Anna M. Buchner

Lansoprazole treatment of patients with chronic idiopathic laryngitis: a placebo-controlled trial

OBJECTIVE:Previous uncontrolled studies suggested a therapeutic benefit for treating gastroesophageal reflux disease (GERD) among patients with laryngitis. The present study is the first randomized, placebo-controlled, double-blind study of gastric acid suppression among patients with laryngitis in the United States.METHODS:Patients diagnosed with idiopathic chronic laryngitis were randomized to receive either lansoprazole 30 mg p.o. b.i.d. or a matching placebo for 3 months. Before randomization, all patients underwent upper endoscopy, dual probe ambulatory 24-h esophageal pH-metry, and laryngoscopy, as well as completing a symptom questionnaire for GERD and laryngitis. The primary outcome of treatment was the complete resolution of laryngeal symptoms.RESULTS:A total of 22 patients with symptoms and signs of chronic laryngitis were enrolled, 20 of whom completed the study. At baseline, there were no significant differences between the two groups with regards to GERD symptoms, erosive esophagitis, proximal and distal esophageal pH-metry, or laryngeal signs and symptoms. In an intention-to-treat analysis, six patients in the lansoprazole group (50%) and only one patient (10%) in the placebo group achieved a complete symptomatic response, p = 0.04. Apart from receiving lansoprazole, there were no significant differences between responders and nonresponders in any of baseline esophageal or laryngeal signs and symptoms.CONCLUSIONS:Empirical treatment with lansoprazole is efficacious in relieving symptoms of laryngitis compared to placebo. Such treatment can be considered as a first-line option in managing patients with idiopathic chronic laryngitis.

Comparison of Probe-Based Confocal Laser Endomicroscopy With Virtual Chromoendoscopy for Classification of Colon Polyps

BACKGROUND & AIMS Probe-based confocal laser endomicroscopy (pCLE) allows in vivo imaging of tissue at micron resolution. Virtual chromoendoscopy systems, such as Fujinon intelligent color enhancement and narrow band imaging, also have potential to differentiate neoplastic colorectal lesions. The accuracy of these systems in clinical practice is, however, unknown. Our primary aim was to compare sensitivity and specificity of pCLE to virtual chromoendoscopy for classification of colorectal polyps using histopathology as a gold standard. A secondary aim was to compare sensitivity and specificity of pCLE to virtual chromoendoscopy using a modified gold standard that assumed that all polyps >/=10 mm had malignant potential and were considered neoplastic or high risk. METHODS Patients underwent colonoscopy using high-resolution colonoscopes. The surface pit pattern was determined with NBI or FICE in all patients. Confocal images were recorded and subsequently analyzed offline, blinded to the endoscopic characteristics and histopathology. Each polyp was diagnosed as benign or neoplastic based on confocal features according to modified Mainz criteria. RESULTS A total of 119 polyps (81 neoplastic, 38 hyperplastic) from 75 patients was assessed. The pCLE had higher sensitivity compared to virtual chromoendoscopy when considering histopathology as gold standard (91% vs 77%; P = .010) and modified gold standard (88% vs 76%; P = .037). There was no statistically significant difference in specificity between pCLE and virtual chromoendoscopy when considering histopathology or modified gold standard. CONCLUSIONS Confocal endomicroscopy demonstrated higher sensitivity with similar specificity in classification of colorectal polyps. These new methods may replace the need for ex vivo histological confirmation of small polyps, but further studies are warranted.

Seasonal distribution in newly diagnosed cases of eosinophilic esophagitis in adults.

