César Vivian Lopes

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-ultrasound-guided endoscopic transmural drainage of pancreatic pseudocysts and abscesses

Objective. Surgery is the traditional treatment for symptomatic pancreatic pseudocysts and abscesses, but morbidity and mortality are still too high. Minimally invasive approaches have been encouraged. The aim of this study was to evaluate the results of the endoscopic-ultrasound-guided (EUS) endoscopic transmural drainage of these pancreatic collections. Material and methods. In this retrospective review of consecutive cases from a single referral centre, cystogastrostomy and cystoduodenostomy were created with an interventional linear echoendoscope under endosonographic and fluoroscopic control by the endoscopic insertion of straight or double pigtail stents. Results. Fifty-one symptomatic patients (33 men; mean age 58 years) were submitted to 62 procedures from January 2003 to December 2005. EUS-guided drainage was successful in 48 (94%) patients. Only three patients needed surgery. There were two procedure-related complications managed clinically. During a mean follow-up of 39 weeks, recurrence due to migration or obstruction of the stent was 17.7%. All these cases were submitted to a new session of endoscopic drainage. There was no mortality. Complications were more frequent in patients with a recent episode of acute pancreatitis (38.5% versus 10%; p=0.083). The endoscopic approach was not more hazardous for abscesses in regard to complications rate (19% versus 16.6%; p>0.05). In abscesses, a nasocystic drain did not decrease the complications rate (27% versus 13%; p=0.619), but the placement of 2 stents did decrease this rate (18% versus 20%; p>0.05), although increased it in pseudocysts (40% versus 13%; p=0.185). Conclusions. Endoscopic transmural drainage is a minimally invasive, effective and safe approach in the management of pancreatic pseudocysts and abscesses.

Computerized virtual chromoendoscopy versus indigo carmine chromoendoscopy combined with magnification for diagnosis of small colorectal lesions: a randomized and prospective study.

Background and study aims Magnifying colonoscopy with indigo carmine dye and the analysis of the capillary and the pit patterns by computed virtual chromoendoscopy (Fujinon Intelligent Color Enhancement, FICE) with magnification are effective for the differential diagnosis of neoplastic and non-neoplastic lesions. This study aimed to compare the accuracy of virtual and real chromoendoscopy in differentiating neoplastic and non-neoplastic colorectal lesions. Patients and methods A prospective randomized trial of magnification colonoscopy with targeted FICE (Group I – 72 patients/111 lesions) versus magnification colonoscopy with targeted indigo carmine dye (Group II – 72 patients/137 lesions) was performed in consecutive patients with lesions 1 cm or less. Histopathology of the specimens was regarded as the gold standard. Results In group I, 86 (77.5%) lesions showed an intense vascular pattern (positive capillary meshwork), of which 80 (93%) were histologically confirmed as adenomas. From 25 lesions with negative capillary meshwork, 23 (92%) were non-neoplastic. Sensitivity, specificity, accuracy, positive and negative predictive values of the capillary meshwork for the differential diagnosis of these lesions was 97.8, 79.3, 92.8, 93 and 92%, respectively. The same parameters for pit pattern analysis by FICE were 92.7, 82.3, 90.1, 93.8 and 80%, respectively. Indigo carmine magnified chromoscopy showed sensitivity, specificity, accuracy, positive and negative predictive values of 97, 88.9, 94.9, 96.1 and 91.4%, respectively in the discrimination between neoplastic and non-neoplastic lesions. Conclusion Magnified virtual chromoendoscopy is as accurate as indigo carmine magnified chromoendoscopy in distinguishing between neoplastic from non-neoplastic small colorectal lesions.

Endoscopic ultrasound-guided endoscopic transmural drainage of pancreatic pseudocysts

BACKGROUND Surgery is the traditional treatment for symptomatic pancreatic pseudocysts, but the morbidity is still too high. Minimally invasive endoscopic approaches have been encouraged. AIMS To evaluate the efficacy of endoscopic ultrasound-guided endoscopic transmural drainage of pancreatic pseudocysts. METHODS From January, 2003 to August, 2006, 31 consecutive symptomatic patients submitted to 37 procedures at the same endoscopic unit were retrospectively analysed. Chronic and acute pancreatitis were found in, respectively, 17 (54.8%) and 10 (32.3%) cases. Bulging was present in 14 (37.8%) cases. Cystogastrostomy or cystoduodenostomy were created with an interventional linear echoendoscope under endosonographic and fluoroscopic control. By protocol, only a single plastic stent, without nasocystic drain, was used. Straight or double pigtail stents were used in, respectively, 22 (59.5%) and 15 (40.5%) procedures. RESULTS Endoscopic ultrasound-guided transmural drainage was successful in 29 (93.5%) patients. Two cases needed surgery, both due to procedure-related complications. There was no mortality related to the procedure. Twenty-four patients were followed-up longer than 4 weeks. During a mean follow-up of 12.6 months, there were six (25%) symptomatic recurrences due to stent clogging or migration, with two secondary infections. Median time for developing complications and recurrence of the collections was 3 weeks. These cases were successfully managed with new stents. Complications were more frequent in patients treated with straight stents and in those with a recent episode of acute pancreatitis. CONCLUSIONS Endoscopic transmural drainage provides an effective approach to the management of pancreatic pseudocysts.

