Carlos Saul

High power setting argon plasma coagulation for the eradication of Barrett’s esophagus

OBJECTIVE:The term Barretts esophagus refers to a premalignant condition that is characterized by the replacement of the esophageal squamous mucosa by a columnar-lined one. Preliminary studies have demonstrated reversal of Barretts mucosa after endoscopic coagulation with different techniques associated with acid inhibition. However, most of these studies have shown that residual Barretts glands are found underneath the new squamous epithelium in up to 40% of patients. The goal of our study is to verify whether complete restoration of Barretts mucosa can be achieved by the combination of high power setting argon plasma coagulation and omeprazole.METHODS:A total of 33 patients (mean age: 55.2 yr, range: 21–84 yr; 21 men and 12 women) with histologically demonstrated Barretts esophagus (mean length: 4.05 cm, range: 0.5–7 cm) were treated. Fourteen cases presented with low-grade dysplasia and one with high-grade dysplasia. All of the extent, or until a maximum of 4 cm, of the Barretts mucosa was cauterized in each session using argon beam coagulation at a power setting of 65–70 W. All patients received 60 mg omeprazole during the treatment period.RESULTS:Complete restoration of squamous mucosa was obtained in all 33 cases after a mean of 1.96 sessions (range, 1–4). Endoscopic results were histologically confirmed. Nineteen (57.5%) patients experienced moderate to severe chest pain and odyno-dysphagia lasting for 3–10 days after the procedure. Five of these cases experienced high fever and a small volume of pleural effusion, and three patients developed esophageal strictures that needed to be dilated. Another patient developed pneumomediastinum and subcutaneous emphysema without evidences of perforation. After a mean follow-up of 10.6 months there was one endoscopic, as well as histological, recurrence of Barretts mucosa in a patient with an ineffective laparoscopic fundoplication.CONCLUSIONS:High power setting argon plasma coagulation combined with intensive acid suppression is an effective treatment for the total endoscopic ablation of Barretts esophagus, at least in the short term. Long-term follow-up of treated patients in whom gastroesophageal reflux is surgically or medically alleviated seems mandatory before drawing definitive conclusions about this therapy.

Endoscopic classification of the capillary-vessel pattern of colorectal lesions by spectral estimation technology and magnifying zoom imaging

BACKGROUND Colonoscopy with spectral estimation technology and magnifying zoom imaging allows the characterization of the fine superficial capillary pattern of normal mucosa and of colorectal lesions. The endoscopic distinction of the capillary pattern of colorectal lesions might contribute to the differential diagnosis among normal, hyperplastic, and neoplastic lesions. OBJECTIVE By means of these latest technologic advances, the objective is to define a classification of the capillary-vessel pattern of colorectal lesions diagnosed during routine colonoscopy. DESIGN A total of 309 colorectal lesions endoscopically or surgically resected were prospectively examined. The capillary pattern was divided into 5 subtypes according to the number, morphology, and distribution of the fine blood vessels. Capillary patterns types I and II were characterized by a few short, straight, and sparsely distributed vessels; types III to V were of numerous, elongated, and tortuous capillaries irregularly distributed. RESULTS The overall accuracy of the capillary-vessel classification in determining the neoplastic or non-neoplastic nature of the colorectal lesions was 98.3% (304/309 lesions). Among 59 non-neoplastic lesions, 56 (94.9%) that showed patterns I or II were diagnosed as normal, inflammatory, or hyperplastic polyps. Of the 250 neoplastic lesions, 248 (99.2%) that had capillary pattern types III, IV, and V were diagnosed as adenomatous or carcinoma. The sensitivity of the capillary pattern classification for distinguishing neoplasia was 99.2% (95% CI, 98.2%-100%), and the specificity was 94.9% (95% CI, 92.5%-97.4%). LIMITATION A single-center study. CONCLUSION The endoscopic classification of the superficial capillary-vessel pattern of colorectal lesions is an accurate method of predicting the histopathologic findings.

