Pascal Burtin

Endoscopic detection of early esophageal cancer in a high-risk population: does Lugol staining improve videoendoscopy?

BACKGROUNDnThe aim of this study was to prospectively compare the diagnostic accuracy of videoendoscopy, with and without Lugol staining, for the detection of esophageal cancer in alcoholic or smoking patients older than 40 years.nnnMETHODSnDaily alcohol and tobacco consumption and overt and latent symptoms were noted. The 158 patients included were examined by videoendoscopy and with Lugol dye.nnnRESULTSnThe mean consumption of alcohol and tobacco was 86 +/- 49 gm/day for 26 +/- 11 years, and 30 +/- 18 pack-years, respectively. Twenty-five patients had no symptoms. Before Lugol staining, 12 patients had endoscopically identified cancerous lesions. After Lugol staining, 13 patients had 17 esophageal cancers, 3 of which were high-grade dysplasia. The prevalence of esophageal cancer was 8.2%: 95% CI [4,14]. Dye-free surfaces were significantly larger than the endoscopic patterns observed before Lugol staining (11.6 +/- 9.2 cm2 vs 1.4 +/- 1.7 cm2; p < 0.02).nnnCONCLUSIONSnIn an alcoholic smoking population, the prevalence of esophageal cancer detected by endoscopy is high and not related to symptoms described by patients. Lugol staining only moderately improves the diagnostic accuracy of videoendoscopy; its main advantage is the assessment of the mucosal extension of esophageal cancer.

Prevention of recurrent variceal bleeding in alcoholic cirrhotic patients: prospective controlled trial of propranolol and sclerotherapy

We conducted a prospective randomized controlled study to evaluate the effectiveness of propranolol and sclerotherapy, compared to a control group, in the prevention of variceal rebleeding in alcoholic cirrhotic patients. Among the 79 patients included, the distribution of patients according to Child-Pugh classification was: A, 22%; B, 40%; and C, 38%. Propranolol was given twice daily with a mean final dose of 54 +/- 16 mg/day, this resulted in a mean reduction in resting heart rate of 26 +/- 7%. Sclerotherapy was performed weekly using 1% polidocanol. End points were rebleeding or death. During the mean follow up of 19 +/- 16 months, 43 patients bled and 22 patients died. The cumulative percentages of patients free of rebleeding at 1 year were: propranolol, 81% (95% confidence interval (CI): 63-92); sclerotherapy, 64% (95% CI: 45-82); control, 54% (95% CI: 36-71); these differences did not reach statistical significance. The cumulative percentages of patients alive at 1 year were: propranolol, 92% (95% CI: 76-98); sclerotherapy, 79% (95% CI: 58-91); control, 81% (95% CI: 60-93); these differences were not statistically significant. Alcohol withdrawal, which occurred in 66% of patients, was an independent predictive factor associated with a decreased risk of rebleeding or death. In conclusion, a life table analysis of patients free of rebleeding, as well as of patients surviving, revealed a tendency in favour of propranolol. The lack of a statistical support for these two favorable effects could be due to poor statistical power.(ABSTRACT TRUNCATED AT 250 WORDS)

Inter-observer and intra-observer variability in hepatology.

Objectives A determination of the inter-observer variability is an important step before determining diagnostic accuracy and requires a specific methodology and statistical tests. The aim of this study was to report the results, characteristics and methodological quality of agreement studies performed in hepatology. Methods A search of published studies yielded 42 that could be used in this evaluation: three were clinical studies, 11 were in the field of endoscopy, 12 in histopathology and 16 in radiology. The studies were described with a grid of 28 items and evaluated with a quality score (QUAS; maximum, 35) including 22 items. Results The following agreement level was noted: intra-observer > inter-observer > inter-centre. The following signs had good agreement. Endoscopy: size and red signs of oesophageal varices; histopathology: cirrhosis, fibrosis and steatosis; Doppler: mean portal vein and superior mesenteric artery velocities, hepatic artery area and perfusion indexes. Frequent methodological weaknesses were noted. The real agreement (such as the kappa index excluding chance), and the prevalence of signs and biases were rarely assessed. Standardized observations (67% of the studies), blind assessment (48%), simultaneous observations (7%), and the recording technique were not frequently used. The mean QUAS was 13 ± 6 with 17 ± 4 in histopathology versus 11 ± 6 in radiology (P < 0.05). Using multiple regression, four variables independently predicted the QUAS with R2 = 0.77: adapted tests, multiple observations, intra-class correlation coefficient and agreement proportion. Conclusions Methodology was often insufficient. Agreement is often measured under biased conditions. Some areas were not or were rarely studied, e.g., biology and ultrasound. The agreement and QUAS were often poor, suggesting the need for studies with improved observation and methodological quality of agreement.

