Stefan Seewald

Stepwise radical endoscopic resection versus radiofrequency ablation for Barrett's oesophagus with high-grade dysplasia or early cancer: a multicentre randomised trial

Objective After focal endoscopic resection (ER) of high-grade dysplasia (HGD) or early cancer (EC) in Barretts oesophagus (BO), eradication of all remaining BO reduces the recurrence risk. The aim of this study was to compare the safety of stepwise radical ER (SRER) versus focal ER followed by radiofrequency ablation (RFA) for complete eradication of BO containing HGD/EC. Methods A multicentre randomised clinical trial was carried out in three tertiary centres. Patients with BO ≤5u2005cm containing HGD/EC were randomised to SRER or ER/RFA. Patients in the SRER group underwent piecemeal ER of 50% of BO followed by serial ER. Patients in the ER/RFA group underwent focal ER for visible lesions followed by serial RFA. Follow-up endoscopy with biopsies (four-quadrant/2u2005cm BO) was performed at 6 and 12u2005months and then annually. The main outcome measures were: stenosis rate; complications; complete histological response for neoplasia (CR-neoplasia); and complete histological response for intestinal metaplasia (CR-IM). Results CR-neoplasia was achieved in 25/25 (100%) SRER and in 21/22 (96%) ER/RFA patients. CR-IM was achieved in 23 (92%) SRER and 21 (96%) ER/RFA patients. The stenosis rate was significantly higher in SRER (88%) versus ER/RFA (14%; p<0.001), resulting in more therapeutic sessions in SRER (6 vs 3; p<0.001) due to dilations. After median 24u2005months follow-up, one SRER patient had recurrence of EC, requiring ER. Conclusions In patients with BO ≤5u2005cm containing HGD/EC, SRER and ER/RFA achieved comparably high rates of CR-IM and CR-neoplasia. However, SRER was associated with a higher number of complications and therapeutic sessions. For these patients, a combined endoscopic approach of focal ER followed by RFA may thus be preferred over SRER. Clinical trial number NTR1337.

Endoscopic resection of early gastric cancer treated by guideline and expanded National Cancer Centre criteria

Criteria for endoscopic resection in patients with early gastric cancer (EGC) have been expanded recently by the National Cancer Centre (NCC). This study compared long‐term outcomes in patients with EGC who underwent endoscopic treatment according to guideline criteria with those treated according to expanded criteria.

A standardized injection technique and regimen ensures success and safety of N-butyl-2-cyanoacrylate injection for the treatment of gastric fundal varices (with videos)

BACKGROUNDnN-butyl-2-cyanoacrylate has been successfully used for the treatment of bleeding from gastric fundal varices (FV). However, significant rebleeding rates and serious complications including embolism have been reported.nnnOBJECTIVEnOur purpose was to analyze the safety and efficacy of N-butyl-2-cyanoacrylate for FV bleeding by using a standardized injection technique and regimen.nnnDESIGNnRetrospective.nnnSETTINGnTwo tertiary referral centers.nnnPATIENTSnA total of 131 patients (91 men/40 women) with FV underwent obliteration with N-butyl-2-cyanoacrylate by a standardized technique and regimen.nnnINTERVENTIONSn(1) Dilution of 0.5 mL of N-butyl-2-cyanoacrylate with 0.8 mL of Lipiodol, (2) limiting the volume of mixture to 1.0 mL per injection to minimize the risk of embolism, (3) repeating intravariceal injections of 1.0 mL each until hemostasis was achieved, (4) obliteration of all tributaries of the FV, (5) repeat endoscopy 4 days after the initial treatment to confirm complete obliteration of all visible varices and repeat N-butyl-2-cyanoacrylate injection if necessary to accomplish complete obliteration.nnnMAIN OUTCOME MEASUREMENTSnImmediate hemostasis rate, early rebleeding rate, bleeding-related mortality rate, procedure-related complications, long-term cumulative rebleeding-free rate, and cumulative survival rate.nnnRESULTSnInitial hemostasis and variceal obliteration were achieved in all patients. The mean number of sessions was 1 (range 1-3). The mean total volume of glue mixture used was 4.0 mL (range 1-13 mL). There was no occurrence of early FV rebleeding, procedure-related complications, or bleeding-related death. The cumulative rebleeding-free rate at 1, 3, and 5 years was 94.5%, 89.3%, and 82.9%, respectively.nnnCONCLUSIONnObliteration of bleeding FV with N-butyl-2-cyanoacrylate is safe and effective with use of a standardized injection technique and regimen.

