Alfredo Mata

Wireless capsule endoscopy in patients with obscure gastrointestinal bleeding: a comparative study with push enteroscopy

Background : The identification and treatment of lesions located in the small intestine in obscure gastrointestinal bleeding is always a clinical challenge.

A prospective trial comparing wireless capsule endoscopy and barium contrast series for small-bowel surveillance in hereditary GI polyposis syndromes

BACKGROUND Capsule endoscopy has demonstrated its clinical utility in the evaluation of the small bowel, and, accordingly, it has been suggested that it could be useful for the identification of small-intestinal polyps in patients with polyposis syndromes. The objective was to establish the effectiveness of wireless capsule endoscopy for detecting small-bowel polyps in patients with hereditary GI polyposis syndromes in comparison with barium contrast series. METHODS Consecutive patients with GI polyposis syndromes were included. Small-bowel follow-through series and capsule endoscopy were performed within 1 week, in a blind fashion. The number and the location of polyps were analyzed. RESULTS Twenty-four patients with familial adenomatous polyposis (n = 20) or Peutz-Jeghers syndrome (n = 4) were included. Capsule endoscopy detected small-bowel polyps in 7 of 24 patients (29%), whereas a barium contrast study identified small-intestinal polyps in only 3 of these 7 patients. In the 4 remaining patients, all of them with familial adenomatous polyposis, polyps detected by the capsule but missed in radiographic series were located at either ileum (2 patients), jejunum (1), or duodenum (1). No procedure-related complication was observed in any patient. CONCLUSIONS Wireless capsule endoscopy is a highly accurate technique for the detection of small-bowel polyps in patients with hereditary GI polyposis syndromes, and it represents a valuable alternative to barium contrast series in the surveillance of patients with Peutz-Jeghers syndrome.

The beneficial effects of argon plasma coagulation in the management of different types of gastric vascular ectasia lesions in patients admitted for GI hemorrhage

BACKGROUND Despite different forms of treatment, few studies have been performed on the outcome and prognosis of patients admitted to the hospital because of gastric vascular ectasia (GVE) and upper-GI bleeding (UGIB). There is also little knowledge on the efficacy of argon plasma coagulation (APC) in different subgroups of GVE lesions. OBJECTIVE This study was designed to evaluate the efficacy of APC in patients admitted to the hospital with UGIB because of GVE. DESIGN Prospective evaluation of consecutive cases of UGIB because of GVE. SETTING Tertiary and university-affiliated hospital. PATIENTS AND INTERVENTIONS Twenty-nine patients were included and divided into 3 subgroups: focal vascular ectasia lesions (FVE) (n = 10), portal hypertensive gastropathy (PHG) (n = 11), and gastric antral vascular ectasia (GAVE) (n = 8). Patients were followed at 3 months and every 6 months thereafter during a mean of 23.1 months (range 18-37 months). All patients received intensive APC treatment that was repeated, depending on the endoscopic appearance or clinical evaluation. RESULTS The overall success of APC treatment was 86%, with only one recurrence of UGIB during the follow-up period. The number of APC sessions was 1.2, 2.2, and 2.3, in each subgroup (not significant), with a total number of sessions of 1.9 +/- 1.3. Treatment success was 90% in the FVE group, 81% in the PHG group, and 87.5% in the GAVE group (NS). The rise in hematocrit from baseline values in the overall group and in each subgroup was significant (P > .01). LIMITATIONS A single-center study and small sample. CONCLUSIONS Endoscopic thermal ablation with APC is effective in managing UGIB and in reducing transfusion requirements in patients admitted for GI hemorrhage because of different endoscopic types of GVE.

The European panel on the appropriateness of gastrointestinal endoscopy guidelines colonoscopy in an open-access endoscopy unit: a prospective study.

Background : The demand for gastrointestinal endoscopy is increasing in most developed countries, resulting in an important rise in overall costs and waiting lists for endoscopic procedures. Therefore, adherence to appropriate indications for these procedures is essential for the rational use of finite resources in an open‐access system.

Endoscopic ultrasound-guided fine needle aspiration: predictive factors of accurate diagnosis and cost-minimization analysis of on-site pathologist

AIMS To evaluate a) new diagnoses by endoscopic ultrasound guided real-time fine-needle aspiration (EUS-FNA) compared with EUS alone; b) the predictive factors for an accurate EUS-FNA diagnosis, and c) the cost-effectiveness of the presence of an on-site cytopathologist. PATIENTS AND METHODS Demographic data, ultrasonographic characteristics, technical information on EUS-FNA and cytological results were prospectively collected in 213 patients. The gold standard used was pathological examination or clinical follow-up. Operating characteristics of EUS-FNA, multivariate analysis, and a cost-minimization study of on-site evaluation were performed with these variables. RESULTS Samples were obtained from a total of 262 lesions: extramural masses (n = 115), lymph nodes (n = 96), cysts (n = 40) and intramural lesions (n = 11). The overall accuracy of EUS-FNA was 89% (234/262 lesions). The accuracy of EUS in discriminating between malignant and benign disease was 92% but 105 lesions (40% of the total) were classified as indeterminate. The addition of FNA to EUS allowed almost all lesions (89%) to be diagnosed with an accuracy of 90%. The only variable independently associated with an incorrect diagnosis was intramural location of the target lesion. The effectiveness of EUS-FNA in the complete series progressively increased, reaching a plateau in the fourth pass. The presence of an attendant cytopathologist was cost-effective. CONCLUSIONS EUS-FNA allows diagnosis of most lesions classified as indeterminate by EUS alone. The only factor independently associated with low accuracy is intramural location of the lesion. The availability of an on-site cytopathologist is cost-effective.