Endoscopic ultrasonographic signs of portal hypertension in cirrhosis

BACKGROUNDnEndoscopic ultrasonography (EUS) has been suggested to investigate portal hypertension (PHT). We compared EUS and endoscopy in the exploration of PHT in cirrhosis.nnnMETHODSnIn 58 patients with cirrhosis and 16 controls, the presence of esophageal varices and gastric varices was recorded by both endoscopy and EUS, peridigestive varices and perforating veins by EUS. Relationships of patterns with each other and with clinical and biologic data were evaluated.nnnRESULTSnIn patients with cirrhosis: esophageal varices were found by endoscopy and EUS in 88% and 55% of cirrhotic cases (p < 0.01), and gastric varices in 17% and 41%, respectively (p < 0.01). Perforating veins, below the gastroesophageal junction, were diagnosed by EUS in 40% of cases and never in controls. A significant relationship was found between perforating veins and the following patterns: peri-digestive varices, gastric varices at EUS, and esophageal varices at endoscopy. In patients with and without cirrhosis: after multivariate analysis, only esophageal varices at endoscopy were independently related to cirrhosis. However, in Child-Pugh class A patients, both esophageal varices and perforating veins were independently related to cirrhosis (diagnostic accuracy, 92%).nnnCONCLUSIONSnEUS is of limited value in the diagnosis of cirrhosis because it gives little additional information to upper gastrointestinal endoscopy. The relationships between perforating veins, varices, and peridigestive varices support the hypothesis that perforating veins are important in the pathogenesis of esophageal and gastric varices.

Severe hemorrhagic radiation proctitis advancing to gradual cessation with hyperbaric oxygen

SummaryWe report a case of a male patient suffering from a severe hemorrhagic radiation proctitis which gradually ceased with hyperbaric oxygen. We discuss the mechanisms of chronic radiation injury and the effect of the hyperbaric oxygen. This therapy is proposed as an alternative to surgical intervention for this abnormality.

Interobserver agreement on endoscopic diagnosis of bleeding peptic ulcers

BACKGROUNDnThe aim of this prospective study was to evaluate the interobserver agreement of stigmata of recent hemorrhage of bleeding peptic ulcers.nnnMETHODSnSixty-one consecutive adult patients were enrolled in the study and nine (three junior and six senior) endoscopists reviewed standardized video recordings of endoscopic examinations. Interobserver agreement was evaluated using the kappa (kappa) index, intraclass correlation coefficient, and proportion of agreement. Observer bias and poorly trained observers were investigated.nnnRESULTSnInterobserver agreement was very good for oozing (kappa = 0.68), good for clot (kappa = 0.51), poor for spurting (kappa = 0.29) and visible vessels (kappa = 0.33), and excellent for the absence of stigmata (kappa = 0.82). Observer bias sometimes occurred and the number of poorly trained observers was low. The kappa indexes were significantly better in senior than in junior investigators: 0.48 +/- 0.16 versus 0.37 +/- 0.26, respectively, p < 0.05. The agreement between the in vivo evaluation and video tape recordings (intraobserver agreement) was good (kappa = 0.60 +/- 0.19). There was no training phenomenon between the first and the second half of the patient group.nnnCONCLUSIONSnThe endoscopic classification of bleeding ulcers might be simplified by limiting grading to a few classes. Special attention should be paid to the training of endoscopists.

Colonic investigations in the elderly: Colonoscopy or barium enema?

Colonoscopy (CS) is currently considered the best diagnostic procedure for colonic imaging. The objectives of this multicentric study were to assess whether CS or simple contrast barium enema (SCBE) has the best effectiveness and tolerance in the elderly (over 80 years old). Except in cases of emergency, 67 elderly patients from 3 centers were randomized among three diagnostic strategies: CS, SCBE or barium enema + rectosigmoidoscopy (BERS). CSs were generally carried out after polyethylene- glycol (PEG) cleansing, and barium enemas after enema cleansing.The diagnostic effectiveness of the three strategies was not significantly different: a colonic abnormality was found in CS, SCBE, BERS groups in 65, 56 and 71% of the cases, respectively. No other investigation was needed in 61 to 76% of cases, and, on the basis of the exploration, final therapy was modified in less than 22% of cases. Overall cleansing quality was significantly better with barium enema (84.1%) than with CS (57.0% p<0.05). This was explained by a poor tolerance to PEG intake, which led to 28.2% of adverse effects, compared with 7.1% after enema preparation (p<0.05). This resulted in a significantly higher failure rate of complete colonic exploration with CS (48%) than with barium enema (9%; p<0.001). In conclusion, the effectiveness of the three diagnostic strategies is similar in the elderly. However, due to a better acceptance of the enema preparation, and to a better success rate of complete exploration, SCBE should be preferred to investigate colonic symptoms when the above preparations are used. (Aging Clin. Exp. Res. 7: 190–194, 1995)

Interobserver agreement in endoscopic ultrasonography staging of esophageal and cardia cancer

