Maite Betes

Use of colonoscopy as a primary screening test for colorectal cancer in average risk people

OBJECTIVE:The use of colonoscopy as a primary screening test for colorectal cancer (CRC) in average risk adults is a subject of controversy. Our primary objective was to build a predictive model based on a few simple variables that could be used as a guide for identifying average risk adults more suitable for examination with colonoscopy as a primary screening test.METHODS:The prevalence of advanced adenomas was assessed by primary screening colonoscopy in 2210 consecutive adults at least 40 yr old, without known risk factors for CRC. Age, gender, and clinical and biochemical data were compared among people without adenomas, those with nonadvanced adenomas, and those with any advanced neoplasm. A combined score to assess the risk of advanced adenomas was built with the variables selected by multiple logistic regression analysis.RESULTS:Neoplastic lesions were found in 617 subjects (27.9%), including 259 with at least one neoplasm that was 10 mm or larger, villous, or with moderate-to-severe dysplasia, and 11 with invasive cancers. Advanced lesions were more frequent among men, older people, and those with a higher body mass index (BMI). These three variables were independent predictors of advanced adenomas in multivariate analysis. A score combining age, sex, and BMI was developed as a guide for identifying individuals more suitable for screening colonoscopy.CONCLUSIONS:Age, gender, and BMI can be used to build a simple score to select those average risk adults who might be candidates for primary screening colonoscopy.

Gastroduodenal Injury After Radioembolization of Hepatic Tumors

BACKGROUND:Radioembolization is a new tool for the treatment of hepatic tumors that consists in the injection of biocompatible microspheres carrying radioisotopes into the hepatic artery or its branches.METHODS:We have performed radioembolization in 78 patients with hepatic tumors using resin-based microspheres loaded with yttrium-90. All patients were previously evaluated to minimize the risk of hazardous irradiation to nontarget organs and to obtain the data needed for dose calculation.RESULTS:We report a complication found in three cases (3.8%) that consists of abdominal pain resulting from gastroduodenal lesions and that had a chronic, insidious course. Microscopically, microspheres were detected in the specimens obtained from all affected gastric areas. Since these gastroduodenal lesions do not appear when nonradiating microspheres are injected in animals, lesions are likely to be due to radiation and not to an ischemic effect of vascular occlusion by spheres.CONCLUSIONS:We believe that a pretreatment evaluation that includes a more thorough scrutiny of the hepatic vascularization in search of small collaterals connecting to the gastroduodenal tract can help prevent this awkward complication.

Prognosis of hepatocellular carcinoma in relation to treatment: A multivariate analysis of 178 patients from a single European institution

BACKGROUND Because the prognosis of patients with hepatocellular carcinoma is not fully understood, particularly regarding therapy, we have evaluated it in a series of patients with a homogeneous diagnostic and therapeutic work-up. METHODS From 1985 to 1996, 42 variables were recorded prospectively in 178 constructive patients who had a diagnosis of hepatocellular carcinoma. Treatment consisted of liver transplantation ( n = 22), partial hepatectomy (n = 11), arterial, chemoembolization ( n = 52), systemic or regional chemotherapy (n = 51), and other therapies (n = 5); 37 patients received no specific therapy. Statistical analysis was performed according to a Cox model. RESULTS There were no differences between the survival of patients receiving chemotherapy, other therapies, or no treatment (control group n = 93). survival rates a 1,3, and 5 years were 81%, 74%, and 74% for liver transplantation, 72%, 58%, and 58% for hepatectomy, 55%, 26%, and 13% for chemoembolization, and 13%, 3%, and 0% for the control group. Cirrhosis, systemic syndrome, bilobar involvement, Childs stage C disease, and treatment were independent predictors of survival. CONCLUSIONS This series shows that certain easily accessible parameters may help establish individual prognosis and stratify patients in clinical trials and indicates that chemoembolization, partial resection, and liver transplantation can prolong life expectancy of patients with hepatocellular carcinoma.