Endoscopic ultrasonography in patients with large gastric folds at endoscopy and biopsies negative for malignancy : Predictors of malignant disease and clinical impact

OBJECTIVES:The aims of the study were to assess in patients with large gastric folds at endoscopy and endoscopic biopsies that tested negative for malignancy: (i) the predictive variables of malignancy in endoscopic ultrasonography (EUS), (ii) the impact of EUS.METHODS:Patients with this condition evaluated with radial EUS (following the standard study protocol of our Unit in these patients) during a 5-yr period were included. Nine variables were evaluated as possible predictors of malignancy (χ2, t-test, and logistic regression procedure) using pathology results, or a minimum of 2 yr of follow-up as gold standard. Likelihood ratios (LR), pre-EUS, and post-EUS probabilities for the diagnosis of malignancy were used to assess the clinical impact of the technique.RESULTS:Sixty-one patients were included (40 benign and 21 malignant). Predictive factors of malignancy were as follows: thickened gastric wall, thickened deep layers, impaired gastric distension, loss of the wall structure, and presence of ascites or lymph nodes, whereas the enlargement of superficial layers was a predictor of a benign condition. The enlargement of deep layers, as assessed by EUS was the only independent predictive factor for malignancy. When using this parameter, the pre-EUS probability of malignancy in our series (34%) increased up to 95% when EUS suggested malignancy (positive LR = 45), whereas it decreased to 4.7% when EUS precluded this diagnosis (negative LR = 0.102).CONCLUSIONS:(i) The enlargement of deep layers is the only independent predictive factor for malignancy in patients with large gastric folds at endoscopy and biopsies testing negative for malignancy and (ii) EUS has a high clinical impact in these patients.

Papel de la cápsula endoscópica en los pacientes con hemorragia digestiva de origen indeterminado

IntroducciON La identificacion y localizacion de las lesiones situadas en el intestino delgado que pueden provocar hemorragia digestiva resultan dificiles. Objetivo Analizar el papel de la capsula endoscopica en los pacientes con hemorragia digestiva de origen indeterminado y comparar los resultados obtenidos entre esta exploracion y la enteroscopia. Pacientes Y Metodos Se analizo a 21 pacientes con hemorragia digestiva de origen indeterminado (hemorragia aguda en 11 casos y anemia cronica en 10) con fibrogastroscopia y fibrocolonoscopia total normales. Se instruyo a todos ellos para recibir la capsula y al cabo de una semana se les realizo una enteroscopia. Se compararon los resultados obtenidos mediante ambos procedimientos de forma independiente y sin conocimiento del resultado de la otra exploracion. Resultados La visualizacion de hallazgos potencialmente relacionados con la hemorragia digestiva fue significativamente mayor (p Conclusiones La capsula endoscopica permite una correcta visualizacion de todo el intestino delgado y posee una eficacia diagnostica superior a la enteroscopia en el estudio de pacientes con hemorragia digestiva de origen indeterminado. Ademas permitio modificar la conducta terapeutica en uno de cada 5 enfermos de nuestra serie.

Impacto de la ultrasonografía endoscópica (USE) y la punción aspirativa guiada por USE (USE-PAAF) en el manejo de los pacientes con cáncer de esófago. Revisión crítica de la literatura

Obviamente, el hecho de que exista evidencia científica a favor de la técnica en uno de estos aspectos no implica necesariamente que exista en los demás, por lo que se requieren estudios específicamente diseñados para cada nivel de conocimiento. El presente trabajo pretende revisar la evidencia científica que existe en el momento actual para la ultrasonografía endoscópica (USE) y la punción aspirativa guiada por USE (USE-PAAF) en el cáncer de esófago en cada uno de estos niveles de evaluación. Puesto que no hay duda acerca de la capacidad técnica ni de la precisión de la USE y USE-PAAF en el diagnóstico de extensión de la neoplasia de esófago, la revisión se centrará en el impacto diagnóstico y terapéutico de esta técnica, en cómo influye en el manejo de los pacientes y en su valor predictor de los distintos acontecimientos de la evolución de la enfermedad. Se revisarán también los datos existentes en cuanto a coste-efectividad de la técnica en esta indicación. El objetivo final es conseguir una revisión crítica para tener un conocimiento más práctico de la utilidad real de esta técnica, así como identificar los aspectos que aún deben ser explorados o estudiados más exhaustivamente. Hasta la fecha se han publicado 2 revisiones sistemáticas, en las que se evalúa no sólo la eficacia diagnóstica de la USE en el cáncer de esófago, sino su impacto en la estadificación y el pronóstico de los pacientes, así como el coste económico que supone. Ambas revisiones detectan una serie de deficiencias metodológicas que se detallan en la tabla I. A pesar de todo, las 2 concluyen a favor de la USE como técnica de elección en la estadificación de la neoplasia de esófago en los siguientes términos:

Usefulness of Endoscopic Ultrasound-Guided Fine Needle Aspiration in the Diagnosis of Mediastinal Lesions

OBJECTIVE Endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) is a safe and effective technique for the diagnosis of focal pancreatic lesions and enlarged abdominal lymph nodes. The aim of this study was to assess the usefulness of EUS-FNA in the diagnosis of mediastinal lesions. PATIENTS AND METHODS A retrospective review was performed of all consecutive cases in which EUS-FNA was used for the diagnosis of a mediastinal lesion between January 2001 and September 2003. We used a radial echoendoscope to assess the characteristics of the lesion and a linear-array echoendoscope to perform transesophageal needle aspiration with a 22-gauge needle. Histopathology of the resected specimen was considered as the gold standard in surgically treated patients whereas cytology obtained by EUS-FNA was the gold standard when surgery was not indicated. RESULTS EUS-FNA was performed in 59 patients with a total of 89 lesions with mean (SD) dimensions of 2.4 (2.0) cm x 1.6 (1.4) cm. Malignant lesions were larger than benign ones (short axis, 2.7 [1.4] as compared with 1.0 [0.9] cm; P< .001). The diagnosis was obtained for 53 patients (90%) and 81 lesions (91%) with a mean of 2 (1) passes per lesion. The sensitivity, specificity, positive and negative predictive values, and diagnostic accuracy of EUS-FNA were 81%, 100%, 100%, 75%, and 88%, respectively, when analyzed by lesion, and 88%, 100%, 100%, 80%, and 92% when analyzed by patient. CONCLUSIONS EUS-FNA is an effective technique for the diagnosis of mediastinal lesions. The likelihood of malignancy increases with size.

Improving the Accuracy of Ultrasound-Endoscopy Fine- Needle Aspiration (EUS-FNA): Factors Predicting a Correct Diagnosis and Usefulness of an Attendant Pathologist

Improving the Accuracy of Ultrasound-Endoscopy FineNeedle Aspiration (EUS-FNA): Factors Predicting a Correct Diagnosis and Usefulness of an Attendant Pathologist Maria Pellise, Angels Gines, Manel Sole, Diana Vera, Gloria Fernandez-Esparrach, Antoni Castells, Alfredo Mata, Josep Llach, Josep Maria Bordas, Josep Maria Pique Background: EUS-FNA is awell established technique for staging gastrointestinal and lung cancer and for diagnosing pancreatic masses. Aim: To evaluate the predictive factors of a correct diagnosis by EUS-FNA and to establish the usefulness of an attendant pathologist. Patients and methods: Between January 2001 and February 2003, we evaluated all consecutive patients referred for EUSFNA. The procedure was carried out with a linear echoendoscop and a 22G needle. An attendant pathologist examinated the samples. Epidemiological data, EUS characteristics,and citological results were registered. EUS-FNA diagnosis was compared with the gold standart (pathology of resected specimen or clinical follow-up). In order to establish the importance of an attendant cytopathologist, the actual results were compared with those that would have been obtained if a particular number of passes had been performed without on-site evaluation. Once a price per pass was established, a cost-minimization study of the availability of an attendant pathologist was performed. Results: 262 lesions were sampled: pancreatic masses (n= 115), lymph nodes (n= 96), cysts (n= 40) and intramural lesions (n= 11). A total of 551 samples was obtained, thus representing 2.1 +/ 1.1 passes per patient on average (range, 1-6). EUS-FNA ascertained the correct diagnosis in 235 (overall accuracy, 89%). Location within the gastrointestinal wall was the only independent factor predicting failure in the diagnosis (multivariate regression analyses). Effectiveness of EUS-FNA in the whole series increased with every pass from 36% to 89%plateauing in the 4th pass. This curve was similar for pancreaticmasses, lymph nodes and cyst but the plateau appeared in the 3rd pass in these last two types of lesions. The effectiveness of EUSFNA for the intramural lesions was always lower, increasing from 0.9% to 45% and reaching a plateau in the 4th pass. The assistance of an attendant cytopathologist was costless with respect to the corresponding strategy without on-site examination for the whole series and for lymph nodes, masses and cysts. Conclusion:1) Location within the gastrointestinal wall was the only independent factor predicting failure in the diagnosis. 2) The availability of an attendant pathologist seems to increase the diagnostic yield of EUS-FNA, minimizing the number of passes and resulting in a costless strategy.