OBJECTIVES:The etiology of eosinophilic esophagitis (EoE) is not well understood. It has been proposed that eosinophils migrate to the esophagus in response to various ingested and inhaled allergens. Recent reports in children found an increased proportion of cases of EoE during months with higher outdoor aeroallergens. To our knowledge, this has not been evaluated in adults. We aimed to determine whether there is a seasonal distribution in the number of newly diagnosed cases of EoE in an adult population.METHODS:We conducted a retrospective review of consecutive adult cases newly diagnosed with EoE in 1 year. Cases were grouped based on the index month when the diagnosis was made at endoscopy. To test the consistency of the observations, a second cohort of consecutive cases of similar sample size diagnosed at a different period in time was also analyzed.RESULTS:In total, 41 patients were diagnosed with EoE at our center during the study period, providing an annual prevalence of 0.98%. More cases were diagnosed with EoE during the months of April and May than any other month (P<0.001). When patients were grouped seasonally, there was a significant increase of EoE cases in spring and summer months (n=28) when compared with the fall and winter months (n=13) (P=0.019). Analysis of the second cohort of cases (n=37) from 2002 to 2006 confirmed a similar seasonal diagnostic pattern for EoE during the outdoor seasons.CONCLUSIONS:Our data demonstrate that EoE has a seasonal prevalence in adults. The seasonal variation pattern found in newly diagnosed EoE cases in adults supports the potential role of aeroallergens in the pathogenesis of EoE.

Outcomes of EMR of defiant colorectal lesions directed to an endoscopy referral center

BACKGROUND Flat and sessile lesions are being identified more frequently because of increased awareness, improved endoscopic skills, and enhanced imaging. The defiant polyp (DP) is a lesion identified at colonoscopy that defies resection by the standard snare polypectomy technique. Increasingly, the DP undergoes photodocumentation and tissue sampling, and the patient is referred for an attempt at curative colonoscopic resection. OBJECTIVE To evaluate the current nature of the DPs and outcomes of their endoscopic resection. DESIGN Retrospective study. SETTING Tertiary referral center. PATIENTS AND INTERVENTIONS Patients with colorectal polyps not amenable to standard snare polypectomy were referred to a single endoscopist at a tertiary center for an attempt at curative endoscopic resection. The indication DP was applied prospectively, as defined previously, beginning in June 2007. An electronic endoscopy report database was searched for this indication from June 2007 to October 2009 for a single endoscopist at an endoscopy referral center. Data pertaining to patient age and sex, polyp site and histopathology, resection technique, use of adjunctive ablation, adverse events, and residual/recurrent neoplasia at follow-up were culled. Submucosal injection of varying quantities of normal saline solution tinted with methylene blue dye was used for endoscopic resection. Standard and mini-snares were used with pure coagulation current. MAIN OUTCOME MEASUREMENTS Complete resection, complications, recurrence. RESULTS This study included 274 patients (50.4% women, age 65 [standard deviation 12] years) with a total of 315 DPs who were referred for attempted endoscopic resection. The majority of DPs were located in the right side of the colon (226; 72%). The mean size was estimated at 23 mm (range 8-100 mm; standard deviation 13). In 29 DPs (10%), surgery was required because endoscopic resection was deemed unsuitable because of the unfavorable appearance (n = 3), the location (n = 9), or the inability to lift (n = 10) or because of submucosal invasion on post-EMR histopathology (n = 7). Complete endoscopic eradication (R0) was achieved in a single session in 286 DPs (91%). En bloc resection was performed in 153 polyps (53.5%) and piecemeal resection in 132 (46%). Histopathology revealed 178 tubular adenomas (56.5%), 62 serrated adenomas (20%), 27 tubulovillous adenomas (9%), 10 hyperplastic polyps (3%), and 14 adenocarcinomas (4.5%). Adjunctive ablation of focal residual neoplastic tissue was applied in 69 DPs (24%) to achieve R0. Procedure-related adverse events were recorded in 29 of 249 patients (11.6%). Acute bleeding occurred in 9 patients (1 required hospitalization and repeat endoscopy). There was 1 microperforation managed with clip closure and antibiotics. Delayed bleeding (1-6 days post-procedure) was observed in 18 patients (7.2%), of whom 8 required hospitalization and 4 colonoscopy for hemostasis. Among the patients who underwent follow-up surveillance colonoscopy (135 of 258 patients), residual/recurrent neoplastic tissue at the site of the previous EMR was identified in 36 (27%). Residual/recurrent neoplasia was successfully eradicated with further endoscopic resection or ablation. LIMITATIONS A retrospective design. CONCLUSIONS DPs consist predominantly of sessile and flat adenomas including serrated adenomas. Most DPs can be successfully eradicated at dedicated therapeutic colonoscopy by using adjunctive resection and ablation techniques. The R0 rate is high and the adverse event rate is low. A relatively high rate of local residual/recurrent neoplasia at the resection site underscores the importance of follow-up colonoscopy.

