G. Cengia

Consensus Statements for Management of Barrett's Dysplasia and Early-Stage Esophageal Adenocarcinoma, Based on a Delphi Process

BACKGROUND & AIMS Esophageal adenocarcinoma (EA) is increasingly common among patients with Barretts esophagus (BE). We aimed to provide consensus recommendations based on the medical literature that clinicians could use to manage patients with BE and low-grade dysplasia, high-grade dysplasia (HGD), or early-stage EA. METHODS We performed an international, multidisciplinary, systematic, evidence-based review of different management strategies for patients with BE and dysplasia or early-stage EA. We used a Delphi process to develop consensus statements. The results of literature searches were screened using a unique, interactive, Web-based data-sifting platform; we used 11,904 papers to inform the choice of statements selected. An a priori threshold of 80% agreement was used to establish consensus for each statement. RESULTS Eighty-one of the 91 statements achieved consensus despite generally low quality of evidence, including 8 clinical statements: (1) specimens from endoscopic resection are better than biopsies for staging lesions, (2) it is important to carefully map the size of the dysplastic areas, (3) patients that receive ablative or surgical therapy require endoscopic follow-up, (4) high-resolution endoscopy is necessary for accurate diagnosis, (5) endoscopic therapy for HGD is preferred to surveillance, (6) endoscopic therapy for HGD is preferred to surgery, (7) the combination of endoscopic resection and radiofrequency ablation is the most effective therapy, and (8) after endoscopic removal of lesions from patients with HGD, all areas of BE should be ablated. CONCLUSIONS We developed a data-sifting platform and used the Delphi process to create evidence-based consensus statements for the management of patients with BE and early-stage EA. This approach identified important clinical features of the diseases and areas for future studies.

TOPOIIα and HER-2/neu overexpression/amplification in Barrett’s oesophagus, dysplasia and adenocarcinoma

Rossi E, Villanacci V, Bassotti G, Donato F, Festa A, Cengia G, Grisanti S & Cestari R
(2010) Histopathology 57, 81–89
TOPOIIα and HER‐2/neu overexpression/amplification in Barrett’s oesophagus, dysplasia and adenocarcinoma

Intestinal metaplasia in Barrett's oesophagus: An essential factor to predict the risk of dysplasia and cancer development

BACKGROUND To date, there is still uncertainty on the role of specialized intestinal metaplasia in the carcinogenic process of Barretts oesophagus (BE); this fact seems of importance for planning adequate surveillance programs. AIMS To predict the risk of progression towards dysplasia/cancer based on typical morphological features by evaluating the importance of intestinal metaplasia in BE patients. METHODS 647 cases with a histological diagnosis of BE, referred to the Endoscopy Unit of a tertiary centre between 2000 and 2012 were retrospectively identified, and divided into two groups according to the presence/absence of intestinal metaplasia. For each patient, all histological reports performed during a follow-up of 4-8 years were analyzed. RESULTS Overall, 537 cases (83%) with intestinal metaplasia and 110 cases (17%) without intestinal metaplasia were included. During the follow-up period, none of the patients without intestinal metaplasia developed dysplasia/cancer nor progressed to metaplasia, whereas 72 patients with intestinal metaplasia (13.4%) showed histological progression of the disease. CONCLUSION The histological identification of intestinal metaplasia seems to be an essential factor for the progression towards dysplasia and cancer in BE patients.

Lack of interference between small bowel capsule endoscopy and implantable cardiac defibrillators: an ‘in vivo’ electrophysiological study

Background Capsule endoscopy is a widely performed procedure for small bowel investigation. Once swallowed by the patient, the capsule transmits images to an external recorder over a digital radiofrequency communication channel. Potential electromagnetic interferences with implantable cardiac devices have been postulated. Clinical studies on the safety of capsule endoscopy in patients with cardiac defibrillators are lacking. Objective The aim of this study was to assess potential mutual electromagnetic interferences between capsule and defibrillators. Methods This study used the Given M2A video capsule system. Ten different types of defibrillators were tested in a clinical setting. Before capsule ingestion, defibrillator electrical therapies were switched off. During capsule endoscopy patients were monitored with cardiac telemetry. At the end of capsule endoscopy the following defibrillator’s parameters were analysed: change in device settings; inappropriate shocks; inappropriate anti-tachycardia therapy; inappropriate sensing or pacing; noise detection; device reset; programming changes; permanent electrical damages. Any technical problem related to capsule image transmission was recorded. Results Neither defibrillator malfunction nor interference in sensing or pacing was recorded; conversely, no capsule malfunction potentially caused by defibrillators was registered. Conclusion Our results suggest that capsule endoscopy can be safely performed in patients with cardiac defibrillators.

