Fauze Maluf-Filho

Kras mutation analysis of fine needle aspirate under EUS guidance facilitates risk stratification of patients with pancreatic mass

Objectives The accuracy of endoscopic ultrasound-fine needle aspiration cytology (EUS-FNAC) for the diagnosis of pancreatic cancer is suboptimal. Mutational activation of the kras oncogene is almost universally present in pancreatic cancer tissue. We, therefore, investigated if analysis for mutant kras gene in the EUS-FNAC aspirates supplements cytopathology for the diagnosis of pancreatic adenocarcinoma (PAC). Methods EUS-FNAC specimens obtained from 74 patients with pancreatic masses were analyzed for the presence of kras mutation on codon 12 using polymerase chain reaction-restriction fragment length polymorphism and MvaI restriction enzyme. Definitive diagnosis was based on surgical pathology or long-term follow-up (median 27.8 mo); 57 patients had PAC, 11 patients chronic pancreatitis, and 9 patients nonfunctioning neuroendocrine tumors. Results Analysis of mutant kras gene in addition to cytopathology allowed the detection of PAC in 4 additional patients as compared with cytopathology alone. Cytopathology and kras mutant analysis were negative for PAC in 17 patients of whom 6 patients (35%) had PAC. The respective sensitivity (90.9% vs. 82.5%), specificity (47.6% vs. 97.9%), positive predictive value (89.5% vs. 83.8%), negative predictive value (98.1% vs. 94.1%), accuracy (89.2% vs. 58.8%) of cytopathology plus kras mutation versus cytopathology were numerically superior but did not reach statistical significance. Conclusions Analysis for the presence of mutant kras gene supplements conventional cytopathology for the diagnosis of PAC even without a cytopathologist in attendance and using only 3 needle passes. Among patients with negative cytopathology, the presence of kras mutation represents pancreatic cancer while the absence of kras mutation increases the possibility of benign lesion.

Deep sedation during gastrointestinal endoscopy: Propofol-fentanyl and midazolam-fentanyl regimens

AIM To compare deep sedation with propofol-fentanyl and midazolam-fentanyl regimens during upper gastrointestinal endoscopy. METHODS After obtaining approval of the research ethics committee and informed consent, 200 patients were evaluated and referred for upper gastrointestinal endoscopy. Patients were randomized to receive propofol-fentanyl or midazolam-fentanyl (n = 100/group). We assessed the level of sedation using the observers assessment of alertness/sedation (OAA/S) score and bispectral index (BIS). We evaluated patient and physician satisfaction, as well as the recovery time and complication rates. The statistical analysis was performed using SPSS statistical software and included the Mann-Whitney test, χ² test, measurement of analysis of variance, and the κ statistic. RESULTS The times to induction of sedation, recovery, and discharge were shorter in the propofol-fentanyl group than the midazolam-fentanyl group. According to the OAA/S score, deep sedation events occurred in 25% of the propofol-fentanyl group and 11% of the midazolam-fentanyl group (P = 0.014). Additionally, deep sedation events occurred in 19% of the propofol-fentanyl group and 7% of the midazolam-fentanyl group according to the BIS scale (P = 0.039). There was good concordance between the OAA/S score and BIS for both groups (κ = 0.71 and κ = 0.63, respectively). Oxygen supplementation was required in 42% of the propofol-fentanyl group and 26% of the midazolam-fentanyl group (P = 0.025). The mean time to recovery was 28.82 and 44.13 min in the propofol-fentanyl and midazolam-fentanyl groups, respectively (P < 0.001). There were no severe complications in either group. Although patients were equally satisfied with both drug combinations, physicians were more satisfied with the propofol-fentanyl combination. CONCLUSION Deep sedation occurred with propofol-fentanyl and midazolam-fentanyl, but was more frequent in the former. Recovery was faster in the propofol-fentanyl group.