High-Definition Colonoscopy Detects Colorectal Polyps at a Higher Rate Than Standard White-Light Colonoscopy

BACKGROUND & AIMS Adenoma detection rates might be improved through use of high-definition colonoscopy, which can detect subtle mucosal changes. We investigated whether the use of high-definition white-light (HDWL) colonoscopy resulted in a higher rate of adenoma detection than standard-definition white-light (SDWL) colonoscopy in a clinical practice setting. METHODS This retrospective study included 2430 patients who underwent colonoscopies from September 2006 to December 2007; 1226 received SDWL colonoscopy and 1204 received HDWL colonoscopy. We analyzed data from consecutive screening, surveillance, and diagnostic colonoscopies, comparing adenoma and overall polyp detection between procedures. Potentially confounding variables were controlled using multivariable logistic regression analysis. RESULTS The adenoma detection rate was higher among patients who underwent HDWL compared with SDWL colonoscopies (28.8% vs 24.3%; P = .012), as was the polyp detection rate (42.2% vs 37.8%; P = .026). These findings remained after adjustments for potentially confounding variables (P = .018 and .022, respectively). CONCLUSIONS In a general clinical practice setting, HDWL colonoscopy resulted in a higher adenoma detection rate compared with SDWL colonoscopy. The use of SDWL colonoscopy could reduce the number of missed adenomas and the subsequent risk for colorectal cancer.

Diagnostic Accuracy of Probe-Based Confocal Laser Endomicroscopy and Narrow Band Imaging for Small Colorectal Polyps: A Feasibility Study

OBJECTIVES:Probe-based confocal laser endomicroscopy (pCLE) allows real-time in-vivo microscopic imaging of tissue. Narrow band imaging (NBI) can also classify colorectal lesions. Both systems may allow accurate optical diagnosis of small (6–9 mm) and diminutive (1–5 mm) polyps without histopathology. This study assesses the accuracy of pCLE and NBI for prediction of histology.METHODS:Participants underwent high-definition colonoscopy. The surface pit pattern of all polyps (1–9 mm) was determined in vivo using NBI. Confocal videos were obtained after administration of IV fluorescein. Recorded videos were subsequently analyzed offline, blinded to endoscopic characteristics, and histopathology. Confocal images were classified as neoplastic and non-neoplastic according to the Miami classification system.RESULTS:A total of 130 polyps (58 neoplastic, 72 non-neoplastic, mean size 4.6 mm) from 65 patients were assessed. Assuming histopathology as gold standard, pCLE had higher sensitivity than NBI (86% vs. 64%, P=0.008), with lower specificity (78% vs. 92%, p=0.027) and similar overall accuracy (82% vs. 79%, P=0.59). When 65 high-confidence cases were analyzed (polyps diagnosed identically with pCLE and NBI and with high-quality confocal videos), sensitivity and specificity were 94 and 97%.CONCLUSIONS:pCLE demonstrated higher sensitivity in predicting histology of small polyps compared with NBI, whereas NBI had higher specificity. When used in combination, the accuracy of pCLE and NBI was extremely high, approaching the accuracy of histopathology. Together, they may reduce the need for histological examination. However, further studies are warranted to evaluate the role of these techniques, especially in the population-based colon cancer screening.

