 143/325 were males (44%) and 182/325 females (56%) with a mean age of 48.6 ± 15.7 years (range 17–89). Mean investigation time was 64 ± 22 min (range 35–135). The depth of insertion beyond the ligament of Treitz was 230 ± 85 cm (range 30–500) by the antegrade approach and 140 ± 75 cm (range 0–320) by the retrograde approach. Total enteroscopy was achieved in 41.66% of the attempts (30 of 72 patients). Overall diagnostic yield was 54.95% (200 of 364 procedures) ranging from 0 to 100% in this series, depending on the indication. Angiodysplasia was the main diagnosis in 24.5% (49 of 200 procedures) and endoscopic treatment, including biopsies, hemostasis, tattooing and polypectomy were performed in 65.38% (238 of 364 procedures). No major complications were reported. Conclusions: DBE is a feasible, safe and well-tolerated procedure allowing endoscopic therapy. Selection of indications increases its diagnostic yield.

Secondary lymphangiectasia of the small bowel: utility of double balloon enteroscopy for diagnosis and management.

Sporadic lymphangiectasias are commonly found throughout the small bowel and are considered to be normal. Not uncommonly, lymphangiectasias are pathologic and can lead to mid-gastrointestinal bleeding, abdominal pain and protein-losing enteropathy. Pathologic lymphangiectasias of the small bowel include primary lymphangiectasia, secondary lymphangiectasia and lymphaticovenous malformations. In this report we present three different cases of small bowel lymphangiectasia detected by double balloon enteroscopy. The patients were diagnosed with South American blastomycosis, tuberculosis and primary small bowel lymphangioma.

Double pylorus: case report and review of the literature

Double pylorus is an unusual condition in which a double communication between the gastric antrum and the duodenal bulb occurs. It may be congenital, or it may be acquired complication of peptic ulcer disease. We present a case of double pylorus in a gentleman with epigastric pain and previous history of peptic ulcer disease. The relationship between Helicobacter pylori and this disease was assessed. A review of the literature, the role of associated diseases and the role of H. pylori are discussed.

Gastric stump mucosa: is there a risk for carcinoma?

BACKGROUND Patients who underwent partial gastric resections are at an increased risk for the development of cancer in the gastric remnant. AIM To assess the long-term patients who underwent surgical treatment for peptic ulcer disease through endoscopic and pathologic evaluation of the gastric stump mucosal alterations. PATIENTS AND METHODS Between 1987 and 1990, 154 patients (mean = 20.4 years after gastrectomy) were evaluated by upper digestive endoscopy with multiple biopsies and pathological examination. RESULTS Endoscopic alterations were present in 111 patients (72.1%). The commonest pathologic alterations were foveolar hyperplasia, intestinal metaplasia and cystic dilation. Severe dysplasia was noted in two (1.25%) and carcinoma in 13 (8.4%) of the cases. In four patients (3.8%) the endoscopic findings did not show any evidence of tumors, however they were detected due to multiple biopsies and histologic studies. CONCLUSIONS Surveillance of these patients with endoscopy and multiple biopsies may provide the means to diagnose tumors at an early stage, but the cost benefit ratio of surveillance requires further study.