Narrow-band imaging without magnification for detecting early esophageal squamous cell carcinoma

AIM To compare narrow-band imaging (NBI) without image magnification, and chromoendoscopy with Lugols solution for detecting high-grade dysplasia and intramucosal esophageal squamous cell carcinoma (SCC) in patients with head and neck cancer. METHODS This was a prospective observational study of 129 patients with primary head and neck tumors consecutively referred to the Gastrointestinal Endoscopy Unit of Hospital das Clínicas, São Paulo University Medical School, Brazil, between August 2006 and February 2007. Conventional examinations with NBI and Lugol chromoendoscopy were consecutively performed, and the discovered lesions were mapped, recorded and sent for biopsy. The results of the three methods were compared regarding sensitivity, specificity, accuracy, positive predictive value, negative predictive value, positive likelihood value and negative likelihood value. RESULTS Of the 129 patients, nine (7%) were diagnosed with SCC, 5 of which were in situ and 4 which were intramucosal. All carcinomas were detected through NBI and Lugol chromoendoscopy. Only 4 lesions were diagnosed through conventional examination, all of which were larger than 10 mm. CONCLUSION NBI technology with optical filters has high sensitivity and high negative predictive value for detecting superficial esophageal SCC, and produces results comparable to those obtained with 2.5% Lugol chromoendoscopy.

Comparison between endoscopic sclerotherapy and band ligation for hemostasis of acute variceal bleeding

AIM To compare band ligation (BL) with endoscopic sclerotherapy (SCL) in patients admitted to an emergency unit for esophageal variceal rupture. METHODS A prospective, randomized, single-center study without crossover was conducted. After endoscopic diagnosis of esophageal variceal rupture, patients were randomized into groups for SCL or BL treatment. Sclerotherapy was performed by ethanolamine oleate intravascular injection both above and below the rupture point, with a maximum volume of 20 mL. For BL patients, banding at the rupture point was attempted, followed by ligation of all variceal tissue of the distal esophagus. Primary outcomes for both groups were initial failure of bleeding control (5 d), early re-bleeding (5 d to 6 wk), and complications, including mortality. From May 2005 to May 2007, 100 patients with variceal bleeding were enrolled in the study: 50 SCL and 50 BL patients. No differences between groups were observed across gender, age, Child-Pugh status, presence of shock at admission, mean hemoglobin levels, and variceal size. RESULTS No differences were found between groups for bleeding control, early re-bleeding rates, complications, or mortality. After 6 wk, 36 (80%) SCL and 33 (77%) EBL patients were alive and free of bleeding. A statistically significant association between Child-Pugh status and mortality was found, with 16% mortality in Child A and B patients and 84% mortality in Child C patients (P<0.001). CONCLUSION Despite the limited number of patients included, our results suggest that SCL and BL are equally efficient for the control of acute variceal bleeding.

Endoscopic Detection of Early Esophageal Squamous Cell Carcinoma in Patients with Achalasia: Narrow-Band Imaging versus Lugol's Staining

Chromoendoscopy with Lugols staining remains the gold standard technique for detecting superficial SCC. An alternative technique, such as narrow-band imaging (NBI), for “optical staining” would be desirable, since NBI is a simpler technique and has no known complications. In this study, we compare NBI without magnification and chromoendoscopy with Lugols staining for detecting high-grade dysplasia and intramucosal esophageal squamous cell carcinoma (SCC) in patients with achalasia. This was a prospective observational study of 43 patients with achalasia referred to the Gastrointestinal Endoscopy Unit of the Hospital of Clinics, São Paulo, University Medical School, Brazil, from October 2006 to February 2007. Conventional examinations with white light, NBI, and Lugol staining were consecutively performed, and the suspected lesions were mapped, recorded, and sent for biopsy. The results of the three methods were compared regarding sensitivity, specificity, accuracy, positive predictive value, negative predictive value, positive likelihood value, and negative likelihood value. Of the 43 patients, one was diagnosed with esophageal squamous cell carcinoma, and it was detected by all of the methods. NBI technology without magnification has high sensitivity and negative predictive value for detecting superficial esophageal squamous cell carcinoma, and it has comparable results with those obtained with Lugols staining.

Histology assessment of bipolar coagulation and argon plasma coagulation on digestive tract.

AIM To analyze the effect of bipolar electrocoagulation and argon plasma coagulation on fresh specimens of gastrointestinal tract. METHODS An experimental evaluation was performed at Hospital das Clinicas of the University of São Paulo, on 31 fresh surgical specimens using argon plasma coagulation and bipolar electrocoagulation at different time intervals. The depth of tissue damage was histopathologically analyzed by single senior pathologist unaware of the coagulation method and power setting applied. To analyze the results, the mucosa was divided in superficial mucosa (epithelial layer of the esophagus and superficial portion of the glandular layer of the stomach and colon) intermediate mucosa (until the lamina propria of the esophagus and until the bottom of the glandular layer of the stomach and colon) and muscularis mucosa. Necrosis involvement of the layers was compared in several combinations of power and time interval. RESULTS Involvement of the intermediate mucosa of the stomach and of the muscularis mucosa of the three organs was more frequent when higher amounts of energy were used with argon plasma. In the esophagus and in the colon, injury of the intermediate mucosa was frequent, even when small amounts of energy were used. The use of bipolar electrocoagulation resulted in more frequent involvement of the intermediate mucosa and of the muscularis mucosa of the esophagus and of the colon when higher amounts of energy were used. In the stomach, these involvements were rare. The risk of injury of the muscularis propria was significant only in the colon when argon plasma coagulation was employed. CONCLUSION Tissue damage after argon plasma coagulation is deeper than bipolar electrocoagulation. Both of them depend on the amount of energy used.