EUS 2008 Working Group document : evaluation of EUS-guided drainage of pancreatic-fluid collections (with video)

Pelvic-fluid collections or abscesses often present a clinical challenge because of their location: surrounded by the bony pelvis, bladder, bowel, uterus, vagina, prostrate, rectum, and other neurovascular structures. These collections may occur as a common complication of surgery and medical diseases. An anastomotic leak after large-bowel resection, particularly low anterior resection, is the most common surgical cause and may occur in 0.5% to 30% of cases. 1-4 Diverticulitis, ischemic colitis, Crohns disease, appendicitis, and sexually transmitted diseases are other etiologies. 5 Because US often fails to detect deep or multifocal collections, the best diagnostic modality for patients suspected to have pelvic-fluid collections is a CT of the abdomen and pelvis. 5 The CT findings, in combination with the patients clinical status, determine the most appropriate mode of treatment. This section of the EUS 2008 Working Group Proceedings evaluates the current evidence and potential role of EUS in the management of patients with pelvic-fluid collections that encompasses abscesses.

LONG‐TERM RESULTS AFTER ENDOSCOPIC DRAINAGE AND NECROSECTOMY OF SYMPTOMATIC PANCREATIC FLUID COLLECTIONS

Aims:u2002 To determine the immediate and long‐term results of endoscopic drainage and necrosectomy for symptomatic pancreatic fluid collections.

Total endoscopic resection of Barrett esophagus.

Barretts esophagus with high grade intraepithelial neoplasia is associated with disease progression at rates of greater than 10% per year. Endoscopic resection is a lower risk alternative to surgery for the management of high grade intraepithelial neoplasia and intramucosal cancer. Two endoscopic approaches have been used, namely localized resection of the lesion and total endoscopic resection of all Barretts mucosa. The latter strategy removes all at-risk mucosa. Currently it is performed mainly using piecemeal endoscopic mucosal resection techniques. In recent years endoscopic submucosal dissection has been attempted to obtain en bloc resection. This review will describe the techniques of total endoscopic resection, and summarize the key published data.

Long-term follow-up in small duct chronic pancreatitis: A plea for extended drainage by "V-shaped excision" of the anterior aspect of the pancreas.

Background:A pancreatic duct diameter (PDD) ranging from 4 to 5 mm is regarded as “normal.” The “large duct” form of chronic pancreatitis (CP) with a PDD >7 mm is considered a classic indication for drainage procedures. In contrast, in patients with so-called “small duct chronic pancreatitis” (SDP) with a PDD <3 mm extended resectional procedures and even, in terms of an “ultima ratio,” total pancreatectomy are suggested. Methods:Between 1992 and 2004, a total of 644 patients were operated on for CP. Forty-one prospectively evaluated patients with SDP underwent a new surgical technique aiming at drainage of the entire major PD (longitudinal “V-shaped excision” of the anterior aspect of the pancreas). Preoperative workup for imaging ductal anatomy included ERCP/MRCP, visualizing the PD throughout the entire gland. The interval between symptoms and therapeutic intervention varied from 12 to 120 months. Median follow-up was 83 months (range, 39–117 months). A pain score as well as a multidimensional psychometric quality-of-life questionnaire was used. Results:Hospital mortality was 0%. The perioperative (30 days) morbidity was 19.6%. Postoperative, radiologic imaging showed an excellent drainage of the entire gland and the PD in all but 1 patient. Global quality-of-life index increased in median by 54% (range, 37.5%–80%). Median pain score decreased by 95%. Twenty-seven patients (73%) had complete pain relief. Sixteen patients (43%) developed diabetes, while the exocrine pancreatic function was well preserved in 29 patients (78%). Conclusion:“V-shaped excision” of the anterior aspect of the pancreas is a secure and effective approach for SDP, achieving significant improvement in quality of life and pain relief, hereby sparing patients from unnecessary, extended resectional procedures. The deterioration of exocrine and endocrine pancreatic functions is comparable with that observed during the natural course of the disease.

Variceal bleeding and portal hypertension : Still a therapeutic challenge?