Self-expandable metallic stents for palliative treatment of digestive cancer.

Background/Goal Self-expandable metallic stents can be used to reestablish luminal continuity in patients with malignancy of the esophagus, gastric outlet, or colon who are at high risk for surgical intervention. Data regarding their complication profiles remain incomplete. Our aim was to evaluate the feasibility and complications of endoscopic stenting in esophageal, gastroduodenal, and colonic malignancies. Study Between January 2003 and December 2005, 153 patients underwent 182 endoscopic procedures for insertion of 199 metallic stents in a single referral center. Complications were assessed retrospectively. Results The mean follow-up was 170 days. The mortality was 73.9% (113 patients), 105 cases between 1 and 60 weeks after the procedure (median survival, 17 wk), but none directly related to the stent placement. One single stent was required in 115 (75%) patients, and 37 (24.2%) cases required an overlapping stent. The procedure was unsuccessful in only 1 case of colonic obstruction. Thirty-eight (26.6%) patients developed 52 complications, of which 16 (9.4%) procedure-related complications (perforation, 5; migration, 5; obstruction, 3; misplacement, 2; and hemorrhage, 1) and 36 (21.3%) late complications (obstruction, 20; migration, 9; fistula, 6; and perforation, 1). Eight (5.6%) patients experienced more than 1 complication. Five (3.5%) cases required surgery (colon: 2 perforations, 1 fistula, and 1 obstruction; esophagus: 1 perforation). No significant difference on the complication rates was found for any site in which a metallic stent was inserted. Conclusions Endoscopic stenting for palliation of digestive cancer, despite a reasonable complication rate, is feasible in most patients. Most dysfunctions are not life-threatening and can be managed endoscopically.

p53 Immunohistochemical expression in Barrett's esophagus before and after endoscopic ablation by argon plasma coagulation

Objective. Few studies have evaluated p53 accumulation in the squamous mucosa contiguous (SMC) to Barretts esophagus (BE) and in the new squamous epithelium after endoscopic ablation. We evaluated the p53 expression in BE, in the SMC, and in the new squamous mucosa generated after ablation by argon plasma coagulation (APC). Material and methods. Endoscopic biopsy specimens from 37 BE patients, before and after ablation by APC, were analyzed. The p53 immunostaining criterion used was the staining of at least half of the nuclei. Results. p53 was detected in BE in 5 (13.5%) cases. In all these cases, SMC was p53(+). In addition, SMC was p53(–) in all cases of p53(–) BE (p<0.001). In the 5 cases with p53(+) BE and SMC, the new squamous mucosa continued to be p53(+). However, in the 32 cases with p53(–) SMC, the new squamous mucosa was also p53(–) (p<0.001). No case with p53(+) SMC turned out to be p53(–) after ablation. Similarly, no case with p53(–) BE and SMC before eradication became p53(+) after ablation (p<0.001). Conclusions. p53 was highly prevalent in the contiguous squamous mucosa when it is present in BE. After ablation, none of the cases lost p53 expression, and none of the negative cases turned out to be positive.

Comparative study between MBI (FICE®) and magnification chromoendoscopy with indigo carmine in the differential diagnosis of neoplastic and non-neoplastic lesions of the colorectum

CONTEXT Multiband imaging (MBI)/Fuji Intelligent Color Enhancement (FICE) is a spectral image processing technology that helps in vivo diagnosis of colorectal neoplasias. OBJECTIVE To compare the diagnostic accuracy of the magnification with either the electronic chromoendoscopy or indigo carmine dye in the differential diagnosis of neoplastic and non-neoplastic colorectal lesions. METHODS Seventy five patients with 157 colorectal lesions were prospectively evaluated. The capillary pattern, as well as the pit pattern according to the Kudo classification, of colorectal lesions were evaluated by means of the FICE system. Absence and presence of meshed capillary networks were labeled as non-neoplastic and neoplastic lesions, respectively. Afterwards, indigo carmine 0.8% was instilled and a new evaluation of the pit pattern was carried out. RESULTS One hundred and sixteen of the 157 lesions were classified as positive meshed capillary network, 115 of them were confirmed histologically as neoplasia. Other 32 lesions out of 41 with negative meshed capillary network were non-neoplastic. Sensitivity, specificity and accuracy were, respectively, 92.7%, 97% and 93.6%. Pit patterns I and II were confirmed as non-neoplastic lesions, and patterns III to V were confirmed as neoplasias. Sensitivity, specificity and accuracy for the electronic chromoendoscopy were, respectively, 94.4%, 97% and 94.9%. Meanwhile, the figures for the magnification with indigo carmine were, respectively, 97.6%, 93.9% and 96.8%. CONCLUSIONS Both methods, either the MBI/FICE system or the use of indigo carmine dye with magnification, achieved a high accuracy for the differential diagnosis between neoplastic and non-neoplastic colorectal lesions.