Use of a neutral gadolinium chelate as a contrast medium for ERCP: case report.

Despite systemic absorption of contrast media that contains iodine, idiosyncratic (anaphylactoid), and nonidiosyncratic (chemotoxic) reactions after ERCP are extremely rare. Nevertheless, for patients with a confirmed history of a serious reaction to contrast media administered intravascularly, pretreatment with corticosteroids and the use of low osmolality nonionic contrast media should be considered for ERCP. A case is presented in which ERCP with an iodinated contrast agent was contraindicated. The procedure was performed successfully and without complication when using a paramagnetic contrast agent.

Predictive Factors for Local Recurrence and Incomplete Resection of Early Gastric Cancer Treated by Endoscopic Resection: A Western Experience

BACKGROUND Early gastric cancer (EGC) is defined as adenocarcinoma limited to the mucosa or submucosa regardless of lymph node involvement. Local EGC recurrence rates have been described in up to 6% of cases. OBJECTIVES To evaluate predictive factors for incomplete resection and local recurrence of EGC treated by endoscopic mucosal resection (EMR) that was followed up for at least one year. METHODS From June 1994 to December 2005, 46 patients with EGC underwent EMR. Possible predictive factors for incomplete endoscopic resection and local recurrence were identified by medical chart analysis. Demographic, endoscopic and histopathological data were retrospectively evaluated. EMR was considered complete or incomplete. Patients from the complete resection group were divided into subgroups (with and without local EGC recurrence). RESULTS Complete resection was possible in 36 cases (76.6%). Predictive factors for incomplete resection were tumour location (P=0.035), histological type (P=0.021), lesion size (P=0.022) and number of resected fragments (P=0.013). On multivariate analysis, undifferentiated histological type (OR 0.8; 95% CI 0.036 to 0.897) and number of resected fragments (OR 7.34; 95% CI 1.266 to 42.629) were independent predictive factors for incomplete resection. In the complete resection group, a larger lesion size was associated with a higher the number of resected fragments (P=0.018). Local recurrence occurred in nine cases (25%). Use of the cap technique was the only predictive factor for local recurrence in five of seven cases (71.4%) (P=0.006). CONCLUSIONS A larger lesion size was associated with a higher number of resected fragments. Undifferentiated adenocarcinoma and piecemeal resection were predictive factors for incomplete resection. Technique type was a predictive factor for local EGC recurrence.

Comparison of Deep Bile Duct Cannulation with Cannulatome Versus Cannulatome with Guide Wire: A Prospective Randomized Trial