EchoBrush may be superior to standard EUS‐guided FNA in the evaluation of cystic lesions of the pancreas

Cystic lesions of the pancreas are being detected with increasing frequency. Endoscopic ultrasound‐guided fine‐needle aspiration (EUS‐FNA) is one of the most precise methods of diagnosis but still has limited accuracy. A new, through‐the‐needle cytologic brush system (EchoBrush; Cook Medical, Bloomington, Ind) has been approved for use during EUS evaluation of cystic pancreatic lesions.

Gallbladder drainage guided by endoscopic ultrasound

The gold-standard management of acute cholecystitis is cholecystectomy. Surgical intervention may be contraindicated due to permanent causes. To date, the classical approach is percutaneous cholecystostomy in patients unresponsive to medical therapy. However, with this treatment some patients may experience discomfort, complications and a decrease in their quality of life. In these cases, endoscopic ultrasound (EUS)-guided gallbladder drainage may represent an effective minimally invasive alternative. Our objective is to describe in detail this new and not well-known technique: EUS-guided cholecystenterostomy. We will describe how the patient should be prepared, what accessories are needed and how the technique is performed. We will also discuss the possible indications for this technique and will provide a brief review based on published reports and our own experience.

Long-term follow-up study of gastroduodenal lesions after radioembolization of hepatic tumors

AIM To evaluate the long-term natural history of the gastroduodenal lesions secondary to extrahepatic embolization with Ytrium 90 (⁹⁰Y) spheres. METHODS From September 2003 to January 2012, 379 procedures of liver radioembolization (RE) using resin microspheres loaded with ⁹⁰Y were performed in our center. We have retrospectively compiled the data from 379 RE procedures performed in our center. We report a comprehensive clinical, analytical, endoscopic and histologic long-term follow-up of a series of patients who developed gastroduodenal lesions after the treatment. RESULTS Six patients (1.5%) developed gastrointestinal symptoms and had gastrointestinal lesions as shown by upper endoscopy in the next 12 wk after RE. The mean time between RE and the appearance of symptoms was 5 wk. Only one patient required endoscopic and surgical treatment. The incidence of gastrointestinal ulcerations was 3.75% (3/80) when only planar images were used for the pre-treatment evaluation. It was reduced to 1% (3/299) when single-photon emission computed tomography (SPECT) images were also performed. The symptoms that lasted for a longer time were nausea and vomiting, until 25 mo after the treatment. CONCLUSION All patients were free from severe symptoms at the end of follow-up. The routine use of SPECT has decreased the incidence of gastrointestinal lesions due to unintended deployment of ⁹⁰Y particles.

Lesiones neoplásicas sincrónicas en el cáncer colorrectal. Análisis de posibles factores que favorezcan su presentación

Aim: few data have been published regardingthe causes of synchronous lesionsinpatientswith colorectal cancer.The aim of our study was to identifypotentialfactors that mightbe implicated in the development of multicentric lesions, since this knowledge could be useful for tailored follow-up once initial synchronousle sions havebeenremoved. Methods: we retrospectively reviewed 382 colorectal cancer cases diagnosedby total colonoscopy and histological study of surgical specimens. We divided our population into 2 groups, based on whether they had synchronous lesions or otherwise. Several data related to personal and family history, habits, symp toms, and tumor characteristics were assessed. Univa riate and multivariate statistical analyseswere performed. Results: 208 (54.5%) patients had synchronous adenomas and 28 (7.3%) had synchronouscancer. A multivariate analysis showed that the followingparameters were consistently related to the presence of multicentriclesions –male gender:OR = 1.97; CI = 1.13-3.45; p = 0.017; age ≥ 59 years: OR = 2.57; CI = 1.54-4.29; p < 0.001; personal history of colonic adeno mas: OR = 3.04; CI = 1.04-8.85; p = 0.042; and obstructivetu mors: OR = 0.48; CI = 0.27-0.85; p = 0.012 . Conclusion: our results show that severalparameters that are easy to measure could be considered risk factors for the develop ment of multicentric lesions. These factors need to be confirmed with follow-up studies analyzingtheir role in patients with and without metachronic lesions once all synchronous lesions have beenremoved.