Digital Chromoendoscopy for Diagnosis of Diminutive Colorectal Lesions

Introduction. To compare the accuracy of digital and real-time chromoendoscopy for the differential diagnosis of diminutive (<5 mm) neoplastic and nonneoplastic colorectal lesions. Materials and Methods. This is a prospective randomized study comparing the Fujinon intelligent color enhancement (FICE) system (65 patients/95 lesions) and indigo carmine (69 patients/120 lesions) in the analysis of capillary meshwork and pit pattern, respectively. All lesions were less than 5 mm in diameter, and magnification was used in both groups. Histopathology was the gold standard examination. Results. Of 215 colorectal lesions, 153 (71.2%) were adenomas, and 62 were hyperplastic polyps (28.8%). Morphological analysis revealed 132 (61.4%) superficial lesions, with 7 (3.3%) depressed lesions, and 83 (38.6%) protruding lesions. Vascular meshwork analysis using FICE and magnification resulted in 91.7% sensitivity, 95.7% specificity, and 92.6% accuracy in differentiating neoplastic from nonneoplastic lesions. Pit pattern analysis with indigo carmine and magnification showed 96.5% sensitivity, 88.2% specificity, and 94.2% accuracy for the same purpose. Conclusion. Both magnifying virtual chromoendoscopy and indigo carmine chromoendoscopy showed high accuracy in the histopathological diagnosis of colorectal lesions less than 5 mm in diameter.

Displasia no esôfago de Barrett - concordância intra e interobservador no diagnóstico histopatológico

BACKGROUND Barretts esophagus is a well-known pre-malignant condition. Pathologic interpretation of biopsy specimens guides endoscopic surveillance as well as the therapeutic approach that will be carried out. However, the predictive value of histopathologic diagnosis can be questioned due to its poor intra- and interobserver reproducibility. AIMS To assess intra- and interobserver variability in the diagnosis of Barretts dysplasia. MATERIAL AND METHODS Three-micrometer thick sections from biopsy specimens from 42 patients with Barretts esophagus were stained with hematoxylin-eosin and PAS-alcian blue. The reading of the slides was carried out blindly in a light microscope. Intra and interobserver variability in the interpretation of the slides was determined by kappa statistics. RESULTS The number of tissue specimens was 229, with average of 5.45 (1 to 18) fragments for patient. Low grade dysplasia was diagnosed by pathologists in 21.4% to 52.4% of the cases. The intra-observer agreement for the diagnosis of low grade dysplasia was slight (kappa = 0.30). The interobserver agreement for the diagnosis of low grade dysplasia was poor, with kappa scores between 0.05 and 0.16. The diagnosis of dysplasia, with agreement for all pathologists examining the same set of slides, was 14.3%. CONCLUSIONS Pathologic interpretation of Barretts dysplasia may be subject to marked intra- and interobserver variabiliaty. Interpretation of low grade dysplasia, as high grade dysplasia, should also be considered for review by two or more pathologists.

Impact of endoscopic ultrasound-guided fine-needle aspiration on incidental pancreatic cysts. A prospective study

Abstract Objective. Widespread use of imaging procedures has promoted a higher identification of incidental pancreatic cysts (IPCs). However, little is known as to whether endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) could change the management strategy of patients having IPCs. This study has aimed to evaluate the management impact of EUS-FNA on IPCs. Material and methods. Patients with pancreatic cysts (PCs) who were referred to EUS-FNA were recruited prospectively. The referring physicians were questioned about the management strategy for these patients before and after EUS-FNA. The impact of EUS-FNA on management was then evaluated. Results. A total of 302 PC patients were recruited. Of these, 159 (52.6%) patients had asymptomatic IPCs. The average size was 2.3 cm (range: 0.2–7.1 cm), and 110 patients having smaller than 3 cm sized cysts. Lesions were located in the pancreatic head in 96 (61%) cases, and most patients (94%) had only a single cyst. The final diagnoses, obtained by EUS-FNA (91) and surgery (68), were 93 (58%) benign lesions, 36 (23%) cysts with malignant potential, 14 (9%) noninvasive malignancies, 10 (6%) malignant precursor lesions (PanIN), and 6 (4%) invasive malignancies. Management strategy changed significantly after EUS-FNA in 114 (71.7%) patients: 43% of the cases were referred to surgery, 44% of the patients were discharged from surveillance, and 13% of the cases were given further periodical imaging tests. Conclusion. EUS-FNA has a management impact in almost 72% of IPCs, with a major influence on the management strategy, either discharge rather than surgical resection or surgery rather than additional follow up.