Redução da prevalência de úlcera duodenal: um estudo brasileiro (análise retrospectiva na última década: 1996-2005)

BACKGROUND: The duodenal ulcer always represented a very prevalent pathology among the gastrointestinal tract diseases worldwide. The average prevalence is approximately 10% of the world population. In the 90s the literature (both European and North American) begin to show a crescent reduction of this prevalence in many countries. AIM: To show through a retrospective analysis the annual prevalence of the duodenal ulcer in the last 10 years in a Digestive Endoscopy Service which is referred to public medical system in Porto Alegre and its suburban area and countryside of the State of Rio Grande do Sul, Brazil. The data analyzed is from March 1996 to December 2005. Specific data: transversal retrospective study with documented analysis of endoscopic diagnosis of upper gastrointestinal endoscopy. METHODS: A retrospective analysis of the diagnosis of the 13.130 procedures of upper gastrointestinal endoscopy between 1996 and 2005. The Sakita classification was used to verify the duodenal ulcer activity taking into consideration the patients who have lesions on A1 to S1 levels. To verify if there was a statistical significant results, a linear regression test was done (linear regression model). RESULTS: A gradate decrease of the prevalence percentuals was observed, year after year, it began with 8.3% of prevalence in 1996 and finished with 3.3% in the beginning of 2006. The average annual reduction of this prevalence was calculated following the regression test and it was placed in the 1.3% a year in the studied period of time. In 2003, in an isolated way, it was an exception in the decrease of the percentage because it presented a prevalence increase of (6.5%) comparing to the first 6 years of study. CONCLUSION: In this study it was observed a decrease of duodenal ulcer prevalence, 1.3% a year to be more accurate in 10 years of study, showing a statistical significance in the linear regression test.

DESENVOLVIMENTO DE NEOPLASIAS/ ADENOMAS AVANÇADOS COLORRETAIS NO SEGUIMENTO A LONGO PRAZO DE PACIENTES SUBMETIDOS A COLONOSCOPIA COM POLIPECTOMIA

CONTEXT Colonoscopy with polypectomy reduces the incidence of colorectal cancer and its associated mortality. The ideal interval between surveillance examinations is determined by clinical features and endoscopic findings considered as risk factors to the development of advanced colonic neoplasias. OBJECTIVE To determine the development rate of advanced neoplasia in patients submitted to surveillance colonoscopy in a tertiary referral center. METHODS Three hundred and ninety two patients who underwent two or more complete colonoscopies between 1995 and 2005, and who have at least one diagnosed colorectal adenoma entered into the study. The endoscopic findings of the first and subsequent colonoscopies of each patient were analysed, considering advanced neoplasia as the main outcome. The patients enrolled were divided in accordance to the first colonoscopy findings in groups 1 or high risk; 2 or low risk; and 3 or without adenoma at the first colonoscopy. The development of advanced colorectal neoplasia and the period of surveillance until the outcome were analysed and compared among groups. RESULTS Twenty eight per cent of patients had advanced adenomas at index colonoscopy; 57.8% presented with low grade dysplasia neoplastic lesions and 14.1% had no adenoma at the first examination. The mean age was 59.54 +/- 11.74 years. Twenty six point four per cent of subjects from group 1 presented with advanced neoplasia during the surveillance period, while this outcome occurred in 10.9% and 5.3% of patients from groups 2 and 3, respectively (P<0,05). The mean period of surveillance was 123.35 months, and the mean time between the first examination and the one which presented with the outcome statistically differed among group 1 and the others, being 104.02, 115.31 and 120.61 months, respectively. CONCLUSIONS Patients with advanced neoplasia at index colonoscopy presented with a higher probability of harbouring this condition during the follow-up when compared with other two groups. These lesions also occur earlier in this patients than in the ones without these lesions at the first examination.

