Jayan Mannath

Narrow band imaging for characterization of high grade dysplasia and specialized intestinal metaplasia in Barrett's esophagus: a meta-analysis.

BACKGROUND AND STUDY AIM Narrow band imaging (NBI), a novel endoscopic technique that highlights mucosal surface structures and microvasculature is increasingly advocated as a tool to detect and characterize neoplasia and intestinal metaplasia in patients with Barretts esophagus. We aimed to assess the diagnostic accuracy of NBI with magnification for the diagnosis of high grade dysplasia (HGD) and specialized intestinal metaplasia (SIM) in patients with Barretts esophagus. METHODS We performed a meta-analysis of studies which compared NBI-based diagnosis of HGD and SIM with histopathology as the gold standard. RESULTS Eight studies including 446 patients with 2194 lesions met the inclusion criteria. For diagnosing HGD, the pooled sensitivity, specificity, diagnostic odds ratio (DOR), and area under the curve (AUC) were 0.96 (95 % confidence interval [CI] 0.93-0.99), 0.94 (95 %CI 0.84-1.0), 342.49 (95 %CI 40.49 - 2896.89) and 0.99 (SE 0.01) on a per-lesion analysis with similar results on per-patient analysis.. For the characterization of SIM, the pooled sensitivity, specificity, DOR, and AUC were 0.95 (95 %CI 0.87-1.0), 0.65 (95 %CI 0.52-0.78), 37.53 (95 %CI 6.50-217.62) and 0.88 (SE 0.08) on a per-lesion analysis. CONCLUSION NBI with magnification is accurate with high diagnostic precision for diagnosis of HGD in Barretts esophagus on the basis of irregular mucosal pit patterns and/or irregular microvasculature. NBI has high sensitivity but poor specificity for characterizing SIM.

Meta‐analysis: the diagnostic yield of chromoendoscopy for detecting dysplasia in patients with colonic inflammatory bowel disease

Aliment Pharmacol Ther 2011; 33: 304–312

High definition colonoscopy vs. standard video endoscopy for the detection of colonic polyps: a meta-analysis

BACKGROUND AND STUDY AIMS High definition colonoscopy may improve adenoma detection rates but studies report conflicting results. The aim of this meta-analysis was to compare the diagnostic yield of colonic polyps between high definition colonoscopy and standard video endoscopy (SVE). METHODS Various electronic databases were searched for articles reporting on high definition colonoscopy. The pooled incremental yield and pooled weighted mean difference of high definition colonoscopy over SVE for polyp detection was determined. RESULTS Five studies involving 4422 patients provided data on the total number of polyps detected. The incremental yield of high definition colonoscopy for the detection of any polyp was 3.8 % (95 % confidence interval [CI] 1 % - 6.7 %) with a number needed to treat (NNT) of 26. For the detection of adenomatous polyps the incremental yield was 3.5 % (95 %CI 0.9 % - 6.1 %) with an NNT of 28. There were no differences between high definition and SVE in the detection of high risk adenomas, with an incremental yield of -0.1 % (95 %CI -1.7 % to 1.6 %). When grouped according to the overall adenoma detection rate of the studies (> 50 % or < 50 %) the pooled weighted mean difference in small adenoma detection was better with high definition colonoscopy ( P = 0.035). CONCLUSIONS There were marginal differences between high definition colonoscopy and SVE for the detection of colonic polyps/adenomas. High definition colonoscopy did not improve the detection of high risk adenomas. Due to differences in the adenoma detection rate between the studies and the nonrandomized study design of three of the five studies, these results need to be interpreted with caution. Prospective randomized trials looking at long term outcomes such as rates of interval or missed cancers are needed to clarify the clinical implications.

Multimodality endoscopic eradication for neoplastic Barrett oesophagus: results of an European multicentre study (EURO-II)

Objective Focal endoscopic resection (ER) followed by radiofrequency ablation (RFA) safely and effectively eradicates Barretts oesophagus (BO) containing high-grade dysplasia (HGD) and/or early cancer (EC) in smaller studies with limited follow-up. Herein, we report long-term outcomes of combined ER and RFA for BO (HGD and/or EC) from a single-arm multicentre interventional study. Design In 13 European centres, patients with BO≤12 cm with HGD and/or EC on 2 separate endoscopies were eligible for inclusion. Visible lesions (<2 cm length; <50% circumference) were removed with ER, followed by serial RFA every 3 months (max 5 sessions). Follow-up endoscopy was scheduled at 6 months after the first negative post-treatment endoscopic control and annually thereafter. Outcomes: complete eradication of neoplasia (CE-neo) and intestinal metaplasia (CE-IM); durability of CE-neo and CE-IM (once achieved) during follow-up. Biopsy and resection specimens underwent centralised pathology review. Results 132 patients with median BO length C3M6 were included. After entry-ER in 119 patients (90%) and a median of 3 RFA (IQR 3–4) treatments, CE-neo was achieved in 121/132 (92%) and CE-IM in 115/132 patients (87%), per intention-to-treat analysis. Per-protocol analysis, CE-neo and CE-IM were achieved in 98% and 93%, respectively. After a median of 27 months following the first negative post-treatment endoscopic control, neoplasia and IM recurred in 4% and 8%, respectively. Mild-to-moderate adverse events occurred in 25 patients (19%); all managed conservatively or endoscopically. Conclusions In patients with early Barretts neoplasia, intensive multimodality endotherapy consisting of ER combined with RFA is safe and highly effective, and the treatment effect appears to be durable during mid-term follow-up. Trial registration number NTR 1211, http://www.trialregister.nl.