BACKGROUNDnEndoscopic ultrasonography has been accepted as an accurate means of staging cardioesophageal cancer, but no study has focused on the variability of interobserver interpretation of images so obtained.nnnMETHODSnWe compared interpretations recorded by five independent observers in 46 cases examined by endoscopic ultrasonography. One observer then reviewed a subset of 28 examinations 6 months later.nnnRESULTSnInterpretations were in nearly full accord for uT0 and uT4 tumors (kappa = > or = 0.73), in good accord for uT1 and uT3 tumors (kappa = > or = 0.42), but in poor accord for uT2 tumors (kappa = 0.16). Agreement was generally good when pertaining to invasion of adjacent organs, but no agreement was noted for invasion of the pericardium. In assessment of lymph node involvement, agreement was good for intra-abdominal, subcarinal, right lower paratracheal, and paraesophageal nodes (kappa = > or = 0.49), but poor for left lower and upper paratracheal lymph nodes. Intraobserver agreement was excellent for extent of tumor infiltration (kappa = 0.91) and good for lymph nodes (kappa > or = 0.51).nnnCONCLUSIONSnIn staging cardioesophageal cancer by endosonographic ultrasonography, improvement is needed in cases of uT2 tumors and of tumors invading the pericardium, and in assessment of lymph nodes in the upper mediastinum.

Interobserver agreement on endoscopic diagnosis of diffuse gastric mucosal features in patients with cirrhosis

Objective: Although diffuse gastric mucosal features have frequently been described in upper gastrointestinal endoscopy, they have never been subjected to a reliability study. Therefore, the aim of this study was to measure the interobserver agreement for gastric mucosal features in patients with cirrhosis, due to the high prevalence of these features in this condition, by means of the kappa index. Design: Prospective study on interobserver agreement in gastric endoscopy. Setting: Consecutive patients seen in an endoscopy unit of a university hospital. Patients, participants: Seventy patients with cirrhosis and seven endoscopists (four seniors and three juniors) were enrolled in this study. Intervention: Endoscopie examinations were recorded on videotape with a standardized technique by the same observer. Endoscopists were asked to judge the presence and location of nine elementary signs (erythema, atrophy, large folds, oedema, mosaic pattern, red spots, erosions, dark spots and microbleeding) and to identify the presence, location and type of three syndromes: gastritis, congestive gastropathy and antral vascular ectasia. Moreover, endoscopists were asked to judge the presence of gastric-associated lesions and varices as well as oesophageal varices and red signs. Results: Interobserver agreement was poor for all diffuse gastric mucosal features except for dark spots and microbleeding. Agreement was good for oesophageal features and associated gastric features. Agreement was not related to the experience of the endoscopists or to the quality of the examination. Agreement slightly improved when the presence of the sign was graded into two categories instead of three. According to a questionnaire, endoscopists greatly overestimated the reliability of their judgement The mean kappa indexes between the first and second portions of patients studied did not vary significantly but the correlation of kappa indexes between these two series was low (r = 0.64) suggesting that agreement studies should involve a large number of patients. Conclusions: The endoscopie diagnosis of diffuse gastric mucosal features is hampered by poor interobserver agreement. These features should be more precisely defined, with a simple and consensual classification. Finally, the training for the identification of gastric mucosal features by endoscopy needs improvement.

4483 Argon plasma coagulation is an effective and well tolerated treatment for rectal bleeding due to chronic radiation proctitis.

The treatment of rectal bleeding due to radiation proctitis is difficult to manage. Argon Plasma Coagulation (APC) is a technique of electrocoagulation which appears to be an effective and low-cost alternative to laser therapy. Aims. Our aim was to evaluate the efficacy and tolerance of APC for treatment of bleeding radiation-induced proctitis. Patients. We retrospectively analyzed the charts of 16 patients with chronic radiation proctitis. The mean age was 73.5 years (range: 62-80). Primary tumor was a prostatic cancer (No=15) and a uterine cancer (No=1). The mean time of onset of symptoms after radiotherapy was 15 months (range: 6-36). All patients complained of intermittent or daily rectal bleeding, of whom 3 needed blood transfusions. After a first colonoscopic evaluation, the patients underwent APC therapy at 1 month intervals. Argon gas flow was set at 0.6 L/min with an electrical power of 40 Watts. Results. All patients were improved by APC and a mean of 3.7 sessions (range: 2-8) was necessary for symptoms relief. During a mean follow-up of 7 months (range: 2-21 months), rectal bleeding did not recur in 7 patients (43.7%); in the other 9 patients (56.3%), bleeding was significantly reduced to occasional and negligible spotting (1 bleeding episode per week). No patient required transfusion after treatment. Immediate tolerance was good and no long-term treatment-related complication was observed. Conclusions. APC is an effective, safe and well tolerated treatment for rectal bleeding due to chronic radiation proctitis and might be considered as a first-line therapy for radiation proctitis.