In the primary prevention of variceal hemorrhage, beta-blockers continue to be the first-line treatment. Newer nonselective beta-blockers with anti-alpha1-adrenergic activity, such as carvedilol, appear to have a better impact on reducing the hepatic venous pressure gradient than propranolol. The addition of isosorbide mononitrate appears to improve the effectiveness of beta-blockers in primary prophylaxis, but not that of somatostatin in the treatment of acute variceal hemorrhage. The use of vasoactive drugs alone in acute variceal bleeding has not proved to be more effective than endoscopic treatment. The advent of endoscopic variceal ligation (EVL) has strengthened the role of endoscopy in the management of bleeding esophageal varices. EVL has improved the results, particularly in terms of lowering the treatment-related morbidity, compared with endoscopic variceal sclerotherapy (EVS). However, the variceal recurrence rate after initial eradication with EVL is relatively high. In contrast to synchronous combined therapy with EVL plus EVS, metachronous combination of EVL and low-dose EVS may improve the results of EVL alone. For bleeding fundic varices, obliteration using cyanoacrylate is currently the treatment of choice. Endosonography (EUS) is coming into more widespread use in the assessment of variceal eradication and in further attempts to improve the results of endoscopic injection therapy. According to two meta-analysis studies, transjugular intrahepatic portosystemic shunt (TIPS) is not yet capable of replacing endoscopic treatment in the secondary prevention of variceal bleeding.

Endoscopic ultrasound-guided drainage of abdominal abscesses and infected necrosis.

Traditionally abdominal abscesses have been treated with either surgical or radiologically guided percutaneous drainage. Surgical drainage procedures may be associated with considerable morbidity and mortality, and serious complications may also arise from percutaneous drainage. Endoscopic ultrasound (EUS)-guided drainage of well-demarcated abdominal abscesses, with adjunctive endoscopic debridement in the presence of solid necrotic debris, has been shown to be feasible and safe. This multicenter review summarizes the current status of the EUS-guided approach, describes the available and emerging techniques, and highlights the indications, limitations, and safety issues.

Combined α-methylacyl coenzyme A racemase/p53 analysis to identify dysplasia in inflammatory bowel disease

Identification of dysplasia in inflammatory bowel disease represents a major challenge for both clinicians and pathologists. Clear diagnosis of dysplasia in inflammatory bowel disease is sometimes not possible with biopsies remaining indefinite for dysplasia. Recent studies have identified molecular alterations in colitis-associated cancers, including increased protein levels of alpha-methylacyl coenzyme A racemase, p53, p16 and bcl-2. In order to analyze the potential diagnostic use of these parameters in biopsies from inflammatory bowel disease, a tissue microarray was manufactured from colons of 54 patients with inflammatory bowel disease composed of 622 samples with normal mucosa, 78 samples with inflammatory activity, 6 samples with low-grade dysplasia, 12 samples with high-grade dysplasia, and 66 samples with carcinoma. In addition, 69 colonoscopic biopsies from 36 patients with inflammatory bowel disease (28 low-grade dysplasia, 8 high-grade dysplasia, and 33 indefinite for dysplasia) were included in this study. Immunohistochemistry for alpha-methylacyl coenzyme A racemase, p53, p16 and bcl-2 was performed on both tissue microarray and biopsies. p53 and alpha-methylacyl coenzyme A racemase showed the most discriminating results, being positive in most cancers (77.3% and 80.3%) and dysplasias (94.4% and 94.4%) but only rarely in nonneoplastic epithelium (1.6% and 9.4%; P < .001). Through combining the best discriminators, p53 and alpha-methylacyl coenzyme A racemase, a stronger distinction between neoplastic tissues was possible. Of all neoplastic lesions, 75.8% showed a coexpression of alpha-methylacyl coenzyme A racemase and p53, whereas this was found in only 4 of 700 nonneoplastic samples (0.6%). alpha-methylacyl coenzyme A racemase/p53 coexpression was also found in 10 of 33 indefinite for dysplasia biopsies (30.3 %), suggesting a possible neoplastic transformation in these cases. Progression to dysplasia or carcinoma was observed in 3 of 10 p53/alpha-methylacyl coenzyme A racemase-positive, indefinite-for-dysplasia cases, including 1 of 7 cases without and 2 of 3 cases with p53 mutation. It is concluded that combined alpha-methylacyl coenzyme A racemase/p53 analysis may represent a helpful tool to confirm dysplasia in inflammatory bowel disease.