Endoscopic Therapy for Esophageal Varices

Among therapeutic endoscopic options for esophageal varices (EV), endoscopic variceal ligation (EVL) has proven more effectiveness and safety compared with endoscopic sclerotherapy and is currently co

“Errare Humanum Est, Perseverare Autem Diabolicum”

DIS 5.4.0 DTD YGAST60934 proof 2 June 2017 2:19 68 69 70 71 72 73 74 75 76 77 78 79 80 81 82 83 84 85 86 87 88 89 90 91 92 93 94 95 96 Question: A 79-year-old man with no significant past medical history presented to the emergency department with a 2-day history of melena. He was hemodynamically stable and laboratory tests were unremarkable, except for normocytic anemia (hemoglobin, 9.1 g/dL; mean corpuscular volume, 82; ferritin, 38 ng/mL). He reported a 7-day history of therapy with ibuprofen 200 mg twice a day for persistent lumbago. The patient underwent gastroscopy with a negative result. A colonoscopy performed the day after was also negative. He was therefore referred for an outpatient capsule endoscopy, which was performed a week later (Mirocam, Intromedic Inc., Seoul Korea). He swallowed the capsule smoothly without real-time monitoring. The patient brought the recorder back the following day; he referred that the recorder light stopped blinking approximately 30 minutes after ingestion. The capsule recording was a 97 98 99 100 101 102 103 104 105 106 107 108 25-minute video showing normal esophageal mucosa, with a very slow capsule progression (Figure A). The short recording time was interpreted as a possible system malfunction. The patient was asymptomatic, but he was unable to report capsule excretion; therefore, 6 days later an abdominal radiograph was performed, as per protocol in our center. No radiopaque object was identified and a new capsule endoscopy was scheduled. The second capsule ingestion was performed under Wi-Fi real time monitoring (Miroview RTV application; Mirocam, Intromedic Inc.). As with the previous examination, the capsule showed normal esophageal mucosa without any obvious lumen; moreover, a nonblinking capsule was clearly identified (Figure B) in several frames 5 minutes after ingestion. Twenty minutes later, the recording suddenly stopped. A plain neck and chest radiograph was performed. It showed 2 radiopaque foreign bodies, compatible with capsules, retained in the patient’s neck (Figure C). What is the diagnosis? Look on page 000 for the answer and see the Gastroenterology website (www.gastrojournal.org) for more information on submitting your favorite image to Clinical Challenges and images in GI. 109 110 111 The title quote is attributed to Seneca the Younger. 112 113 114 115 116 Conflicts of interest The authors disclose no conflicts.

P.1.167: ROLE OF SMALL BOWEL CAPSULE ENDOSCOPY IN PATIENTS WITH HEREDITARY INTESTINAL POLYPOSIS: A SINGLE CENTER EXPERIENCE

22.4% required additional argon-plasma-coagulation. Due to size ( 4 mm), 5.1% were treated by forceps biopsy and additional APC-therapy. Local recurrence developed in 42.3% and was retreated endoscopically. Only one major complication (single perforation) was recorded. Minor complications (14.2%) consisted in either immediate bleeding after resection or bleeding up to 48 h after endoscopic therapy. All complications could be managed endoscopically.Endoscopic mucosal resection, if necessary combined with argonplasma-coagulation, represents an efficient and acceptably safe technique for treating duodenal adenomata. However, in comparison with colonic polypectomy, local recurrence and complications are more common. Follow-up endoscopy is recommended in short intervals such as 3 months. As relevant bleeding can occur up to 48 hours after resection, patients are in need of close monitoring. EMR should therefore not be performed in an outpatient setting.

Lower Gastrointestinal Endoscopy For Polyps and Polyposis

Colonoscopy has become the leading method to explore the entire colon, and is currently considered the gold standard for colorectal cancer screening. Improvements in technology have provided specific diagnostic capability, and the treatment of dysplastic and neoplastic superficial lesions is now achievable in the majority of patients, by adopting sophisticated resection techniques. Endoscopic treatment of polyps must be performed in order to both minimize the risks of the procedure and optimize the completeness of the removal, thereby reducing recurrence; therefore operators must be skilled and continuously trained, in order to perform local treatment by either endoscopic mucosal resection (EMR) or endoscopic submucosal dissection (ESD). In this way, endoscopic resection can be considered a safe and effective alternative to surgery for the treatment of colorectal polyps.