Blue Rubber Bled Nevus syndrome: three cases

Syndrome (BRBNS) have been diagnosed in our center. In the younger patients (18 and 49-year old), endoscopic examinations were indicated because of the presence of iron deficiency anemia (IDA); in the older patient (77year old), endoscopy was performed because of hematochezia without laboratory or clinical involvement. In all patients, we observed nodular, bluish, tender, wrinkled or slightly depressed lesions at the skin and gastrointestinal (GI) tract. Most severe cutaneous lesions were observed on the upper limbs of the older patient (Fig. 1). On the other hand, endoscopic examinations of patients with IDA showed many of these lesions throughout the GI tract, and the greater ones were located in the colon (Figs. 2 and 3). Because of the symptoms of these three patients were mild, they were treated with conservative measures. Outcome was favorable in all cases. BRBNS, also known as Bean ́s syndrome, is a rare and probably inherited disorder characterized by the presence of cutaneous hemangiomas and vascular tumors of the GI tract (1,2). The lesions in the GI tract are usually multiple and may involve Blue Rubber Bled Nevus syndrome: three cases

Successful endoscopic mesh removal after laparoscopic Nissen fundoplication

A 72-year-old male was admitted because of dysphagiafor solids and liquids. He had undergone a laparoscopic Nis-sen fundoplication due to erosive esophagitis and hiatal her-nia. Three years later, due to symptomatic recurrence of thehernia, surgery with placement of a polypropylene mesh wasindicated. After four years he developed epigastric pain anddysphagia for liquids. Gastroduodenoscopy showed apolypropylene mesh occluding almost all the esophageallumen (Fig. 1).The symptoms worsened, with dysphagia forsolids and liquids, with weight loss. First of all, we decidedto remove the mesh endoscopically.A first attempt was doneby exerting strong traction on the mesh with biopsy forcepswithout any result. At this point we looked for each one ofthe blue Prolene 3/0 (Fig. 2A) sutures and cut them with endo -scopic scissors FS – 3L1 and FS – 5U - 1 (Fig. 2B) (Olympus,Tokyo, Japan). The mesh was extracted successfully in two

7204 Effect of pre-medication on cardiopulmonary changes during upper gastrointestinal endoscopy.

Munoz-Navas, Univ Clin OF NAVARRA, Pamplona, Spain. Aims: To study the changes in arterial oxygen saturation (SaO 2 ), heart rate (HR), systolic (SBP) and diastolic blood pressure (DBP) occurring during routine gastroscopy regarding type of pre-medication. Methods: 150 consecutive patients referred for routine gastroscopy were randomized to 3 groups: I) deep sedation (propofol); II) conscious sedation (midazolam 1.5-2mg + pethidine 20 mg); III) no sedation. Patients with arterial hypertension or cardiopulmonary diseases were excluded. SaO 2 , SBP, DBP and HR were monitorized recording basal values, every one minute during endoscopy and 5 minutes after finishing the exploration. The same endoscopist performed all the explorations. Supplemental oxygen was administered to all patients of group I and to half patients of groups II and III. Results: No significant differences were found regarding age, sex, body mass index, tobacco and basal values of SaO 2 , SBP, DBP and HR. During gastroscopy we observed a significant increment in: HR (I: 15.98 ± 13.1 bpm; II: 33.6±15.1 bpm; III: 30.4± 12.9 bmp); SBP (I: 6.8 ± 11.9 mm Hg; II: 28.9 ± 16.2 mm Hg; III: 31.2 ± 17.2 mm Hg); DBP (I: 7.0 ± 9 mm Hg; II: 26 ± 17.7 mm Hg; III: 24.5 ± 15.8 mm Hg). These increments were significantly lower (p 2 2 2 registered during gastroscopy are similar in those patients sedated with midazolam plus pethidine (at doses used in this study) and in cases without sedation. Supplemental oxygen reduces desaturation episodes in these cases. Deep sedation with propofol prevents the hypertensive response and produces a significantly lower increment in HR; it induces more desaturation episodes, more in patients with low basal SaO 2 . These data may be useful to choose the kind of pre-medication in each particular clinical condition.