Patrice A. Michaletz

Prospective randomized comparison of polyvinyl bougies and through-the-scope balloons for dilation of peptic strictures of the esophagus.

We prospectively compared the efficacy of polyvinyl bougies (Savary type) passed over a guide wire and through-the-scope balloons for the dilation of peptic esophageal strictures in a randomized study. Thirty-four patients, 17 in each treatment arm, were studied. At entry, dysphagia was assessed according to a six-point scale (0, unable to swallow; 5, normal). The end-point for dilation was to size 45F or 15 mm. Discomfort during the procedure was graded on a four-point scale (0, no discomfort; 1, mild; 2, moderate; 3, severe discomfort). Follow-up visits were at 1 week, 1 month, 3 months, and every 3 months thereafter for 2 years. At the 1-week visit, the size of esophageal lumen was measured by 8-, 10-, and 12-mm pills. Both devices effectively relieved dysphagia. By life-table analysis, stricture recurrence during the first year of follow-up was similar in both groups, but during the second year, the risk of recurrence was significantly lower in patients whose strictures were dilated with balloons. Other advantages of balloons included the need for fewer treatment sessions to achieve the defined end-diameter for dilation (1.1 + 0.1 versus 1.7 + 0.2, p < .05), and less procedural discomfort (p < .05). The differences in luminal size after dilation, measured by the barium pill test, were not significant. Ability to pass the 12-mm pill and absence of dysphagia were correlated. Our results indicate that both devices are effective in relieving dysphagia, but balloons may have a long-term advantage.

Epidemiology of Campylobacter pylori Infection: Ethnic Considerations

A proper perspective of the association of Campylobacter pylori with various diseases can be achieved only when the incidence of C. pylori infection in the normal population is known. We used the 13C urea breath test (a simple, specific, noninvasive, safe, and reproducible method to assess the presence of active C. pylori infection) to compare the frequency of C. pylori infection in healthy young adults from three areas of the world. We studied 26 women and 32 men (ages 20 to 29): 29 from the United States, 10 from China, 6 from Mexico, and 13 from India. All foreign nationals had been in the United States 5 years or less. The frequency of C. pylori infection was 21%, 67%, 33% and 46%, for those from the U.S., China, Mexico and India, respectively. Although, we found no difference in the frequency of C. pylori infection among ethnic groups from North America (U.S. citizens compared with citizens of Mexico), all individuals studied were of middle to upper class socioeconomic status. Subsequent studies will investigate whether the prevalence of C. pylori infection is different in economically disadvantaged populations. Our results suggest that there may be major differences in the age-related frequency of C. pylori infection in individuals from different parts of the world.

Endoscopic variceal ligation in patients who have failed endoscopic sclerotherapy

Endoscopic variceal ligation has been developed as an alternative to endoscopic sclerotherapy. We report a series of 12 men with a history of bleeding esophageal varices who were treated with endoscopic variceal ligation after they had failed sclerotherapy. Hemostasis was achieved in all 10 patients who were bleeding at the time of initial endoscopy and again in those who subsequently re-bled. Over a follow-up period of up to 22 months, varices have been and remain eradicated in five patients; in four others, a reduction in grade was noted before death (two patients), liver transplant, or loss to follow-up (one patient each); two patients died before they could be re-evaluated, while in the remaining patient, no reduction in variceal grade was noted before loss to follow-up. No complication was recorded after 35 endoscopic treatment sessions involving a total of 245 rubber band ligations. Our results indicate that endoscopic variceal ligation may be used with success in patients who fail sclerotherapy.