Learning Semantic and Visual Similarity for Endomicroscopy Video Retrieval

Content-based image retrieval (CBIR) is a valuable computer vision technique which is increasingly being applied in the medical community for diagnosis support. However, traditional CBIR systems only deliver visual outputs, i.e., images having a similar appearance to the query, which is not directly interpretable by the physicians. Our objective is to provide a system for endomicroscopy video retrieval which delivers both visual and semantic outputs that are consistent with each other. In a previous study, we developed an adapted bag-of-visual-words method for endomicroscopy retrieval, called “Dense-Sift,” that computes a visual signature for each video. In this paper, we present a novel approach to complement visual similarity learning with semantic knowledge extraction, in the field of in vivo endomicroscopy. We first leverage a semantic ground truth based on eight binary concepts, in order to transform these visual signatures into semantic signatures that reflect how much the presence of each semantic concept is expressed by the visual words describing the videos. Using cross-validation, we demonstrate that, in terms of semantic detection, our intuitive Fisher-based method transforming visual-word histograms into semantic estimations outperforms support vector machine (SVM) methods with statistical significance. In a second step, we propose to improve retrieval relevance by learning an adjusted similarity distance from a perceived similarity ground truth. As a result, our distance learning method allows to statistically improve the correlation with the perceived similarity. We also demonstrate that, in terms of perceived similarity, the recall performance of the semantic signatures is close to that of visual signatures and significantly better than those of several state-of-the-art CBIR methods. The semantic signatures are thus able to communicate high-level medical knowledge while being consistent with the low-level visual signatures and much shorter than them. In our resulting retrieval system, we decide to use visual signatures for perceived similarity learning and retrieval, and semantic signatures for the output of an additional information, expressed in the endoscopist own language, which provides a relevant semantic translation of the visual retrieval outputs.

Diagnostic accuracy of probe-based confocal laser endomicroscopy in detecting residual colorectal neoplasia after EMR: A prospective study

BACKGROUND Residual neoplasia after EMR of colorectal lesions is common. There is a critical need for imaging methods to accurately diagnose residual disease and to guide retreatment in real time. OBJECTIVE The aim was to estimate and compare the accuracy of virtual chromoendoscopy (VCE) and probe-based confocal laser endomicroscopy (pCLE) for detection of residual neoplastic tissue at the site of prior EMR. DESIGN Prospective, blind, pilot comparison of advanced endoscopic imaging (VCE and pCLE) by using matching histology as reference standard. SETTING Three tertiary-care referral hospitals. PATIENTS This study involved 92 participants who underwent follow-up colonoscopies for the evaluation of prior EMR sites within 1 year. INTERVENTION The EMR scars were assessed during follow-up high-resolution colonoscopy by using VCE (narrow-band imaging/Fujinon Intelligent Color Enhancement [FICE]), and pCLE. Confocal videos of EMR scars were interpreted in real time and were also stored and reviewed offline, blinded to histopathology and endoscopic appearance. Tissue confirmation by biopsies or polypectomy/repeat EMR was performed in all cases. MAIN OUTCOME MEASUREMENTS Sensitivity, specificity, and accuracy for VCE and pCLE alone and in combination against histopathology as the standard reference standard. RESULTS Among 129 EMR scars, residual neoplasia was confirmed by histology in 29 sites (22%). For VCE, the sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and accuracy were 72%, 77%, 49%, 91%, and 77%, respectively, and were 97%, 77%, 55%, 99%, and 81% for pCLE (P = .045 for sensitivity). When only EMR scars for which VCE and pCLE agreed on the diagnosis were analyzed (95/129 scars), the accuracy, sensitivity, specificity, PPV, and NPV of pCLE and VCE were 90%, 100%, 87%, 67%, and 100%, respectively. LIMITATIONS Small sample size, lack of power, involvement of highly experienced pCLE experts. CONCLUSION Confocal endomicroscopy significantly increases the sensitivity for detecting residual neoplasia after colorectal EMR compared with endoscopy alone. When confocal endomicroscopy is used in combination with VCE, the accuracy is extremely high, and sensitivity approaches that of histopathology. Together, they may reduce the need for histologic examination and allow a highly accurate on-table decision to treat again or not, thus avoiding unnecessary repeat procedures. ( CLINICAL TRIAL REGISTRATION NUMBER 00874263.).