Comparison of high definition with standard white light endoscopy for detection of dysplastic lesions during surveillance colonoscopy in patients with colonic inflammatory bowel disease

Background:Dysplasia in colonic inflammatory bowel disease (IBD) is often multifocal and flat. High-definition (HD) colonoscopy improves adenoma detection rates by improving the ability to detect subtle mucosal changes. The utility of HD colonoscopy in dysplasia detection in patients with IBD has not been reported so far. We aimed to compare the yield of dysplastic lesions detected by standard definition (SD) white light endoscopy with HD endoscopy. Methods:A retrospective cohort study of patients with long-standing (>7 years) colonic IBD undergoing surveillance colonoscopy at Nottingham University Hospital was studied between September 2008 and February 2010. Details of diagnosis, duration of disease, and outcomes of the colonoscopy were collected from the endoscopy database, electronic patient records, and patient notes. Results:There were 160 colonoscopies (101 ulcerative colitis [UC] and 59 Crohns disease [CD]) in the SD group and 209 colonoscopies (147 UC and 62 CD) in the HD group. The groups were well matched for all demographic variables. Thirty-two dysplastic lesions (27 on targeted biopsy) were detected in 24 patients in the HD group and 11 dysplastic lesions (six on targeted biopsy) were detected in eight patients the SD group. The adjusted prevalence ratio of detecting any dysplastic lesion and dysplastic lesion on targeted biopsy was 2.21 (95% confidence interval [CI] 1.09–4.45) and 2.99 (95% CI 1.16–7.79), respectively, for HD colonoscopy. Conclusions:HD colonoscopy improves targeted detection of dysplastic lesions during surveillance colonoscopy of patients with colonic IBD in routine clinical practice. Randomized controlled studies are required to confirm these findings.

EUS-Guided Pancreatic Cyst Brushing: A Comparative Study in a Tertiary Referral Centre

CONTEXT Fluid analysis obtained by EUS guided FNA is used to aid in diagnosis and management of cystic lesions in the pancreas. Complementing fluid aspiration with brushing of cyst wall may increase the cellular yield. OBJECTIVE To compare cellular yield of pancreatic cyst FNA with and without wall brushing. DESIGN Comparative study. SETTING Tertiary referral centre. PATIENTS Fifty-one patients with cystic pancreatic lesions referred for EUS-guided aspiration/sampling were included (median age 69 years; interquartile range: 49-77 years). MAIN OUTCOME MEASURES Comparing adequacy of cellular yield between EUS-guided aspiration alone vs. EUS-guided aspiration and cyst wall brushing. INTERVENTION EUS-guided FNA and/or wall brushing (aspiration only: No. 27; brushing: No. 24). RESULTS There was no significant difference in age (P=0.496) cyst size (P=0.084) or cyst location (P=0.227) between groups. Overall 29.5%; (15/51) of samples were acellular/insufficient with no significant difference between the two groups (22.2% in the aspiration only group vs. 37.5% in the brushing group; P=0.356). The remaining samples were adequate for cytological evaluation (77.8% vs. 62.5%; aspiration only vs. brushing groups). Seventeen cases were neoplastic (8 benign, 9 malignant). The diagnostic accuracy was 61.9% and 55.0% in aspiration only and brushing groups, respectively. Two out of 4 (50.0%) patents were diagnosed as having cancer in the brushings group compared to 1/5 (20.0%) in the FNA only group (P=0.524). LIMITATIONS Non-randomised series. CONCLUSIONS The cellular yield was similar in FNA and brushing group. Greater proportion of patients with malignant cystic pancreatic lesions diagnosed by EUS sampling was in the brushing group, but this did not reach statistical significance.