Comparison of Deep Bile Duct Cannulation with Cannulatome Versus Cannulatome with Guide Wire: A Prospective Randomized Trial Everson L. Artifon, Paulo Sakai, Fabio Y. Hondo, Fauze Maluf-Filho, Jose E. Monteiro-da-Cunha, Shinichi Ishioka, Joaquim Gama-Rodrigues Background: During the endoscopic retrograde cholangiopancreatography (ERCP) the main step is the cannulation of major duodenal papilla to obtain deep cannulation of bile duct, and it is correlated to pancreaticobiliary complications being that acute pancreatitis is the most frequent. Aim: compare the rate of success to achieve selective cannulation of common bile duct using a cannulatome and cannulatome with guide-wire; compare the amylase, lypase and C reactive protein serum level between the groups and evaluate the incidence of pancreatitis in the groups. Patients and Methods: From July 2002 to October 2003 341 ERCP were performed at our institution. Three hundred consecutive patients were randomized to duodenal papilla cannulation using cannulatome (Group I) and cannulatome with guide wire (Group II). All the endoscopic procedures were performed by the first author. All patients were hospitalized for 24 hours after ERCP. Amylase , lipase, C-reactive protein were assessed before, 4, 12 and 24 hours after the procedure. CT scan was performed if the patient complained of pain and presented an amylase over three times the normal level. Results: The frequency of cannulations of pancreatic duct were similar in both Groups (p=0,161). Deep biliary cannulation without precut was more frequent in Group II (p=0,023). The precut was applied more frequently in Group I (p=0,01). Group II presented a significant lower incidence of acute pancreatitis (p=0,04). More patients in Group I presented hiperamylasemia at 4, 12 and 24 hours (p=0,0087; p=0,045; p=0,0475, respectively). The number of pancreatic cannulations was related to hiperamylasemia and acute pancreatitis. The acute pancreatitis post ERCP were significantly higher in Group I (p=0,037). Conclusion: The biliary access with cannulotome loaded with guide wire is related to higher success rate of selective biliary cannulation and less pancreatic trauma. T1230 Single Stage Biliary Stone Treatment by Laparoscopic Cholecystectomy and Intraoperative Endoscopic Sphincterotomy Experience with 204 Patients Thierry Barrioz, Marcel Happi Nono, Jean Pierre Faure, Michel Carretier, Michel Beauchant How to approach common bile-duct stones discovered during laparoscopic cholecystectomy is still a subject for debate. After sequential strategies, the natural trend is now towards single-stage therapy. The aim of this study was to establish the feasibility, the efficacy and long term outcome of intraoperative endoscopic sphincterotomy when common bile duct stones are discovered or strongly suspected on cholangiography during laparoscopic cholecystectomy. Patients and Methods: Between july 1995 and december 2002, 3802 patients with symptomatic biliary stone were evaluated for laparoscopic cholecystectomy, with intraoperative cholangiography in all cases. In 204 patients (5%), 125 women, 79 men, mean age 62 years (range 16-91) choledocolithiasis were strongly suspected on laparoscopic cholangiography, an intraoperative endoscopic sphincterotomy was performed just after laparoscopic cholecystectomy during the same anesthetic session. Results: Intraoperative endoscopic sphincterotomy was successful in all cases (100%). Common bile duct stones were definitively found in 190 cases (93%). Complete clearance of the ductal stones was achieved in 189 patients (99.5%) by single stage treatment : in 187 (98.4%) by intraoperative endoscopic procedure and in 2 (1%) stones were push into the duodenum through the sphincterotomy by laparoscopic procedure in the same session. In only one patient, common bile duct stones were removed by additional postoperative endoscopic procedure after extracorporeal shock wave lithotripsy. The mean duration of the intraoperative endoscopic procedure was 21 minutes (range 3-40), and 73 minutes (range 43-93) for the single stage laparoscopic-endoscopic treatment. The short-term complication rate was 3%, all with conservative treatment. The mean postoperative hospital stay was 3 days (range 2-10). At a mean 7 years follow up, no long term complications related to the laparoscopic-endoscopic procedure were observed. Conclusion: single stage biliary stone treatment by Laparoscopic cholecystectomy and intraoperative endoscopic sphincterotomy is a feasible, effective and safe approach, saving patients a subsequent invasive procedure.

Opinion: How to manage subepithelial lesions of the upper gastrointestinal tract?

Subepithelial lesions (SELs) in the upper gastrointestinal (GI) tract are relatively frequent findings in patients undergoing an upper GI endoscopy. These tumors, which are located below the epithelium and out of reach of conventional biopsy forceps, may pose a diagnostic challenge for the gastroenterologist, especially when SELs are indeterminate after endoscopy and endoscopic ultrasound (EUS). The decision to proceed with further investigation should take into consideration the size, location in the GI tract, and EUS features of SELs. Gastrointestinal stromal tumor (GIST) is an example of an SEL that has a well-recognized malignant potential. Unfortunately, EUS is not able to absolutely differentiate GISTs from other benign hypoechoic lesions from the fourth layer, such as leiomyomas. Therefore, EUS-guided fine needle aspiration (EUS-FNA) is an important tool for correct diagnosis of SELs. However, small lesions (size < 2 cm) have a poor diagnostic yield with EUS-FNA. Moreover, studies with EUS-core biopsy needles did not report higher rates of histologic and diagnostic yields when compared with EUS-FNA. The limited diagnostic yield of EUS-FNA and EUS-core biopsies of SELs has led to the development of more invasive endoscopic techniques for tissue acquisition. There are initial studies showing good results for tissue biopsy or resection of SELs with endoscopic submucosal dissection, suck-ligate-unroof-biopsy, and submucosal tunneling endoscopic resection.