Trainee participation is associated with increased small adenoma detection

BACKGROUND Previous studies examining the effect of fellow participation on adenoma detection rate in colonoscopy have yielded conflicting results, and factors such as adenoma size and location have not been rigorously evaluated. OBJECTIVE To examine whether fellow participation during screening, surveillance, or diagnostic colonoscopy affects overall, size-specific, or location-specific adenoma or polyp detection rate. METHODS This was a retrospective study of 2430 colonoscopies performed in our ambulatory surgical center between September 2006 and December 2007, comparing adenoma and polyp detection rates of colonoscopies performed by fellows with supervising staff endoscopists (n = 318) with colonoscopies performed by staff endoscopists without fellow participation (n = 2112). Study participants included patients who underwent screening, surveillance, or diagnostic colonoscopies in our GI suite. Logistic regression analysis was used to evaluate the association of fellow participation with adenoma and polyp detection. RESULTS There was evidence of a higher rate of small (<5 mm) adenoma detection in colonoscopies with a fellow present (25% vs 17%, P = .001). This remained significant after multiple-testing adjustment (P ≤ .003 considered significant). Findings were similar, although not significant for small polyps (36% vs 29%, P = .007). There was a trend toward increased adenoma detection in colonoscopies with a fellow present compared with those without (30% vs 26%, P = .11). Multivariable adjustment for potentially confounding variables did not alter these associations. LIMITATIONS The study had a retrospective design, and information regarding bowel preparation was not available for 37% of patients. CONCLUSION Fellow involvement was associated with increased detection rates of small adenomas, providing evidence that the presence of a fellow during colonoscopy plays a role in enhancing the effectiveness of the examination.

Use of antimicrobials for EUS-guided FNA of pancreatic cysts: a retrospective, comparative analysis

BACKGROUND Pancreatic cystic lesions present a challenge for patients and physicians alike. Morphology alone is inaccurate in discriminating lesion pathology, and use of EUS-guided FNA (EUS-FNA) improves accuracy. Current American Society for Gastrointestinal Endoscopy guidelines recommend prophylactic antibiotics during FNA of cystic lesions to minimize infection risk. However, evidence pertaining to infection risk has been conflicting. The use of prophylactic antibiotics might not be free of other adverse events and might not prevent infection. OBJECTIVE To assess the impact of antimicrobial therapy for prophylaxis during EUS-FNA of pancreatic cysts. DESIGN Retrospective cohort study. PATIENTS This study involved all patients who underwent EUS-FNA of pancreatic cysts at one institution from May 2007 to April 2010. INTERVENTION Antibiotic prophylaxis for EUS-FNA. MAIN OUTCOME MEASUREMENTS Infection of a pancreatic cyst, fever, or bacteremia after EUS-FNA. Secondary variables included other complications of the procedure related to the use of prophylaxis (ie, allergic reactions, secondary infections). RESULTS EUS-FNA was performed on 253 patients in 266 procedures. Antibiotics were used in 88 endoscopy cases (ATB group), whereas no antibiotics were used in 178 cases (NATB group). There were no differences in patient or cyst characteristics between groups. There were 4 major complications in the NATB group (localized bleeding, 2; pancreatitis, 1; bile leakage, 1) and 2 in the ATB group (possible cyst infection, 1; bile leakage, 1) (P = 1.0). Eight mild adverse events were observed in the NATB group and 6 in the ATB group (P = .56). Infections and antibiotic-related complications occurred in 1 (0.6%) (transient fever) in the NATB group and 4 (4.5%) in the ATB group (local allergic reaction, 2; possible cyst infection, 1; Clostridium difficile diarrhea, 1) (P = .04). LIMITATIONS Retrospective analysis. CONCLUSION The incidence of infectious complications after EUS-FNA of pancreatic cystic lesions, with or without antibiotic prophylaxis, appears very low. We have not observed a protective effect from periprocedural prophylactic antibiotic administration.