Morphometric digital measurement of the luminal opening area of colonic crypts (pits) can differentiate the adenomas from other colonic lesions

CONTEXT Differential diagnosis of hyperplastic vs adenomatous lesions is of crucial importance on the daily practice of colonoscopy. OBJECTIVES This study aimed at quantifying digital morphometric characteristics of colonoscopic images obtained with magnification and chromoscopy of three different types of colonic lesions: hyperplastic, adenomas and carcinomas, and the normal mucosa surrounding the lesions. METHODS A total of 2,177 consecutive colonoscopies were analyzed and 105 images were chosen for analysis, divided into 37 hyperplastic lesions, 42 adenomas and 26 carcinomas. Specific digital morphometry was used, to measure the diameter and area of the pits from hyperplastic lesions, adenomatous and carcinomatous lesions, always comparing them with the normal mucosa surrounding pits. RESULTS Different morphometric measures were performed via image analysis software to measure the mean pit opening diameters and their respective area. The mean pit opening diameters and corresponding area measurements were statistically significant for all groups of lesions examined. CONCLUSIONS The morphometric characteristics of colonoscopy images allowing the observer to compare differences between hyperplastic and adenomatous polyps and colorectal carcinoma lesions. Digital morphometric studies are feasible like the present study shows. This can help the colonoscopist in clinical decisions. A software with morphometric measures can apply and will permit the digital morphometric analysis. The data generated from the application of software, can provide valuable points in differentiation of various lesions, guiding the conduct clinical, already during the endoscopic procedure. Morphometric analysis is more an instance of decision to the colonoscopist and it has important value not for being subjective, but for being objective, since it generates digits of its measures. In these aspects, and among different characteristics, the measure of the area showed to be the most important measure in the differential aspect. Different lesions have different patterns of morphometric measures and theses patterns can be obtained from the study of the characteristics in databases. The endoscopic removal of adenomatous polyps (polypectomy), or a more detailed study of the neoplastic lesions for helping the decision if endoscopic removal (mucosectomy) or surgical resection, and a conservative position in hyperplastic lesions, are proceedings that morphometrics, with another parameters, can help to decide.

4485 Incidence of depressed colorectal neoplasia in southern brazil.

Flat and depressed colorectal lesions despite being increasingly reported in Japan, are still a matter of controversy in western countries and the true incidence of these lesions is poorly undestood. The AIM of this study is to evaluate the incidence of depressed lesions diagnosed on routine colonoscopy in a brazilian endoscopic center. METHODS During January 1996 to May 1999, all total colonoscopies performed with magnifying colonoscope(Fujinon410CM) allowing up to 40x magnification of the standard videoimage, were included in the analysis. Patients with familial polyposis and inflammatory bowel disease were excluded. Macroscopically, colorectal neoplastic lesions were classified as polyps, flat elevated lesions, depressed lesions(IIc) and lateral spreading tumors. On colonoscopy the lesions were examined in detail by chromoscopy with indigo-carmine 2% and/or pyoktanin-blue 0.5% and the pit pattern on the surface of the lesion was determined as Kudos classification. All lesions were resected by polypectomy or endoscopic mucosal resection (EMR). RESULTS Among 1930 total colonoscopies, 13 depressed lesions (0.7%) were diagnosed. Size of the lesions varied from 1.4 to 7mm in diameter. Seven lesions were located in the sigmoid, 3 in ascending, 2 in the transverse and 1 in the descending colon. Histologic diagnosis was carcinoma in 6 lesions, adenoma with high-grade dysplasia in 5 lesions and low grade in 2 lesions. Pit pattern of the depressed lesions were IIIs in 9 lesions, V in 3 lesions and IV in one lesion. Other diagnosed lesions in this group of patients were 1594 polyps, 63 flat elevated lesions and 51 lateral spreading tumors. CONCLUSIONS Depressed colorectal neoplasia exhibiting the same features as reported by japanese investigators were also diagnosed in our group of patients. Despite the small size and low incidence (0.7%) of depressed lesions, the high frequency of carcinoma and high-grade dysplasia diagnosed in these lesions emphasize the need for the endoscopic diagnosis and resection of these lesions to prevent colorectal cancer.