Microwave energy compared with heater probe and BICAP in canine models of peptic ulcer hemorrhage

The safety and efficacy of a new endoscopic microwave hemostatic device (Microtaze) was compared with BICAP and heater probe using previously established canine models of endoscopic hemostasis. Parameters evaluated included (a) depth of injury, (b) efficacy of hemostasis (bleeding gastric ulcer model), and (c) strength of coaptive bonding (mesenteric artery model). Depth of injury was graded histologically 1 wk after coagulation as the percentage of lesions showing gastric full-thickness damage for each probe. In depth-of-injury studies probes were applied at maximum force (established endoscopically with a specially designed force gauge) and at maximum power settings (50 W Microtaze, 30 J heater probe, dial setting 10 BICAP) to determine safety. There was no significant difference in the percentage of external muscle layer damage: 85%, 74%, and 86% for Microtaze, heater probe, and BICAP, respectively. Hemostasis was achieved 100% of the time in endoscopically induced bleeding gastric ulcers in heparinized dogs. Canine mesenteric arteries measuring 1-2 mm in diameter were isolated at laparotomy and coaptively sealed, and the bond strength was measured by application of hydrostatic pressure. Bursting pressures were not significantly different for Microtaze, heater probe, or BICAP probes (1062 +/- 77 mmHg, 863 +/- 85 mmHg, and 1154 +/- 139 mmHg, respectively). In conclusion, microwave energy may be applied endoscopically to produce hemostasis with similar safety and efficacy to BICAP and heater probe.

A Randomized Comparison of Dilatation Alone Versus Dilatation Plus Laser in Patients Receiving Chemotherapy and External Beam Radiation for Esophageal Carcinoma

Most patients with carcinoma of the esophagushave advanced disease at presentation. Since cure isusually not possible, the goal of treatment is thepalliation of dysphagia. Palliative modalities include bougies, balloons, stents, tumor probe, laser,surgery, chemotherapy, and radiation. In recent years,combined chemotherapy and radiation has shown promisingresults. However, the relief of dysphagia is slow and frequently incomplete. We compared theeffectiveness of dilatation alone versus dilatation plusNd-YAG laser therapy for the relief of dysphagia whileassessing the role of chemotherapy and radiation as an adjunct to surgery. Fifteen patients withsquamous cell carcinoma of esophagus who were deemed fitfor intensive chemotherapy and radiation were randomizedto receive either dilatation alone (N = 7) or dilatation plus laser (N = 8); theend-point for initial success was the passage of a 45French Savary dilator, and the relief of dysphagia. Atentry, 13 of these 15 patients were judged potentially resectable. However, after chemotherapy andradiation, only 3 of 13 (20%) patients could be offeredsurgery; the remainder were considered too poor asurgical risk. Follow-up was for 30 months, or until death. Further dilatations were performed asneeded for relief of dysphagia. No difference wasobserved between the laser plus dilatation and thedilatation alone group with respect to the degree ofdysphagia, weight record, quality of life index (Karnofskyscore), or mortality rate. Our results indicate that inpatients undergoing chemotherapy and radiation foresophageal carcinoma, dilatation alone provides adequate palliation of dysphagia, and in thesepatients, chemotherapy and radiation is a poor adjunctto surgical treatment.

Endoscopic needle biopsy: a comparative study of forceps biopsy, two different types of needles, and salvage cytology in gastrointestinal cancer

One of the goals of gastrointestinal endoscopy is to diagnose whether a lesion is malignant. The desire to improve the sensitivity of biopsy-sampling techniques prompted us to compare prospectively the reliability and accuracy of obtaining tissue by forceps biopsy, needle biopsy (21 gauge 13-mm long metal needles versus 18 gauge 20-mm long plastic needles), and salvage cytology in patients with endoscopically suspected malignancy. Samples were obtained in the order of needle biopsy (the order of metal and plastic needle biopsy was randomized), forceps biopsy, followed by salvage cytology. Needle biopsies were obtained by puncturing the lesion under direct vision while aspirating with a syringe. Twenty-three patients with gastrointestinal malignancy were studied (7 esophageal, 4 gastric, and 12 colonic). Forceps biopsies were positive in 18 of 23 (78%), missing 1 gastric and 4 colon malignancies. Metal needle biopsy was positive in 16 of 19 (84%), plastic needle biopsy in 17 of 22 (77%), and salvage cytology in 20 of 22 (91%). Accuracy was increased by a combination of techniques. Endoscopic needle biopsy is a simple and rapid method to evaluate lesions seen at endoscopy and is especially useful in evaluation of submucosal lesions.