Role of endoscopy in early oesophageal cancer

Incidence of oesophageal adenocarcinoma has increased exponentially in the West over the past few decades. Following detection of advanced cancers, 5-year survival rates remain bleak, making identification of early neoplasia, which has a better outcome, important. Detection of subtle oesophageal lesions during endoscopy can be challenging, and advanced imaging techniques might improve their detection. High-definition endoscopy has become a standard in most endoscopy centres, and this technology probably provides better delineation of mucosal features than standard-definition endoscopy. Various image enhancement techniques are now available with the development of new electronics and software systems. Image enhancement with chromoendoscopy using dyes has been a cost-effective option for many years, yet these techniques have been replaced in some contexts by electronic chromoendoscopy, which can be used with the press of a button. However, Lugols chromoendoscopy remains the gold standard to identify squamous dysplasia. Identification and characterization of subtle neoplastic lesions could help to target biopsies and perform endoscopic resection for better local staging and definitive therapy. In vivo histology with techniques such as confocal endomicroscopy could make endotherapy feasible within a shorter timescale than when relying on histology on tissue samples. Once early neoplasia is identified, treatments include endoscopic resection, endoscopic submucosal dissection or various ablative techniques. Endotherapy has the advantage of being a less invasive technique than oesophagectomy, and is associated with lower mortality and morbidity. Endoscopic ablation therapies have evolved over the past few years, with radiofrequency ablation showing the best results in terms of success rates and complications in Barrett dysplasia.

Endoscopic mucosal resection: who and how?

Many of the gastrointestinal cancers are diagnosed at an advanced stage, necessitating major surgery that is associated with significant morbidity and mortality. The outcome of such cases is suboptimal due to local or distant metastases. Superficial cancers involving the mucosa are unlikely to cause nodal or distant spread and these cases could be managed endoscopically. Endoscopic mucosal resection was pioneered in Japan [Soetikno et al. 2003] for the management of early gastric cancer. This has gained wider acceptance as a therapeutic option for various gastrointestinal lesions around the globe. The indications have expanded to include treatment of Barrett’s dysplasia, oesophageal squamous dysplasia, small bowel and colorectal adenomas and early cancers. Endoscopic mucosal resection (EMR) also has the advantage of providing an accurate local staging of the disease compared with ablative therapies such as argon plasma coagulation (APC), photodynamic therapy or radiofrequency ablation (RFA). However, this technique needs expertise and adequate training is essential to provide a safe and effective procedure.

Endoscopic evaluation of the gastro-duodenal tolerance of short-term analgesic treatment with 25 mg diclofenac-K liquid capsules.

Diclofenac‐potassium (diclofenac‐‐K) 25 mg liquid capsule is absorbed more quickly than the tablet formulation. It offers potential for rapid pain relief, but may alter gastro‐duodenal tolerability.

Comparison of high definition with standard white light endoscopy for detection of dysplastic lesions during surveillance colonoscopy in patients with inflammatory bowel disease

Introduction Dysplasia in colonic inflammatory bowel disease (IBD) is often multifocal and flat, making it easy for significant lesions to be overlooked. Dye spraying the mucosal surface is believed to enhance visualisation of subtle mucosal abnormalities, but is cumbersome and messy and has poor uptake among endoscopists. High definition (HD) colonoscopy improves adenoma detection rates by improving the ability to detect subtle mucosal changes and is as good as chromoendoscopy in polyp detection. The utility of high definition colonoscopy in dysplasia detection in patients with IBD has not been reported so far. The authors aimed to compare the yield of dysplastic lesions detected by standard definition white light endoscopy (SD) with high definition endoscopy (HD). Methods Details of consecutive patients with long standing (>7 years) colonic IBD who underwent surveillance colonoscopy at Nottingham University Hospitals between September 2008 and February 2010 were extracted from the endoscopy database. Details of diagnosis, duration of disease and outcomes of the colonoscopy were then collected from the electronic patient records and patient notes. The colonoscopies were done at 2 sites, of which one had only HD systems and the other SD. SPSS v17 was used for the data analysis. Results 360 colonoscopies were done on 353 patients. There were 162 colonoscopies (102 UC and 60 CD) in the SD group and 208 colonoscopies (146 UC and 62 CD), in the HD group. The groups were well matched for mean age of patients, duration of disease, gender and number of biopsies taken. Table 1 gives information on the number and characterisation of dysplastic lesions detected. Table 1 PTH-061 Dysplastic lesions detected by standard and high definition colonoscopy Standard definition (n=162) High definition (n=208) p Value Number of lesions 15 30 NS Number of patients with dysplasia 12 23 NS Number of patients with HGD/cancer 1/2 2/5 NS Number of patients with lesions on targeted biopsy 6 22 <0.05 Number of flat lesions detected 2 10 <0.05 Conclusion HD colonoscopy is superior to SD colonoscopy in targeted detection of dysplastic lesions during surveillance colonoscopy of patients with colonic IBD in routine clinical practice. HD colonoscopy could facilitate endoscopic resection in these patients. Randomised controlled studies are required to confirm these findings.